V06-11: Robotic Nephroureterectomy for Complex Renal Anatomy
Robotic nephroureterectomy (RNU) has demonstrated the ability to provide decreased morbidity associated with minimal invasive surgery but facilities the complete excision of the distal ureter and bladder cuff which is the standard for open surgery. We present our technique in two cases of upper tract transitional cell carcinoma (UT-TCC) in patients with complex renal anatomy. These cases required the application of principles from both partial nephrectomy and nephroureterectomy.
Case 1 depicts a 54 year old male with a horseshoe kidney and renal insufficiency (GFR 42) and left high grade UT-TCC confirmed by endoscopic biopsy. Case 2 is of a 61 year old male with atrophic left kidney (GFR 65) and high grade T1 TCC in the upper moiety of a duplicated right system treated with neoadjuvant chemotherapy. Both patients had negative metastatic workup and opted for RNU given their decreased renal function. Both cases are complicated by variant renal anatomy (horseshoe kidney vs duplicated kidney) and anomalous renal vasculature. We employed a 4 arm robotic technique with the Xi platform using a linear port configuration to facilitate dissection of the kidney and distal ureter without the need for redocking or additional port placement. Unique to our technique, the ureter and bladder cuff were addressed prior to nephrectomy which we find facilitates complete dissection of the ureter. For case 1, port position was more medial and caudad given the location of horseshoe kidney. The ureter was identified and dissected down to the bladder detrusor. Prior to excising the bladder cuff completely, a 3-0 V-loc suture was placed in the detrusor muscle to provide a handle of the bladder and ensure complete, watertight closure of the bladder. Bladder closure was then tested to 240 cc. For case 2 a double-J stent was placed endoscopically in the lower moiety ureter to allow differentiation between the two ureters prior to ureteral dissection and removal. Indocyanine green (ICG) with Near Infrared imaging (NIF) was utilized in both cases to allow vessel identification and ensure selective clamping of the arterial supply of both the left moiety of horseshoe kidney (case 1) or the upper moiety of the duplicated system (case 2). Intraoperative ultrasound was used to define the margin of resection in both cases allowing division of the isthmus (case 1) or the junction between upper/lower pole moieties (case 2). Renorrhapy was performed using a two layer closure technique with an inner layer and an outer layer using the sliding clip renorrhaphy technique. Retroperitoneal lymph node dissection was then performed with meticulous use of Hemo-lock clips to prevent lymphatic leak.
There were no complications for either case. Discharge was on POD1 and POD2 for patients 1 and 2, respectively. Pathology for case 1 was pT3N0 invasive papillary TCC with negative margins and case 2 was pTis/TaN0 high grade TCC with negative margins. Both patients are disease free and have good residual GFR after surgery (GFR 32 for patient 1 and GFR 33 for patient 2).
Robotic nephroureterectomy is a safe and feasible alternative to open or laparoscopic approach for management of UT-TCC. It allows complete removal of the distal ureter with bladder cuff in keeping with established oncologic principles. With surgeon experience, RNU can be applied to cases with complex renal anatomy.