V1-06: Robotic-assisted laparoscopic stump ureterectomy with partial cystectomy
Urothelial cell carcinoma of the ureteral stump after radical nephrectomy for renal cell carcinoma is rare. There are limited case reports on the subject and a paucity of reports on minimally invasive approaches for a completion ureterectomy. To the authors' knowledge, there are no reports of a robotic approach to the surgery. Here we present a video of a robotic-assisted laparoscopic stump ureterectomy.
An 86 year old male presented with gross hematuria 5 years after a radical right nephrectomy for papillary renal cell carcinoma performed at an outside institution. On cystoscopy, he was found to have a papillary bladder tumor overlying the right ureteral orifice and retrograde pyelogram demonstrated multiple filling defects of the ureteral stump. MRI demonstrated a thickened remnant ureter without any apparent pelvic lymphadenopathy. Decision was made to undergo a robotic-assisted laparoscopic right stump ureterectomy with partial cystectomy.
Port placement resembled our usual placement for robotic prostatectomy. A 12 mm camera port was placed at the umbilicus and three 8 mm robotic trocars were placed - two in the left lower quadrant and one in the right. A 12 mm assistant port was placed between the right robotic port and the umbilicus. Extended right pelvic lymph node dissection was performed. The ureteral stump was identified with prior clip just inferior to the iliac vessels and dissected free. Dissection boundaries were guided by recognizing non-desmoplastic tissue planes to ensure clear margins. A wide bladder cuff was scored and partial cystectomy performed. Cystotomy was closed in 2 layers with running barbed absorbable 3-0 sutures. A drain was placed. Operative time was 188 minutes and estimated blood loss was 25 cc despite the patient requiring full dose aspirin. The patient had an uneventful hospital course and was discharged post-operative day 2. Pathology revealed pT2N0 high grade urothelial cell carcinoma with negative surgical margins. One week postop, CT cystogram demonstrated no extravasation and the foley was removed. At 6 month follow-up, the patient did not experience any increased irritative voiding symptoms and cystoscopy demonstrated no recurrence.
Robotic-assisted laparoscopic stump ureterectomy is a safe and feasible approach to an uncommon clinical situation following radical nephrectomy. We advise a wide bladder cuff for adequate margins as peri-ureteral bladder muscle invasion may be difficult to discern preoperatively.