Introduction
Upper tract urothelial carcinoma (UTUC) accounts for 5% to 10% of urothelial cancer, with approximately 60% muscle invasive at the time of diagnosis. Extirpative surgery, traditionally open nephroureterectomy, was considered the gold standard curative procedure. Robotic-assisted radical nephroureterectomy (RANU) has been shown to have equivalent oncological outcomes while benefiting from the advantages of minimally invasive surgery with reduced blood loss and shorter length of hospital stay. RANU also allows for more precise dissection of tissue planes for the distal ureterectomy and a wide bladder cuff for distal ureteric tumors when required. The surgeon can be confident that the whole length of the ureter is taken down to the bladder along with its opening into the bladder.
Transperitoneal
- 1.
Patient positioning lateral decubitus
- 2.
Open Hassan insertion of 8-mm robotic camera port, pneumoperitoneum, and visual port placement
- 3.
Bowel mobilization; identification of ureter and gonadal vessels with dissection toward renal hilum
Retroperitoneal
- 1.
Patient positioning lateral decubitus over operating table break
- 2.
Landmarks: twelfth rib and pelvic brim marked
- 3.
Infra–twelfth rib incision, balloon dilatation of retroperitoneal space, port placement
- 4.
Incision of posterior layer of Gerota fascia and identification of the ureter with dissection toward the renal hilum
Transperitoneal/retroperitoneal
- 1.
Gonadal vessel dissection and sparing medially
- 2.
Hilar dissection, isolating the renal artery(ies) and renal vein(s)
- 3.
Dissection and clipping of renal artery(ies)
- 4.
Dissection and clipping of renal vein(s)
- 5.
Complete mobilization of kidney within Gerota fascia and adrenal sparing dissection cranially
- 6.
Ureteric dissection along psoas to iliac crossing and mobilization of ureter to bladder cuff
- 7.
Ureteric excision with bladder cuff and two-layer bladder closure
- 8.
Bladder leak test, specimen placed in retrieval bag, low-pressure hemostasis (± drain placement), specimen bag delivered via iliac fossa port (transperitoneal) or camera port (retroperitoneal) incision extension, patient positioning neutralized on operating table, and closure.
Indications/contraindications
UTUC can present as either disease of the renal pelvis or proximal ureter, distal ureter, or panurothelial. Low-risk UTUC must include all of the following factors :
- •
Unifocal
- •
Tumor size less than 2 cm
- •
Low-grade cytology
- •
Noninvasive on computed tomography (CT) urography
- •
Low-grade ureteroscopic (URS) biopsy
In low-risk disease, consideration of kidney-sparing surgery, endoscopic management, segmental resection, or rarely a percutaneous approach may be offered. Other indications where one may wish to avoid a radical extirpative approach includes a solitary kidney, bilateral disease, palliation, renal insufficiency, high surgical risk, and patient preference.
Patients with high-risk tumors limited to the distal ureter may be offered a distal ureterectomy. This can be performed as an open, minimally invasive, or robot-assisted laparoscopic procedure. In all other cases, a RANU may be offered for UTUC.
Contraindications for RANU include invasive or large (T3/T4 and/or N1/M1) tumors because the oncological outcome is worse compared with an open approach.
Preoperative assessment
Older patients or those with significant comorbidities should undergo medical assessment and optimization of fitness and preparation for radical surgery.
Up to date staging investigations should be completed within 2 months of the date of surgery. This includes a complete staging narrow slice (2 mm) contrast-enhanced CT of the chest, abdomen, and pelvis for full staging, to exclude metastases, locally advanced disease, or involvement of hilar lymph nodes. A delayed urographic phase is essential to diagnose and characterize the renal pelvic or ureteric tumor. This often presents on CT as a filling defect. Sensitivity of UTUC on CT imaging is 92%. Multifocality of the tumor can also be reviewed because this will impact on surgical planning and potential approach.
Magnetic resonance urography (MRU) is indicated in those patients unable to undergo CT urography, usually when radiation or iodinated contrast media is contraindicated. MRU has a sensitivity of 75% after gadolinium contrast injection for tumors less than 2 cm.
Cystoscopic evaluation of the lower urinary tract is essential to rule out a concomitant urothelial tumor that would potentially alter the discussion with and management options for the patient. Abnormal cytology may indicate high-grade UTUC in the presence of a normal bladder cystoscopy with no evidence of bladder or prostatic carcinoma in situ.
Diagnostic URS ± biopsy using a semirigid and flexible ureterorenoscope to evaluate the ureter, renal pelvis, and collecting system allows the determination of the size, appearance, and volume of the tumor burden. Selective urine cytology may be used if imaging and cytology are not sufficient for the diagnosis and risk stratification of the tumor. Barbotage urine cytology has been shown to detect up to 91% of UTUC cancers, being as effective as biopsy histology.
Staging and risk categorization for surgical planning are performed with information from the radiological imaging, renal function, cytology, ureteroscopy, histopathology, and existing comorbidities. Any single risk factor outlined in Fig. 21.1 would result in high-risk stratification.
Stages of procedure
Theater setup, patient positioning, and robot docking
The setup of the robotic theater, along with positioning and da Vinci Xi robot docking for both the transperitoneal and retroperitoneal approach, is the same as for a robot-assisted radical/partial nephrectomy, as covered in previous chapters.
A 16-Fr two-way urethral catheter is inserted, 10 mL to the balloon, with a Y-connector to the outflow channel, allowing for a 0.9% normal saline 1 L bag to be attached to fill the bladder when required and a urometer outflow bag to measure urine output during the procedure.
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