Single-docking transperitoneal robotic-assisted nephroureterectomy: surgical techniques and outcomes

Objective To introduce and discuss the efficacy of a new technique to perform transperitoneal single-docking robot-assisted laparoscopic nephroureterectomy (RNU). Methods A total of 44 patients diagnosed with urothelial neoplasm of the renal pelvis or were investigated from January 2016 to November 2019. RNU was performed by a single surgeon. Among the 44 patients, 31 were male, and 13 were female. The median age was 63 (IQR: 58-71). The median body mass index (BMI) was 23.08 (IQR: 21.55-24.60) kg/m2. All operations were performed with general anesthesia. The patients were positioned 80 degrees flank with the diseased side up, and the head was tilted 10 degrees downwards. The camera port was placed one finger lateral to the umbilicus. For the right-sided tumors, robotic arm 1 was inserted through the trocar on the right pararectus line, 8 cm above the umbilicus, and robotic arm 2 was inserted through the trocar on the same line, 8 cm below the umbilicus. Assistant trocar 1 was placed where the anterior midline joins the perpendicular bisector of the camera port and robotic 2, and assistant trocar 2 was placed below the xiphoid process. For the left-sided tumors, all trocars were centrosymmetric to that of the right-sided tumors, except that assistant port 2 was placed 3 finger width above the pubic symphysis. The peritoneum was incised along the Toldt line, and the inferior vena cava was isolated (for left sided tumor, the abdominal aorta was isolated instead). The renal artery and vein were clipped with Hem-o-lok and ligated, and the kidney were isolated. The ureter was identified and isolated downwards across the common iliac artery and then clipped distal to the tumor site. The bladder cuff was resected and sutured under the laparoscopy. Results The median operation time was 145 (IQR: 130-175) min, with the median console time of 119 (IQR: 108.5-136.0) min, the anastomosis of bladder cuff of 12 min, and the median estimated blood loss of 50(20-100)ml. After the surgery, 6 Clavien-Dindo grade 2 complications occurred, including 2 chylous leakage, 1 hemostasis, 1 blood transfusion, 1 deep vein thrombus, and 1 acute coronary syndrome. The median length of stay (LOS) was 8 (IQR: 6.5-10.0) d. The median length of follow-up was 12 months. In total, 5 patients were dead, including 3 cancer-specific death. Four recurrence occurred and caused 3 death. The 2-year overall survival and progression-free survival were 68.2% and 77.9%, respectively. Conclusions The technique of RNU with simultaneous bladder cuff excision (BCE). Our technique improved the surgical outcome. The perioperative complication rate was low, and the short-term survival outcomes were satisfactory. Key words: Ureteral neoplasms; Upper tract urothelial carcinoma(UTUC); Nephroureterecto-my; Robotic surgery; Laparoscopic surgery