Robotic Surgery for Upper Tract Urothelial Carcinoma. Li-Ming Su, MD
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1 Robotic Surgery for Upper Tract Urothelial Carcinoma Li-Ming Su, MD David A. Cofrin Professor of Urology, Associate Chairman of Clinical Affairs, Chief, Division of Robotic and Minimally Invasive Urologic Surgery, University of Florida College of Medicine; Gainesville, Florida Objectives: Describe the indications and contraindications for robotic surgery for upper tract urothelial carcinoma Outline operative setup and surgical steps for robotic nephroureterectomy with regional lymphadenectomy Discuss the operative setup and surgical steps Psoas hitch and ureteral reimplantation Review the published literature on robotic surgery for upper tract urothelial carcinoma as compared to conventional laparoscopic surgery
2 UF U N I V E R S I T Y of FLORIDA The Foundation for The Gator Nation Robotic Surgery for Upper Tract Urothelial Carcinoma Li-Ming Su, M.D. David A. Cofrin Professor of Urology Chief, Division of Robotic and Minimally Invasive Urologic Surgery Department of Urology University of Florida College of Medicine
3 Is The Robot Necessary? Laparoscopy Robotic Surgery vs. Not necessary for experienced laparoscopists Surgeons with limited laparoscopic experience Expansion of robotic practice and offerings Stepping stone towards robotic partial NTx
4 Indications and Contraindications Indications: Same as open or laparoscopic surgery Endoscopic or biopsy proven upper tract TCCa Normal contralateral kidney and renal function Contraindications: Contraindication to laparoscopy?evidence of regional spread (e.g. N+ disease) consider chemo
5 Robotic NUx: General Principles 3-armed robotic technique Single patient positioning Single trocar configuration (4 trocars) For NUx: Two robot docking setup nephrectomy distal ureterectomy and bladder cuff Extravesical approach to bladder cuff Single cystotomy
6 Operative Steps: RANUx Step 1: Dock robot 45 o angle from the head of OR table Step 2: Mobilize of ipsilateral colon Step 3: Clip ureter beneath lesion Step 4: Dissect renal hilum Step 5: Transect renal artery and vein Step 6: Complete mobilization of kidney Step 7: Perihilar lymphadenectomy Step 8: Dissect ureter as far distally as possible
7 Operative Steps: RANUx (cont.) Step 9: Instill intravesical mitomycin C Step 10: Re-dock robot at 45 o angle from the foot of OR table Step 11: Mobilize ipsilateral bladder Step 12: Dissect out ureterovesical junction; drain bladder Step 13: Excise bladder cuff and close cystotomy Step 14: Pelvic lymphadenectomy Step 15: Entrap specimens and place drain
8 Trocar Configuration: Nephrectomy 5 mm liver retractor (optional) 12 mm assistant trocar
9 Robot is docked at a 45 o angle from the head of the bed
10 Instrumentation: RANUx Endoscope 30 degree down lens Left robotic arm Maryland bipolar forceps Right robotic arm Monopolar curved scissors Assistant Suction-irrigator Clip applier EndoGIA linear stapler Ligasure Specimen entrapment bag
11 Dissection of Renal Hilum ureter clipped
12 Transection of Renal Vessels
13 Perihilar Lymphadenectomy
14 Trocar Configuration: Bladder Cuff New assistant trocar 8-12 mm hybrid robotic trocar
15 8-13 mm Robotic Convertible Trocar Avoids capacitance coupling
16 Robot is re-docked at a 45 o angle from the foot of the bed
17 Pelvic Lymphadenectomy
18 Dissection of Ureterovesical Junction
19 Excision of Bladder Cuff
20 Instrumentation: Cystotomy Closure Endoscope 30 degree down lens Left robotic arm Needle driver Right robotic arm Needle driver Assistant Suction irrigator Ligasure Clip applier Lap needle driver
21 Sutures Bladder mucosa 3-0 polyglactin SH (8 inches) Bladder muscularis propria 2-0 polyglactin UR6 (8 inches)
22 2-layered Closure of Cystotomy
23 Specimen Extraction Sites Drain Drain
24 Case Presentation
25 CT Scan Left lower pole filling defect
26 Flexible Ureteroscopy Multiple papillary tumors Biopsy: High grade urothelial carcinoma
27 Video: Robotic Nephrectomy
28
29 Video: Robotic Distal Ureterectomy and Bladder Cuff
30
31 Perioperative Data Total OR time: 4 hours EBL: Minimal LOS: 2 day Complications: none Pathology: pt2n0mx, high grade urothelial carcinoma of renal pelvis 11 nodes negative for tumor Margins free of tumor
32 Pugh J, Stifelman M, Hemal A and Su LM BJU Int, 2013
33 Robotic NUx: Published Series OR Time EBL LOS Study Technique N (min) (ml) (days) Park et al Eandi et al Hemal et al Su, Hemal, Stifelman, 2013 Berger et al Wolf et al RANUx RANUx RANUx RANUx Lap NUx HAL NUx
34 Pathologic Outcomes Mean LN count: 11 (4-23) Pugh J, Stifelman M, Hemal A and Su LM BJU Int, 2013
35 Complications 1 tx for postop bleed Grade II 2 postop pneumonia Grade II 1 TB for splenic bleed Grade IV 2 transient rhabdomyolysis Grade II, IV Pugh J, Stifelman M, Hemal A and Su LM BJU Int, 2013
36 Video: Robotic Psoas Hitch
37 umbilicus assistant port pubis
38 Robot is docked between the legs
39 Instrumentation: Robotic Psoas Hitch Endoscope Left robotic arm Right robotic arm Assistant 0 or 30 degree down lens Maryland bipolar forceps Monopolar curved scissors Monopolar hook Suction-irrigator Clip applier Ligasure Specimen entrapment bag
40 Sutures Cystotomy closure: mucosa 3-0 polyglactin SH (8 inches) Cystotomy closure: muscularis propria 2-0 polyglactin UR6 (8 inches) Psoas hitch 0 prolene (8 inches) Ureteral reimplantation 4-0 polyglactin RB1 (8 inches)
41
42 Conclusions Robotic nephroureterectomy and distal ureterectomy Easy techniques to adopt esp. for experienced robotic teams Simplifies bladder cuff dissection Avoids a second cystotomy Favorable ergonomics esp. suturing as compared to laparoscopic May serve as a stepping stone towards performing robotic partial NTx Similar perioperative outcomes to conventional laparoscopic techniques Longer oncologic followup required
43 Thank You
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