robot-assisted surgery for upper tract urothelial carcinomaureterectomy is a viable alternative.20...

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Robot-Assisted Surgery forUpper Tract Urothelial
Carcinoma Eric M. Lo, BSa, Hyung L. Kim, MDb,*
KEYWORDS

� Cancer � Transitional cell carcinoma � Urothelial carcinoma � Upper tract � Robotic surgery� Ureterectomy

KEY POINTS

� Upper tract transitional cell carcinoma is a rare malignancy for which surgery is the only definitivetreatment.

� Robot-assisted surgery provides a minimally invasive approach and has become more popular inrecent years.

� Robot-assisted techniques for upper tract urothelial carcinoma seem to have similar outcomes toopen and laparoscopic approaches.

� For select ureteral cancers, the involved kidney can be spared by performing robot-assisted distalureterectomy or segmental ureterectomy.

INTRODUCTION AND BACKGROUND categories, with each category representing an

Upper tract urothelial carcinoma (UC), alsoreferred to as upper tract transitional cell carci-noma, is a rare disease that makes up approxi-mately 5% of all UCs and less than 5% to 7%of all renal tumors.1 Upper tract UC is two timesmore common in men than in women and iscommonly diagnosed in the eighth decade oflife.2 The disease is often multifocal at presenta-tion because the entire urothelial surface hasbeen exposed to urinary carcinogens resulting ina “field cancerization” effect.3 Staging of uppertract UC is based on the tumor, node, metastasis(TNM) system.4 In the eighth edition of the stagingsystem, stage IV cancers have metastasized tothe lymph nodes or distant sites.5 Lower stagesare categorized by the invasiveness of the pri-mary tumor. Stage 0a and 0is refer to tumorsthat are papillary and noninvasive carcinoma(Ta), and carcinoma in situ (Tis), respectively.Stages 1 to 3 correspond to T1, T2, and T3 tumor

a Baylor College of Medicine, 1 Baylor Plaza, Houston,West Third Street, Los Angeles, CA 90048, USA* Corresponding author.E-mail address: [email protected]

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increase in tumor invasiveness. Survival corre-lates with tumor stage at diagnosis, with 5-yearsurvival rates of 100% for stage Ta and Tis versus41% for stage T3 disease.6 Surgery is consideredthe only definitive treatment for upper tract UC.Historically, open nephroureterectomy wasconsidered the treatment of choice. However,technological developments have ushered innewer, minimally invasive techniques, such aslaparoscopic nephroureterectomy and robot-assisted laparoscopic nephroureterectomy. Clay-man and colleagues described the first laparo-scopic nephroureterectomy in 1991, andsubsequent reports demonstrated comparableoncologic outcomes with reduced morbiditywhen compared with open surgery.7,8,9 The firstrobot-assisted nephrectomy was reported in2000, and the robotic platform rapidly grew inpopularity for numerous urologic procedures inthe following two decades.10,11 Robot-assistednephroureterectomies demonstrated comparable

TX 77030, USA; b Cedars-Sinai Medical Center, 8635

urologic.th

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clinical outcomes to laparoscopic and open ap-proaches, and were also associated with theshortest hospital stays.12 Increased use ofrobot-assisted surgeries can be attributed toimproved dexterity provided by the da Vinci surgi-cal system (Intuitive Surgical, Sunnyvale, CA),increased use of minimally invasive techniquesin training programs, and increased availabilityof the robot platform.13 Techniques, such asdistal ureterectomy with ureteral reimplant, whichhas the advantage of sparing both kidneys, canbe performed using the robotic platform.Segmental ureterectomy with primary ureteroure-terostomy is an additional method of managingupper tract UC and also can be performed robot-ically. Compared with open surgery, robot-assisted surgery offers the advantage ofimproved cosmesis and shorter recovery.14

OUTCOMES

Historically, open radical nephroureterectomy wasconsidered the gold standard for definitive treat-ment of upper tract UC.15 Technological develop-ments led to laparoscopic and robot-assistedtechniques in the management of upper tractUC. With the increased dexterity offered by theda Vinci surgical system, minimally invasive ap-proaches have become more widely available.Although the robotic approach has not been eval-uated in prospective, randomized trials, retrospec-tive data show cancer control outcomes that aresimilar to open and laparoscopic approaches.Clements and colleagues12 performed a compara-tive survival analysis of 3801 patients undergoingrobot-assisted versus laparoscopic or open sur-gery for upper tract UC and found that robotic sur-gery was associated with the shortest length ofhospital stay with no difference in readmissionrates, overall, or cancer-specific survival (CSS)rates. De Groote and colleagues16 performed aretrospective review from three high-volume cen-ters for robotic surgery and assessed periopera-tive, pathologic, and oncologic outcomes. Theyconcluded that robot-assisted nephroureterec-tomy is safe and feasible, has low postoperativemorbidity, is rarely associated with major compli-cations, and has acceptable oncologic out-comes.16 Lenis and colleagues17 identified 3116patients in the National Cancer Database and eval-uated whether choice of surgical approach hadany effect on decision to perform lymph nodedissection, lymph node yield, and overall survival.The authors concluded that compared with opennephroureterectomy, robot-assisted nephroure-terectomy did not compromise performance of alymphadenectomy and that robot-assisted

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nephroureterectomy may actually be associatedwith improved lymph node yield.17

Robotic surgery provides dexterity to performminimally invasive reconstructive surgeries thatcan preserve the kidney. Therefore, it is relevantto review the data supporting the safety and effi-cacy of kidney-sparing surgeries, such as distalureterectomy with ureteral reimplant andsegmental ureterectomy with primary ureteroure-terostomy. Fukushima and colleagues18 retro-spectively reviewed a multi-institution databaseof 1329 patients treated for upper tract UC andfound that there was no statistically significant dif-ference in CSS and recurrence-free survival be-tween the distal ureterectomy andnephroureterectomy, even when patients werestratified by tumor stage. Dalpiaz and colleagues19

performed a retrospective chart review of 49 pa-tients who underwent distal ureterectomy and 42patients who underwent radical nephroureterec-tomy. Notably, both high- and low-grade cancerswere represented in both treatment groups. Theauthors found that CSS and recurrence-free sur-vival at 5 years did not differ significantly betweenthe two groups. Jeldres and colleagues20

compared the outcomes of segmental ureterec-tomy with nephroureterectomy in an analysis of2044 patients and found no significant differencesin cancer-specific mortality rates at 5 years.Seisen and colleagues21 performed a meta-analysis comparing segmental ureterectomy withnephroureterectomy and found no significant dif-ferences in CSS between the two groups at3 years, 5 years, or last follow-up.

PREOPERATIVE WORK-UP

Patients with upper tract UC often present with he-maturia as the first clinical sign of disease, withgross or microscopic hematuria found in 70% to80% of patients at time of diagnosis. Flank painsecondary to ureteral obstruction caused by amass is another common presenting symptomand occurs in approximately 20% of patients.22

Physical examination may reveal a flank mass ina rare cases. Imaging is critical to diagnosing up-per tract UC. Computed tomography urographyis the most accurate imaging technique for diag-nosing upper tract UC with a reported sensitivityof 0.97 and specificity of 0.93.23 In patients whocannot undergo computed tomography, MRI canbe performed. The sensitivity of magnetic reso-nance urography is 0.75 for detecting tumorsless than 2 cm.22 Urine cytology and cystoscopyprovide additional means of evaluating the urothe-lium. Positive urine cytology with negative cystos-copy is highly suggestive of upper tract UC and

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Fig. 1. Positioning of patient on table for robot-assisted nephroureterectomy.

Robot-Assisted Surgery 73

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further evaluation with upper tract imaging is crit-ical. However, it is important to keep in mind thatcytology from the bladder is less sensitive for up-per tract UC when compared with UC of thebladder, andMesser and colleagues24 recommen-ded that when upper tract UC is suspected,cytology be performed using samples obtaineddirectly from the renal cavities. Fluorescence insitu hybridization is commonly used in the diag-nosis of bladder cancer, but like urine cytology,has a limited role in upper tract UC. Diagnosticureteroscopy provides direct visualization and al-lows for sampling from the renal pelvis for urinecytology. Furthermore, flexible ureteroscopy al-lows biopsies to be taken from suspicious lesionsand is critical in diagnosing upper tract UC. Whenconsidering kidney-sparing surgery for ureteralcancer, it is critical to visually inspect the uppertract and ensure that there is no visible diseasein the portion of the urothelial being spared.

Following appropriate clinical assessment anddiagnosis, the urologist must decide on theoptimal treatment strategy. Surgery is the onlydefinitive treatment for nonmetastatic upper tractUC and open, laparoscopic, and robot-assistedapproaches have all been found to be equallyeffective for controlling the cancer.12 Althoughnot the focus of this article, ablative therapiesare appropriate for some small UCs. Comparedwith open surgery, minimally invasive techniquesresult in lower morbidity, but the use of thesetechniques ultimately depends on surgeon exper-tise. Nephroureterectomy has long been the goldstandard. However, in carefully selected patientswith disease localized to the ureter, segmentalureterectomy is a viable alternative.20 Distal ure-terectomy with reimplantation of the ureter isideal for patients with low-grade disease in thedistal ureter. Overall, kidney-sparing surgeryshould be strongly considered in patients withnormally functioning kidneys with low-grade dis-ease, or in patients with solitary kidney and/orimpaired renal function.

Ureteral stents can promote periureteral inflam-mation, making surgery more challenging. There-fore, if a ureteral stent is present, it can beremoved 3 to 7 days before the procedure; howev-er, in patients with symptomatic ureteral obstruc-tion this may not be possible. A urine cultureshould be strongly considered preoperatively andculture-specific antibiotics given at least 3 to5 days before surgery, because these patientsare more susceptible to becoming septic duringthe perioperative period. Historically, bowel prep-aration to decompress the colon was routinelyperformed; however, the surgery can be safelyperformed without a formal bowel preparation.

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The role of neoadjuvant and adjuvant chemo-therapy has not been definitively defined for uppertract UC. For stage II-IIIa bladder cancer, neoadju-vant chemotherapy has been shown to improvesurvival.25,26 Therefore, it is reasonable to considerneoadjuvant chemotherapy in select patients withhigh-grade upper tract disease, particularly if im-aging suggests at least stage II disease. Anotherimportant consideration is the benefit of neoadju-vant chemotherapy for bladder cancer that hasbeen associated with cisplatin-based chemo-therapy, which requires adequate renal function.Therefore, some patients may have adequaterenal function to tolerate neoadjuvant chemo-therapy but not adjuvant chemotherapy.

ROBOT-ASSISTED NEPHROURETERECTOMY

Radical nephroureterectomy involves removal ofthe kidney and ureter along with bladder cuff exci-sion and is recommended for UC of the renalpelvis and upper ureter. The patient is positionedin a lateral decubitus position with the umbilicusat the level of kidney rest. The surgical table ispartly flexed to open the space between the thoraxand hip. An axillary role is placed two finger-breadths below the axilla. A gel roll is placedagainst the back to keep patients in a 45� to 90�

flank position. Three-inch cloth tape may be strap-ped across the upper chest and hip to help securethe patient (Fig. 1). The contralateral, lower armshould be placed on an arm board, supported byfoam and loosely secured to the arm board withtape. The ipsilateral arm should be loosely securedwith tape to an arm rest, which may be composedof pillows stacked on top of the lower arm. Afterthe patient has been secured to the operating ta-ble, the abdomen and flank are shaved, prepared,and draped in standard sterile fashion.


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The robot provides the greatest advantagewhen performing the distal ureterectomy andbladder repair. With older generations of the daVinci robot, such as the da Vinci S and Si, it wasoften necessary to dock the robot separately forthe nephrectomy and the distal ureterectomy. Toavoid having to dock twice, it was often simplerto perform the nephrectomy laparoscopically anddock the robot for the distal ureterectomy. Howev-er, with the da Vinci Xi, it is possible to dock therobot once because the robotic arms have greatermobility.Pneumoperitoneum is established using any va-

riety of techniques. Fig. 2 shows the port place-ment for a left nephroureterectomy using the daVinci Xi. It is often helpful to plan port placementafter establishing pneumoperitoneum, which candistend the abdominal wall. The camera portshould be placed superior to the umbilicus andimmediately lateral to the rectus muscle. Thefourth arm is the inferior-most port and care shouldbe taken to avoid inadvertently entering thebladder. A 12-mm assistant port is required. Alltrocars should be placed under vision if possible.For a right-sided nephroureterectomy, an addi-tional 5-mm port is placed in the midline, justbelow the xyphoid and used to retract the liver(Fig. 2).Access to the retroperitoneum is gained via inci-

sion lateral to the colon along the white line ofToldt.27 Excision of this avascular tissue lateral tothe colon allows the colon to then be reflectedmedially, providing access to the retroperitoneum.Depending on the laterality of the nephroureterec-tomy, either the spleen or the liver must then bemanipulated. For a left-sided nephroureterectomy,the spleen is mobilized after excision of its lateralattachments. If the spleen is sufficiently mobilized,it will remain off the kidney during the remaining

Fig. 2. Port placement for robot-assisted nephroureterectoplacement.


dissection without having to apply any instrumentsto the spleen. For a right-sided nephroureterec-tomy a blunt, locking grasper is inserted throughthe 5-mm trocar below the xyphoid to lift the liverand lock onto the abdominal wall near the lateralattachment of the liver. The duodenum is alsomobilized and deflected medially to provide expo-sure to the inferior vena cava and renal hilum.Attention is then directed toward the lower pole

of the kidney where the ureter and gonadal veincan be readily identified (Fig. 3). The ureter shouldbe identified as early as possible so that a lockingclip can be placed below the tumor to preventdistal seeding of cancer during manipulation ofthe kidney. The ureter is superiorly retracted asthe dissection is continued to the hilum. The renalvein should be clearly identified and separatedfrom tissue posterior to the vein, which is expectedto contain the renal artery. A laparoscopic vascularstapler can be used to staple and cut the arteryand vein separately (Fig. 4). Using this approach,it is not necessary to completely mobilize and visu-alize the renal artery as long as the renal vein hasbeen lifted off the structures immediately posteriorto it and hilar tissue containing the artery has beenthinned out sufficiently to accommodate the lapa-roscopic vascular stapler. The adrenal glandshould be spared. On the left, the adrenal veinshould be visualized, and care should be takento divide the renal vein distal to the adrenal vein.The importance of performing a retroperitoneal

lymph node dissection (RPLND) has not beenestablished. However, it is likely that an RPLNDwill improve nodal staging and help determineprognosis.28 During an RPLND, bulky nodes andnodes visible on preoperative imaging should beprioritized for removal. A complete nodal dissec-tion may include the retroperitoneal packageextending from the crus of the diaphragm down

my. (A) Right-sided port placement. (B) Left-sided port


Fig. 3. Identification of ureter andgonadal vein at lower pole of kidneyduring a right-sidednephroureterectomy.


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to pelvic nodes. However, the template can bemodified based on the location of the tumor. Fora left renal pelvis tumor, our practice is to performan RPLND using the following structures to definethe template: crus of the diaphragm, the left ureter,the aortic bifurcation, and the vena cava. For aright renal pelvis tumor, the following structuresdefine our template: crus of the diaphragm, theright ureter, bifurcation of the vena cava, andaorta. Patients undergoing RPLND are at risk fordeveloping a chyle leak. Therefore, all lymphaticvessels should be clipped using metal clips before


being divided. The assistant can apply the clipsusing a multifire laparoscopic clip applier.

The goal is to remove kidney, ureter, andbladder cuff en bloc. To complete the distal ureter-ectomy and bladder cuff excision, the ureter istraced down to its entry into the bladder. Beforedoing this, it is helpful to move the three workingrobotic trocars from the top three 8-mm trocarsto the bottom three 8-mm trocars. While tracingthe ureter, the vas deferens should be ligatedwhere it crosses the ureter anteriorly. As dissec-tion of the ureter is continued distally, the

Fig. 4. Exposure of vessels of renal hi-lum during robot-assistednephroureterectomy.


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obliterated umbilical artery and bladder pediclesare encountered lateral and perpendicular to thecourse of the ureter (Fig. 5). These structuresshould be divided between Hem-o-lok clips tofacilitate the ureteral dissection. When the detru-sor is encountered, 2-cm incisions are made atthe 12- and 6-o’clock positions. This shouldexpose the underlying mucosal layer. A full-thickness apical stitch is placed at the top of thisincision. The mucosal layer can be pulled into thesurgical field by gently pulling on the ureter. Thisfacilitates resection of the bladder cuff and helpsidentify the mucosal layer for the subsequentbladder closure (Fig. 6). Care should be taken toavoid damaging the contralateral ureter. Thebladder is closed in two layers with a 2–0 polyglac-tin 910 barbed stitch placed in a running fashion. Aleak test is performed through a urethral catheter.A Foley catheter should remain in place forapproximately 1 week; however, if the patientpasses the intraoperative leak test, some sur-geons remove the Foley catheter as early as post-operative Day 1. The 12-mm assist port may beused to insert a specimen bag and the specimenmay be removed through a Pfannenstiel incision.It should be noted that the distal ureterectomyand bladder repair can be performed before thenephrectomy and this provides the advantage ofkeeping the kidney and upper ureter in their


orthotopic position, allowing more tension to beapplied to the ureter.

ROBOT-ASSISTED DISTAL URETERECTOMYWITH REIMPLANT

Although nephroureterectomy is considered thegold standard for treatment of upper tract UC,kidney-sparing surgery may be considered in pa-tients with distal ureteral tumors, particularlywhen renal function is compromised. The preoper-ative evaluation must include ureteroscopy of theproximal collecting system that will be preservedto ensure that this portion of the urothelium isfree of visible cancer. Uberoi and colleagues29 firstdescribed the robot-assisted distal ureterectomywith ureteral reimplantation and since then,various retrospective studies have compareddistal ureterectomy with nephroureterectomy,and identified similar outcomes.For surgery, the patient is placed supine and

near-maximum Trendelenburg position. Foampads should be placed under all pressure pointsand the surgeon should verify that the patient issecured to the operating table. A urinary catheteris inserted into the bladder, which is drained afterthe balloon is inflated. Once positioned, theabdomen is shaved, prepared, and draped in stan-dard sterile fashion. Pneumoperitoneum isachieved with Veress needle. Five to six robotic

Fig. 5. Exposure of distal ureter duringnephroureterectomy.


Fig. 6. Bladder cuff excision during nephroureterectomy. (A, B) Placement of a holding stitch into the detrusormuscle. (C) Tenting of the bladder mucosa before incision.


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arm ports are placed (Fig. 7). The robot is thendocked along the side of the bed.

In most cases, the ureteral tumor should beidentifiable based on a bulging appearance. Pre-operative imaging should provide additional guid-ance on location of the tumor. However, forsmaller masses where no appreciable mass maybe detected via the robotic scope, a ureteroscopemay be used. In these cases, a guidewire is placedcystoscopically and advanced to the renal pelvisbefore docking. During the robotic portion of thecase, a ureteroscope is introduced and advanced

Fig. 7. Port placement for distal ureterectomy.


over the guidewire to the level of the tumor. At thispoint, the light from the ureteroscope should bevisible laparoscopically and help the surgeonlocalize the tumor.30

Once the robot is fully docked, the surgeonshould mobilize the colon to access the retroperi-toneum. The ureter should be identified, and thedistal ureter should be dissected along with acuff of bladder. The ureteral lesion should be iden-tified, and the ureter tied off or clipped proximaland distal to the tumor to prevent tumor spillage.When dissecting the distal ureter, the vas deferens


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(round ligament in women), obliterated umbilicalartery, and bladder pedicle are divided betweenHem-o-lok clips. The bladder detrusor is thenincised and opened adjacent to the ureter. Aretracting stitch can be placed in the bulging mu-cosa, just inside the detrusor, or in the full thick-ness of the bladder to help provide tractionduring subsequent bladder closure. The bladdercuff is excised circumferentially around the ure-teral orifice. The ureter is divided proximal to theureteral tumor and the proximal margin of the ure-ter is sent for frozen section analysis. Because ofthe small size of most ureteral tumors, a specimenretrieval bag is usually not required. The specimenmay be removed through a trocar, but if the trocarneeds to be removed to enlarge the incision, aspecimen bag should be used to prevent tumorspillage and port-site seeding by tumor. Thebladder is then closed with a 2–0 polyglactin 910barbed suture. A pelvic lymph node dissection isperformed within the borders of the genitofemoralnerve, aortic bifurcation, obturator nerve, andlymph node of Cloquet. Following confirmationfrom frozen section analysis that the proximal ure-teral margin is negative, the surgeon can preparefor ureter reimplantation.The surgeon first removes the previously placed

clip on the ureter and then proceeds to spatulatethe ureter for approximately 1.5 cm using roboticPotts scissors. Next, the bladder is dropped fromthe abdominal wall by incising the peritoneumlateral to the obliterated umbilical ligaments anddividing the obliterated urachal structures. Thecontralateral bladder pedicle should be preservedbecause the ipsilateral bladder pedicles will havebeen divided while mobilizing the ureter. Onadequate mobilization of the bladder, a psoashitch or a Boari flap can be performed to allowfor a tension-free ureterovesical anastomosis.For a psoas hitch, 2–0 polyglactin 910 suture is

used to hitch the bladder superiorly to the psoastendon with special care taken to avoid the genito-femoral and ilioinguinal nerves. Once the bladderis appropriately fixed, the surgeon proceeds toureteral reimplantation, using either running orinterrupted sutures. A 1.5-cm incision is madethrough the bladder muscle and mucosa. Oncehalf of the anastomosis is complete, a double-Jureteral stent is placed. A guidewire is placedthrough the assistant’s trocar and up the ureter.The proximal end of the stent is advanced up theureter using robotic arms. The guidewire is thenremoved and the robotic arms are used to insertthe distal end of the stent into the bladder withoutneed for a guidewire. The anastomosis is thencompleted (Fig. 8). Anastomosis patency can betested by filling the bladder.


ROBOT-ASSISTED SEGMENTALURETERECTOMY WITH PRIMARYURETEROURETEROSTOMY

Robot-assisted segmental ureterectomy with ure-teroureterostomy is considered for mid-ureteraltumors. Ideal candidates have low-grade, mid-ureteral tumors that are not amenable to endo-scopic ablation.31 High-grade tumors are treatedwith this approach when there is a solitary kidneyor poor renal function, and distal ureterectomy isnot technically feasible. The preoperative evalua-tion must include ureteroscopy of the collectingsystem, which is preserved to ensure that the uro-thelium is free of visible cancer.The patient is positioned on the operating table

in lateral decubitus position with ipsilateral sideup.32 Patient positioning and trocar placement isthe same as described for robotic nephroureterec-tomy. A urinary catheter is inserted into thebladder. On entry into the abdomen, the colonshould be mobilized and the white line of Toldtincised to expose the retroperitoneum. The uretershould be visualized, and the tumor may belocated based on its bulging appearance. Howev-er, if tumor location is not completely clear, a ure-teroscope may be advanced over a guidewire tolocate the ureteral tumor as described for roboticdistal ureterectomy. The surgeon should then beable to identify the location of the ureteral tumorlaparoscopically from the light emitted by the ure-teroscope. Once the ureter has been sufficientlymobilized to completely excise the tumor andperform a tension-free anastomosis, the uretercan be clipped above and below the tumor to mini-mize the risk of tumor spillage. Proximal and distalmargins are sent for frozen section before pro-ceeding with ureteroureterostomy. The surgeonensures that the ureteral ends may be anasto-mosed in a tension-free manner. Ureteral resec-tions larger than 2 cm may require a morecomplex reconstruction, such as ileal interposi-tion.32 A segmental ureterectomy may be thebest option for a small high-grade ureteral tumorwith a solitary kidney; lymphadenectomy in thedraining lymph area is performed for high-gradetumors. For the primary ureteroureterostomy, theproximal and distal ends of the divided uretershould be spatulated on opposing sides by 1 cmand stay sutures should be placed on each end.Care must be taken to avoid twisting the ureteralends during this process. The ureteral ends arethen positioned so that the spatulated side ofone ureter is sewn to the unspatulated side ofthe other ureteral end. A stent is placed after thefirst side of the anastomosis is complete, the ure-ter is flipped, and the anastomosis is completed.


Fig. 8. Reimplantation of ureter ontobladder with psoas hitch followingdistal ureterectomy.


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SUMMARY

Upper tract UC is a rare malignancy for which sur-gery provides definitive management. Openradical nephroureterectomy was the gold standardtreatment, but laparoscopic and robot-assistedapproaches are alternative options. Kidney-sparing approaches are feasible for carefullyselected patients with ureteral cancer.

DISCLOSURES

The authors have no disclosures to make.

REFERENCES

1. Jemal A, Siegel R, Ward E, et al. Cancer statistics,

2009. CA Cancer J Clin 2009;59(4):225–49.

2. Raman JD, Messer J, Sielatycki JA, et al. Incidence

and survival of patients with carcinoma of the ureter

and renal pelvis in the USA, 1973–2005. BJU Int

2011;107(7):1059–64.

3. Kakizoe T. Development and progression of urothe-

lial carcinoma. Cancer Sci 2006;97(9):821–8.

4. Honda Y, Nakamura Y, Teishima J, et al. Clinical

staging of upper urinary tract urothelial carcinoma


for T staging: review and pictorial essay. Int J Urol

2019;26(11):1024–32.

5. Amin MB, Edge SB. AJCC cancer staging manual.

New York: Springer; 2017.

6. Hall MC, Womack S, Sagalowsky AI, et al. Prog-

nostic factors, recurrence, and survival in transi-

tional cell carcinoma of the upper urinary tract: a

30-year experience in 252 patients. Urology 1998;

52(4):594–601.

7. Clayman RV, Kavoussi LR, Figenshau RS, et al.

Laparoscopic nephroureterectomy: initial clinical

case report. J Laparoendosc Surg 1991;1(6):343–9.

8. Ni S, Tao W, Chen Q, et al. Laparoscopic versus

open nephroureterectomy for the treatment of upper

urinary tract urothelial carcinoma: a systematic re-

view and cumulative analysis of comparative

studies. Eur Urol 2012;61(6):1142–53.

9. Margulis V, Shariat SF, Matin SF, et al. Outcomes of

radical nephroureterectomy: a series from the upper

tract urothelial carcinoma collaboration. Cancer

2009;115(6):1224–33.

10. Klingler DW, Hemstreet GP, Balaji K. Feasibility of

robotic radical nephrectomy: initial results of

single-institution pilot study. Urology 2005;65(6):

1086–9.


http://refhub.elsevier.com/S0094-0143(20)30076-8/sref1



































Lo & Kim80

Descarg 20

11. Ludwig WW, Gorin MA, Pierorazio PM, et al. Fron-

tiers in robot-assisted retroperitoneal oncological

surgery. Nat Rev Urol 2017;14(12):731–41.

12. Clements MB, Krupski TL, Culp SH. Robotic-assis-

ted surgery for upper tract urothelial carcinoma: a

comparative survival analysis. Ann Surg Oncol

2018;25(9):2550–62.

13. Rodriguez JF, Packiam VT, Boysen WR, et al. Utiliza-

tion and outcomes of nephroureterectomy for upper

tract urothelial carcinoma by surgical approach.

J Endourol 2017;31(7):661–5.

14. Hemal AK, Nayyar R, Gupta NP, et al. Experience

with robot assisted laparoscopic surgery for upper

and lower benign and malignant ureteral pathol-

ogies. Urology 2010;76(6):1387–93.

15. Roupret M, Babjuk M, Comperat E, et al. European

guidelines on upper tract urothelial carcinomas:

2013 update. Eur Urol 2013;63(6):1059–71.

16. De Groote R, Decaestecker K, Larcher A, et al.

Robot-assisted nephroureterectomy for upper tract

urothelial carcinoma: results from three high-

volume robotic surgery institutions. J Robot Surg

2020;14(1):211–9.

17. Lenis AT, Donin NM, Faiena I, et al. Role of surgical

approach on lymph node dissection yield and sur-

vival in patients with upper tract urothelial carci-

noma. Paper presented at: Urologic Oncology:

Seminars and Original Investigations, 2018.

18. Fukushima H, Saito K, Ishioka J, et al. Equivalent

survival and improved preservation of renal function

after distal ureterectomy compared with nephroure-

terectomy in patients with urothelial carcinoma of

the distal ureter: a propensity score-matched multi-

center study. Int J Urol 2014;21(11):1098–104.

19. Dalpiaz O, Ehrlich G, Quehenberger F, et al. Distal

ureterectomy is a safe surgical option in patients

with urothelial carcinoma of the distal ureter. Paper

presented at: Urologic Oncology: Seminars and

Original Investigations, 2014.

20. Jeldres C, Lughezzani G, Sun M, et al. Segmental

ureterectomy can safely be performed in patients

with transitional cell carcinoma of the ureter. J Urol

2010;183(4):1324–9.

21. Seisen T, Peyronnet B, Dominguez-Escrig JL, et al.

Oncologic outcomes of kidney-sparing surgery

versus radical nephroureterectomy for upper tract

urothelial carcinoma: a systematic review by the


EAU non-muscle invasive bladder cancer guidelines

panel. Eur Urol 2016;70(6):1052–68.

22. Roupret M, Babjuk M, Comperat E, et al. European

Association of Urology guidelines on upper urinary

tract urothelial carcinoma: 2017 update. Eur Urol

2018;73(1):111–22.

23. Cowan NC, Turney BW, Taylor NJ, et al. Multidetec-

tor computed tomography urography for diagnosing

upper urinary tract urothelial tumour. BJU Int 2007;

99(6):1363–70.

24. Messer J, Shariat SF, Brien JC, et al. Urinary

cytology has a poor performance for predicting

invasive or high-grade upper-tract urothelial carci-

noma. BJU Int 2011;108(5):701–5.

25. Grossman HB, Natale RB, Tangen CM, et al. Neoad-

juvant chemotherapy plus cystectomy compared

with cystectomy alone for locally advanced bladder

cancer. N Engl J Med 2003;349(9):859–66.

26. International Collaboration of Trialists. International

phase III trial assessing neoadjuvant cisplatin, meth-

otrexate, and vinblastine chemotherapy for muscle-

invasive bladder cancer: long-term results of the

BA06 30894 trial. J Clin Oncol 2011;29(16):2171.

27. Taylor BL, Scherr DS. Robotic nephroureterectomy.

Urol Clin 2018;45(2):189–97.

28. Chapman TN, Sharma S, Zhang S, et al. Laparo-

scopic lymph node dissection in clinically node-

negative patients undergoing laparoscopic ne-

phrectomy for renal carcinoma. Urology 2008;

71(2):287–91.

29. Uberoi J, Harnisch B, Sethi AS, et al. Robot-assisted

laparoscopic distal ureterectomy and ureteral reim-

plantation with psoas hitch. J Endourol 2007;21(4):

368–73.

30. Glinianski M, Guru KA, Zimmerman G, et al. Robot-

assisted ureterectomy and ureteral reconstruction

for urothelial carcinoma. J Endourol 2009;23(1):

97–100.

31. McClain PD, Mufarrij PW, Hemal AK. Robot-assisted

reconstructive surgery for ureteral malignancy: anal-

ysis of efficacy and oncologic outcomes. J Endourol

2012;26(12):1614–7.

32. Aboumohamed AA, Ghavamian R. Distal and

segmental ureterectomy. In: Urothelial malignancies

of the upper urinary tract. New York: Springer; 2018.

p. 171–7.





















































































robot-assisted surgery for upper tract urothelial carcinomaureterectomy is a viable alternative.20...

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