Nephroureterectomy (NU) with bladder cuff excision is the gold standard treatment option for high grade and/or large volume upper tract urothelial cancer (UTUC). NU can be accomplished with an open approach as well as pure laparoscopy, hand-assisted laparoscopy, hybrid robotic-laparoscopy, robot-assisted laparoscopy and even extraperitoneal laparoscopy.

Many surgical concepts remain from a traditional open approach; however, new technologies and operative techniques have emerged. Recent systematic reviews concluded that robot-assisted radical NU has superior outcomes compared to open and laparoscopic approaches with respect to blood loss and length of stay without any significant differences in oncologic control (although long-term data are still lacking).^1,2

In this article we focus specifically on technical “tips and tricks” for robot-assisted laparoscopic NU as this approach has gained more traction in recent years. We will discuss recommendations using the da Vinci Xi^® robotic platform and organize our discussion into 2 parts: patient positioning and port placement, and management of the distal ureter, bladder cuff and lymphadenectomy.

Patient Positioning and Port Placement

As with any robotic surgery, patient positioning and port placement are crucial to an efficient operation. Several institutions have reported their experience with single docking for robotic NU.^3,4 The authors find that over 75% of the time, a single docking position at approximately 90 degrees to the operating table is sufficient to complete the entire operation. However, in patients with a deep pelvis or difficult body habitus, dedicating 5 to 10 minutes for distinct positioning and robotic docking for the “pelvic” (3–4 cm proximal to the ureteral crossing over the iliac vessels to the bladder cuff) and “retroperitoneal” (kidney to 3–4 cm proximal to the ureteral crossing over the iliac vessels) portions of the case may facilitate efficient operative progression. Decisions on single versus double docking and the sequence of pelvic versus retroperitoneal dissection are governed by surgeon preference and patient characteristics. For illustrative purposes, we will consider a right robotic NU for this discussion.

For initial positioning (both single and double docking) we mark the patient’s midline for proper orientation, then place the patient in a modified flank position (roughly 30 degrees for a nonobese patient, but closer to 90 degrees with increasing obesity). The 8 mm robotic trocars should be placed in a roughly straight line with the most cephalad (right working arm) at a point just below the costal margin in a paramedian location and the most caudal (4th arm) close to the midline. This would resemble a standard robot-assisted laparoscopic nephrectomy with slight angulation toward the pelvis. Full port placement is shown in figure 1. It is essential to perform a tilt test in all predicted intraoperative positions to ensure patient safety throughout the case.

Figure 1. Modified right flank position for renal portion with port placement. Estimated location of right kidney and 11th/12th ribs are marked. Port placement from left to right: “4” is fourth robotic arm (da Vinci ProGrasp™), “L” is left working arm (bipolar forceps), “C” is robotic camera, “R (with circle)” is right working arm (scissors or needle driver), “A” is 12 mm assistant port (can utilize AirSeal® if available), “L (with circle)” is liver retractor (for right side only).

The majority of the time, the use of a moderate Trendelenburg position with modified flank position is adequate for bowel retraction for the entire operation when utilizing the single docking technique. However, in patients with abundant intraperitoneal/mesenteric fat, with bowels impeding adequate visualization, or based on surgeon preference, a double docking technique may be used. For the pelvic portion, the patient would be “airplaned” to the right to achieve a more neutral axial position. The patient would then be put in a steeper Trendelenburg position (roughly 26–28 degrees), as if performing a robotic prostatectomy, to maximize exposure of pelvic anatomy (fig. 2).

Figure 2. Patient positioning and port placement for “pelvic” portion of right robotic NU for double docking technique.

Figure 3. Patient positioning and port placement for “retroperitoneal” portion of right robotic NU for double docking technique.

When utilizing double docking for the retroperitoneal portion, the patient should be “airplaned” to the left until the abdominal wall nearly reaches a perpendicular angle with the floor to optimize medial displacement of the colon and to facilitate kocherization of the duodenum (fig. 3). This positioning is nearly identical to performing a robotic radical nephrectomy.

Management of Distal Ureter and Bladder Cuff

The robotic platform optimizes distal ureteral and bladder cuff dissection, given the small geometric space in the pelvis. First, we recommend early clipping of the ureter distal to the tumor, if possible, to prevent anterograde seeding of tumor cells from proximal upper tract dissection. A vessel loop around the ureter minimizes trauma during ureteral dissection. Once the distal ureter is adequately dissected, we distend the bladder with intravesical instillation of roughly 200 to 300 cc normal saline.

Figure 4. Bladder cuff management. A, 3-zero V-lock suture at 12 o’clock position for holding stitch. B, tacking of holding stitch to anterior abdominal wall. C, excision of bladder cuff posterior to preplaced holding stitch.

The bladder cuff should be opened with cold scissors from the 10 o’clock to 2 o’clock position. We use a 3-zero V-lock suture on a GS-21 needle as a full-thickness holding stitch incorporating both the detrusor and mucosal layers (later used for cystorrhaphy). We then tack this holding suture to the anterior abdominal wall with appropriate tension. Excision of the bladder cuff is completed using a gentle spread with the 4th arm to expose the bladder cuff and utilization of the left working arm to dynamically toggle the distal ureter and/or apex holding stitch to gain favorable traction/countertraction for cuff excision (fig. 4).

After single layer bladder cuff closure and testing for watertight integrity, instillation of an approved chemotherapeutic agent such as mitomycin C or gemcitabine should be performed. Use of gemcitabine is preferred at our institution, given the significant cost advantages ($36.90 per instillation for gemcitabine versus $1,068 for mitomycin C).⁵ We use gemcitabine (2 gm/100 cc saline) with a dwell time of 60 minutes.

Gemcitabine solution is instilled under gravity through an 18Fr 3-way Foley catheter with a Toomey syringe, the Foley clamped just proximal to port trifurcation, 1 L normal saline is attached to the inflow port (clamped), and the drainage bag is attached to the outflow port to maintain a closed loop system. After 60 minutes of dwell time, the Kelly retractor is removed, the gemcitabine is passively drained, 1 L normal saline rinses the bladder and the Foley catheter is subsequently removed. This can be easily performed in the operating room or by the nursing staff in the recovery area.

Lymphadenectomy should be performed as clinically indicated for high grade disease and should be template-based according to tumor laterality and location (renal pelvis versus upper two-thirds of the ureter versus lower third of the ureter). As retrospective data have suggested, the number of nodes removed is an independent predictor of cancer-specific mortality and overall survival (at least 8 nodes should be removed to increase the likelihood of achieving true pN0 status).⁶ Overall, we believe that a robotic approach to lymphadenectomy offers superior visualization and ergonomics compared to an open approach or traditional laparoscopy. Care must be taken to avoid excessively lateral port placement to facilitate medial dissection around the great vessels. Robotic clip appliers can be utilized to occlude lymph channels.

In summary, a robot-assisted laparoscopic approach should be considered by an appropriately trained urological surgeon for successful completion of NU in a well-selected patient. These tips and tricks should optimize technical efficiency.