V2162: Robotically-Assisted Laparoscopic Nephroureterectomy without Robot Redocking or Changes in Patient Positioning
VideoIntroduction and Objectives
In recent years, laparoscopic and robotic nephroureterectomy has become the preferred, less invasive procedure utilized in the surgical treatment of high-grade upper tract transitional cell carcinoma (TCC). Multiple techniques have been described for the excision of the distal ureter and the bladder cuff. We describe our technique of robotically assisted laparoscopic nephroureterectomy without robot redocking or repositioning of the patient.
A 12-mm camera port is placed at the level of the 11th rib and just medial to the lateral edge of the rectus muscle. At the same level as the camera port, an 8-mm robotic port and a 12-mm assistant port are placed in the epsilateral lower quadrant. A 5-mm assistant port and an 8-mm robotic port are placed in the epsilateral upper quadrant, at the same level as the previously placed ports. The table is placed in the Trendelenberg position and the robot is docked at a 90 degree angle to the patient. The kidney and ureter are dissected down to and through the bladder detrusor muscle. Prior to excising the bladder cuff, two 3-0 Vicryl sutures are placed, one laterally and the other medially. The distal ureter along with a bladder cuff are excised. The bladder defect is then closed from each end by running the two sutures towards each other and then tying them together. The total intact nephroureterectomy specimen is delivered through a specimen bag and removed through a Pfannenstiel incision. Retrospective data analysis was performed of all cases for which this technique was performed.
Between April 2010 and October 2012, 14 patients underwent the above procedure. Median age was 79 (interquartile range (IQR) 71-83) and median BMI was 24 Kg/m2 (21.2-27.9). Median estimated blood loss (EBL) was 175 mL (100-263) and median operative time was 4.29 hours (3.46 – 4.50). Six patients (43%) underwent a regional lymphadenectomy. Two patients had minor post-operative complications and median hospital stay was 5 days. Four patients had low-grade TCC and nine patients had high-grade TCC. No positive lymph nodes were identified in patients who underwent lymphadenectomy. No positive margins were identified.
Specific trocar, patient, and robot positioning as those presented allow the surgeon to perform a robotically assisted laparoscopic nephroureterectomy without having to undock and redock the robot or reposition the patient. This may decrease operative time as will as minimize the complexity of the procedure.