Robot-Assisted Radical Nephroureterectomy

Efficacy and safety of robotic-assisted laparoscopic "one-step" radical nephroureterectomy and bladder cuff excision

OBJECTIVE

To investigate the effect and safety of robotic-assisted laparoscopic "one-step" radical nephroureterectomy and bladder cuff excision.

METHODS

The clinical data of 69 patients who underwent robotic-assisted laparoscopic "one-step" radical nephroureterectomy and bladder cuff excision at the Department of Urology, Zhongda Hospital, Southeast University, from January 2019 to June 2023 were retrospectively analyzed, and the surgical position, Trocar position, and key surgical steps were described, and the perioperative conditions, postoperative complications, and tumor recurrence rate at 1 year after the operation were also counted. The perioperative period, postoperative complications, and tumor recurrence rate at 1 year after surgery were also described.

RESULTS

All 69 surgeries were successfully completed, the operation time was (149.66 ± 30.10) min, the bleeding volume was (64.57 ± 23.49) mL; the drainage tube was removed in (3.12 ± 2.41) days, the average hospitalization days were (4.62 ± 2.10), and 8 patients had Clavien-Dindo grade II complications. During the follow-up period, 3 cases of tumor recurrence, 1 case of incomplete intestinal obstruction, and serum creatinine (102.96 ± 37.03) µmol/L were detected.

CONCLUSIONS

Robot-assisted laparoscopic "one-step" radical nephroureterectomy and bladder cuff excision has a good safety profile, which can effectively minimize the occurrence of postoperative complications, improve the prognosis and increase the survival rate of patients.

Trends, outcomes, and predictors of open conversion during minimally invasive radical nephroureterectomy for upper tract urothelial carcinoma: a national analysis from 2010 to 2020

We evaluated trends, predictors, and outcomes of unplanned open conversion for patients with upper tract urothelial carcinoma (UTUC) undergoing robotic radical nephroureterectomy (R-RNU) or laparoscopic RNU (L-RNU). The National Cancer Database was queried from 2010 to 2020 for patients with non-metastatic UTUC treated with RNU. Trends in surgical approach and conversion were evaluated. Demographics and outcomes including lymph node dissection, lymph node yield, positive surgical margins (PSM), prolonged length of stay (PLOS) (≥ 90th percentile), unplanned readmission (UR), and 30- and 90-day mortality were compared between converted and unconverted cases. Multivariate logistic regression evaluated predictors of conversion and whether conversion predicted adverse clinical outcomes. 25,523 cases were included (robotic = 40.4%, laparoscopic = 36.9%, open = 22.7%), where 3.2% and 9.2% of R-RNU and L-RNU cases were converted, respectively. From 2010 to 2020, robotic cases increased while open and laparoscopic approaches decreased, p < 0.001. A higher T-stage and a ureteral tumor site predicted conversion while a higher R-RNU and L-RNU facility volume, respectively, were protective against conversion, all p < 0.05. Compared to unconverted cases, conversion generally resulted in a higher rate of all adverse outcomes, and was predictive of 30-day mortality, PLOS, UR, and PSM, all p < 0.05. Conversion to open RNU is becoming less frequent but is more common with a laparoscopic approach. Oncologic complexity and facility surgical volume influence conversion rates which in turn are associated with higher rates of morbidity, mortality, and greater resource utilization when compared to unconverted cases.

Gold standard nephroureterectomy, chemoprophylaxis and surveillance in upper tract urothelial carcinoma

PURPOSE OF REVIEW

The purpose of this review is to summarize the most recent evidence on surgical management, strategies to reduce tumor recurrence, and surveillance regimens in patients diagnosed with upper tract urothelial carcinoma (UTUC) and elected for radical treatment.

RECENT FINDINGS

Minimally invasive surgery is gaining momentum in the surgical management of UTUC. Chemoprophylaxis is still the gold standard to reduce intravesical recurrence after radical nephroureterectomy (RNU). Novel surveillance strategies have been proposed to adapt follow-up regimens to patients' characteristics.

SUMMARY

Minimally invasive surgery has been associated with comparable oncological outcomes to the open approach while improving postoperative morbidity. In these cases, bladder cuff excision (BCE) is mostly performed by an extravesical approach, that demonstrates a noninferiority compared to the intravesical one in terms of oncological outcomes. Although lymphadenectomy is recommended in patients with high-risk tumors, its benefits are still unclear. Currently, there is a lack of recent prospective trials on chemoprophylaxis to reduce intravesical recurrence post RNU, making single-dose postoperative chemotherapy instillation the standard treatment. Although novel risk stratification models were released by international urological guidelines, their validity is mainly nonevidence-based. Risk-adapted follow-up strategies incorporating cystoscopy and cross-sectional imaging accounting for individual patient factors should be implemented.

Perioperative and oncological outcomes of distal ureter management during nephroureterectomy for upper urinary tract urothelial carcinoma: a systematic review and meta-analysis

INTRODUCTION

The best approach of the bladder cuff (i.e., transvesical, extravesical, endoscopic) during radical nephroureterectomy (RNU) remains an unsolved question. The aim of this review is to compare the oncological and perioperative outcomes among three different approaches of the distal ureter during RNU.

EVIDENCE ACQUISITION

A literature search was conducted through June 2022 using PubMed/Medline, Embase, and Web of Science databases. Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) guidelines were followed to identify eligible studies. The primary outcome was bladder recurrence-free survival and secondary outcomes included: perioperative outcomes, metastasis-free survival, and cancer-specific survival.

EVIDENCE SYNTHESIS

A total of 19 non-randomized studies comprising 6581 patients met our inclusion criteria. The risk of bladder recurrence, metastasis and cancer-related death did not differ significantly between each approach (all P>0.05). In subgroup analysis excluding patients with history of bladder cancer, the risk of bladder recurrence remained similar between each approach (all P>0.05). There was no significant difference in terms of operative time, estimated blood loss, length of hospital stay, and postoperative complications between each approach (all P>0.05). The main limitation is the retrospective design of 18/19 included studies.

CONCLUSIONS

The present systematic review and meta-analysis highlights the lack of high-level evidence on distal ureter management during RNU. On the basis of the available data, the present review supports the equivalence of different techniques of bladder cuff excision during RNU. The extravesical approach seems non-inferior to the transvesical approach in terms of oncological and perioperative outcomes.

Perioperative, renal function and oncological outcomes of robot-assisted radical nephroureterectomy for patients with upper tract urothelial carcinoma

PURPOSE

To report perioperative, renal function and oncological outcomes of robot-assisted radical nephroureterectomy (RNU) for patients with upper tract urothelial carcinoma (UTUC).

METHODS

This was a retrospective single-arm monocentric study including all consecutive UTUC patients treated with robot-assisted RNU at our institution between 2014 and 2022. Descriptive statistics with median and interquartile range (IQR) for continuous variables and numbers with frequencies for categorical variables were used to report perioperative and renal function outcomes while Kaplan-Meier curves were computed to present extravesical and intravesical recurrence-free survival(RFS) as well as cancer-specific (CSS) and overall survival (OS) with the corresponding 95% confidence intervals(CIs).

RESULTS

Overall, 70 patients with a median age of 69.6 [63.3-74.9] years were included in our study. With regards to perioperative outcomes, the median operative time was 157 [130-182] min with a median blood loss of 200 [100-300] cc. Intraoperative complications occurred in 4 (5.7%) patients but no conversion to open or laparoscopic surgery was required. Postoperative complications occurred in 9 (12.9%) patients, including 5 (7.1%) with grade ≥ 3 complications according to the Clavien-Dindo classification. The median length of stay was 4 [3-6] days. With regards to renal function outcomes, the median postoperative loss in estimated glomerular filtration rate at discharge was 16 [10.25-26] mL/min/1.73 m2. With regards to oncological outcomes, the 3-year extravesical and intravesical RFS, CSS and OS rates were 73.6 [62.8-86.2]%, 68.1 [54.6-85]%, 82.5 [72-94.4]% and 75.3 [63.4-89.5]%, respectively.

CONCLUSION

We report favorable perioperative and oncological outcomes with expected decrease in renal function after robot-assisted RNU for patients with UTUC.

Retroperitoneal Single-Port Robot-Assisted Nephroureterectomy with Bladder Cuff Excision: Initial Experience and Description of the Technique

BACKGROUND

With the introduction of the single-port (SP) robot, surgery that was difficult to attempt is becoming possible. Nephroureterectomy (NUx) for upper tract urothelial carcinoma also seems to be able to attempt a retroperitoneal (RP) approach.

PURPOSE

to investigate the feasibility of SP robotic RP NUx with bladder cuff excision.

DESIGN, SETTING, AND PARTICIPANTS

we sequentially analyzed 20 patients who underwent SP robot NUx from January 2021 to December 2022.

SURGICAL PROCEDURE

all patients were diagnosed with upper tract urothelial carcinoma (UTUC) and were operated upon by a single expert using the da Vinci SP platform (Intuitive Surgical, Sunnyvale, CA, USA) with retroperitoneal approach.

RESULTS AND LIMITATIONS

A total of 20 patients underwent SP robotic NUx with bladder cuff excision. The mean age of patients was 69.45 ± 8.68 years, and the mean body mass index (BMI) was 25.37 ± 3.00 kg/m2. The mean tumor size was 2.42 ± 1.03 cm on a CT scan, with right-sided tumors in eight patients (40%) and left-sided tumors in 12 patients (60%). The median console time was 106 min and 40 s, and the expected blood loss was 122.50 ± 75.18 mL. Final pathology showed that all of the patients were diagnosed as having urothelial carcinoma; one patient was classified as Ta (5.00%), three patients were classified as T1 (15.00%), seven patients were classified as T2 (35.00%), eight patients were classified as T3 (40.00%), and one patient was classified as T4 (5.00%). None of these 20 patients showed any complications based on the Clavien-Dindo scale.

CONCLUSIONS

SP robotic NUx using a retroperitoneal approach provides feasible perioperative and postoperative outcomes for UTUC.