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
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
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
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
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
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
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
Trocar Configuration: Nephrectomy 5 mm liver retractor (optional) 12 mm assistant trocar
Robot is docked at a 45 o angle from the head of the bed
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
Dissection of Renal Hilum ureter clipped
Transection of Renal Vessels
Perihilar Lymphadenectomy
Trocar Configuration: Bladder Cuff New assistant trocar 8-12 mm hybrid robotic trocar
8-13 mm Robotic Convertible Trocar Avoids capacitance coupling
Robot is re-docked at a 45 o angle from the foot of the bed
Pelvic Lymphadenectomy
Dissection of Ureterovesical Junction
Excision of Bladder Cuff
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
Sutures Bladder mucosa 3-0 polyglactin SH (8 inches) Bladder muscularis propria 2-0 polyglactin UR6 (8 inches)
2-layered Closure of Cystotomy
Specimen Extraction Sites Drain Drain
Case Presentation
CT Scan Left lower pole filling defect
Flexible Ureteroscopy Multiple papillary tumors Biopsy: High grade urothelial carcinoma
Video: Robotic Nephrectomy
Video: Robotic Distal Ureterectomy and Bladder Cuff
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
Pugh J, Stifelman M, Hemal A and Su LM BJU Int, 2013
Robotic NUx: Published Series OR Time EBL LOS Study Technique N (min) (ml) (days) Park et al. 2009 Eandi et al. 2010 Hemal et al. 2011 Su, Hemal, Stifelman, 2013 Berger et al. 2008 Wolf et al. 2005 RANUx 11 247 106 7 RANUx 11 326 200 5 RANUx 15 184 103 3 RANUx 43 249 133 3 Lap NUx 100 182 248 4 HAL NUx 53 279 330 4
Pathologic Outcomes Mean LN count: 11 (4-23) Pugh J, Stifelman M, Hemal A and Su LM BJU Int, 2013
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
Video: Robotic Psoas Hitch
umbilicus assistant port pubis
Robot is docked between the legs
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
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)
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
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