What are the steps of robotic nephroureterectomy (removal of the kidney and ureter using a robotic system)?

Robotic Nephroureterectomy: Surgical Steps

Robotic nephroureterectomy (RNU) for upper tract urothelial carcinoma involves six main procedural steps performed according to strict oncologic principles: nephrectomy, ureterectomy, bladder cuff excision, cystorrhaphy, template-based lymph node dissection when indicated, and perioperative chemotherapy instillation. 1

Fundamental Oncologic Principles

Before detailing the steps, the procedure must adhere to these critical principles to prevent tumor seeding 2:

• Perform en bloc removal of the kidney, ureter, and bladder cuff 2
• Avoid entry into the urinary tract except during bladder cuff excision, and only after prior clipping of the ureter and complete bladder drainage 2
• Achieve negative surgical margins in all cases 1

Patient Positioning and Port Placement

Modified flank position is utilized, with strategic port placement allowing access to kidney, ureter, and bladder without patient repositioning 3, 4. This represents a key technical advancement over earlier techniques requiring intraoperative repositioning.

Step-by-Step Surgical Technique

Step 1: Nephrectomy

• Mobilize the kidney using standard robotic techniques with the second robotic arm holding the scope, fourth arm with monopolar curved scissors, first arm with fenestrated bipolar forceps, and third arm with Prograsp forceps 3
• Identify and ligate the renal hilum early in the procedure 4
• Immediately clip (but do not divide) the ureter after hilar ligation to minimize tumor seeding risk from kidney manipulation 4

Step 2: Ureterectomy

• Perform wide dissection of the ureter to avoid positive margins or ureteral entry, particularly crucial for ureteric tumors 4
• Maintain the ureter intact until bladder cuff excision to prevent tumor spillage 4
• For distal ureteral tumors, use a Bugbee electrode to cauterize and mark the ureteral orifice transurethrally, aiding in subsequent robotic excision 3

Step 3: Bladder Cuff Excision

Multiple approaches exist (extravesical, intravesical, transvesical), with no data suggesting superiority of one over another 1. The intravesical robotic approach offers distinct advantages:

• Place bladder stay sutures lateral to the ureterovesical junction to prevent bladder retraction once the cuff is excised 4
• Perform bladder clamshell incision in a coronal orientation at the dome 5
• Excise the distal ureter and bladder cuff completely—incomplete excision leads to worse oncologic outcomes and inferior cancer-specific survival 1
• Several simplified techniques (pluck technique, stripping, transurethral resection of intramural ureter, intussusception) have been considered, but no convincing evidence supports these as equal to complete bladder-cuff excision 2

Step 4: Cystorrhaphy

• Close the bladder defect in a watertight fashion after cuff excision 1
• Ensure complete bladder drainage was achieved prior to cuff excision 2

Step 5: Template-Based Lymph Node Dissection

• Perform template-based LND in all patients with high-risk disease, as it may improve cancer-specific survival and reduce local recurrence risk 2
• LND templates vary according to primary tumor location 2
• LND is probably unnecessary in patients with Ta/T1 UTUC, though preoperative staging is often inaccurate 2
• The completeness of dissection and adherence to templates likely has greater impact on survival than the absolute number of nodes removed 2

Step 6: Robotic Arm Reconfiguration (When Needed)

For procedures requiring repositioning of robotic arms between nephrectomy and bladder cuff excision 3:

• Release and reconfigure all robotic arms after completing nephrectomy
• Switch the third and second robotic arms between camera port and fourth port
• Maintain first port with monopolar curved scissors
• Move Prograsp forceps to second port and fenestrated bipolar forceps to third port

Technical Innovations

The da Vinci Xi system enables completion of both nephrectomy and distal ureterectomy/bladder cuff excision without patient or trocar repositioning 3. Alternatively, a completely retroperitoneal approach using unique port placement and two-step docking without robot relocation has been described, avoiding entry into the abdominal cavity entirely 6.

Critical Pitfalls to Avoid

• Never divide the ureter before bladder cuff excision to prevent tumor spillage 4
• Avoid inadequate bladder cuff excision, as this directly compromises oncologic outcomes 1
• Do not enter the urinary tract during dissection except during planned bladder cuff excision 2
• Be aware that robotic RNU carries higher risk of intravesical recurrence compared to open or laparoscopic approaches, though other oncologic outcomes remain equivalent 2

Perioperative Outcomes

Expected outcomes include 3, 4, 6:

• Console time: 140-184 minutes
• Estimated blood loss: 100-300 mL
• Hospital stay: 2.7-5.4 days
• Low complication rates with proper technique