Robotic Surgery for

Upper Tract Urothelial Carcinoma

Li-Ming Su, MD David A. Cofrin Professor of Urology, Associate Chairman of Clinical Affairs, Chief, Division of Robotic and Minimally Invasive Urologic

Surgery, University of Florida College of Medicine; Gainesville, Florida

Objectives: • Describe the indications and contraindications for robotic surgery

for upper tract urothelial carcinoma • Outline operative setup and surgical steps for robotic

nephroureterectomy with regional lymphadenectomy • Discuss the operative setup and surgical steps Psoas hitch and

ureteral reimplantation • Review the published literature on robotic surgery for upper tract

urothelial carcinoma as compared to conventional laparoscopic surgery

Robotic Surgery for Upper Tract Urothelial Carcinoma

Li-Ming Su, M.D.David A. Cofrin Professor of Urology

Chief, Division of Robotic and Minimally Invasive Urologic SurgeryDepartment of Urology

University of Florida College of Medicine

U N I V E R S I T Y of

FLORIDA UFThe Foundation for The Gator Nation

Is The Robot Necessary?

vs.

Laparoscopy Robotic Surgery

• Not necessary for experienced laparoscopists• Surgeons with limited laparoscopic experience• Expansion of robotic practice and offerings• Stepping stone towards robotic partial NTx

Indications and ContraindicationsIndications:• Same as open or laparoscopic

surgery

• Endoscopic or biopsy proven upper tract TCCa

• Normal contralateral kidney and renal function

Contraindications:• Contraindication to laparoscopy

• ?Evidence of regional spread (e.g. N+ disease) consider chemo

Robotic NUx: General Principles

• 3-armed robotic technique• Single patient positioning• Single trocar configuration (4 trocars)• For NUx:

– Two robot docking setup• nephrectomy • distal ureterectomy and bladder cuff

– Extravesical approach to bladder cuff– Single cystotomy

Operative Steps: RANUx

• Step 1: Dock robot 45o angle from the head of OR table

• Step 2: Mobilize of ipsilateral colon

• Step 3: Clip ureter beneath lesion

• Step 4: Dissect renal hilum

• Step 5: Transect renal artery and vein

• Step 6: Complete mobilization of kidney

• Step 7: Perihilar lymphadenectomy

• Step 8: Dissect ureter as far distally as possible

Operative Steps: RANUx (cont.)

• Step 9: Instill intravesical mitomycin C

• Step 10: Re-dock robot at 45o angle from the foot of OR table

• Step 11: Mobilize ipsilateral bladder

• Step 12: Dissect out ureterovesical junction; drain bladder

• Step 13: Excise bladder cuff and close cystotomy

• Step 14: Pelvic lymphadenectomy

• Step 15: Entrap specimens and place drain

Trocar Configuration: Nephrectomy

5 mm liver retractor (optional)

12 mm assistant trocar

• Robot is docked at a 45o angle from the head of the bed

Instrumentation: RANUx

Endoscope • 30 degree down lens

Left robotic arm • Maryland bipolar forceps

Right robotic arm • Monopolar curved scissors

Assistant • Suction-irrigator• Clip applier• EndoGIA linear stapler• Ligasure• Specimen entrapment bag

Dissection of Renal Hilum

ureterclipped

Transection of Renal Vessels

Perihilar Lymphadenectomy

Trocar Configuration: Bladder Cuff

New assistant trocar

8-12 mm hybrid robotic trocar

8-13 mm Robotic Convertible Trocar

Avoids capacitance coupling

• Robot is re-docked at a 45o angle from the foot of the bed

Pelvic Lymphadenectomy

Dissection of Ureterovesical Junction

Excision of Bladder Cuff

Instrumentation: Cystotomy Closure

Endoscope • 30 degree down lens

Left robotic arm • Needle driver

Right robotic arm • Needle driver

Assistant • Suction irrigator• Ligasure• Clip applier• Lap needle driver

Sutures

Bladder mucosa 3-0 polyglactin SH (8 inches)

Bladder muscularis propria 2-0 polyglactin UR6 (8 inches)

2-layered Closure of Cystotomy

Specimen Extraction Sites

Drain Drain

Case Presentation

CT Scan

Left lower pole filling defect

Flexible Ureteroscopy

• Multiple papillary tumors

• Biopsy: High grade urothelial carcinoma

Video: Robotic Nephrectomy

Video: Robotic Distal Ureterectomy and Bladder Cuff

Perioperative Data

• Total OR time: 4 hours

• EBL: Minimal

• LOS: 2 day

• Complications: none

• Pathology: – pT2N0Mx, high grade

urothelial carcinoma of renal pelvis

– 11 nodes negative for tumor

– Margins free of tumor

Pugh J, Stifelman M, Hemal A and Su LM BJU Int, 2013

Robotic NUx: Published Series

Study Technique NOR Time

(min)EBL(mL)

LOS(days)

Park et al.2009

RANUx 11 247 106 7

Eandi et al.2010

RANUx 11 326 200 5

Hemal et al.2011

RANUx 15 184 103 3

Su , Hemal, Stifelman, 2013

RANUx 43 249 133 3

Berger et al.2008

Lap NUx 100 182 248 4

Wolf et al.2005

HAL NUx 53 279 330 4

Pugh J, Stifelman M, Hemal A and Su LM BJU Int, 2013

Mean LN count: 11 (4-23)

Pathologic Outcomes

Pugh J, Stifelman M, Hemal A and Su LM BJU Int, 2013

Complications

• 1 tx for postop bleed Grade II• 2 postop pneumonia Grade II• 1 TB for splenic bleed Grade IV• 2 transient rhabdomyolysis Grade II, IV

Video: Robotic Psoas Hitch

pubis

umbilicus

assistantport

• Robot is docked between the legs

Instrumentation: Robotic Psoas Hitch

Endoscope 0 or 30 degree down lens

Left robotic arm Maryland bipolar forceps

Right robotic arm • Monopolar curved scissors• Monopolar hook

Assistant • Suction-irrigator• Clip applier• Ligasure• Specimen entrapment bag

Sutures

Cystotomy closure: mucosa 3-0 polyglactin SH (8 inches)

Cystotomy closure: muscularis propria

2-0 polyglactin UR6 (8 inches)

Psoas hitch 0 prolene (8 inches)

Ureteral reimplantation 4-0 polyglactin RB1 (8 inches)

ConclusionsRobotic nephroureterectomy and distal ureterectomy

– Easy techniques to adopt esp. for experienced robotic teams

• Simplifies bladder cuff dissection

• Avoids a second cystotomy

• Favorable ergonomics esp. suturing as compared to laparoscopic

– May serve as a stepping stone towards performing robotic partial NTx

– Similar perioperative outcomes to conventional laparoscopic techniques

– Longer oncologic followup required

Thank You