ArticlePDF Available

Robotic and 3D laparoscopic radical nephroureterectomy with en bloc specimen excision (kidney, ureter, bladder cuff excision and extended lymphadenectomy) – Case report

Authors:
  • George Emil Palade University of Medicine, Pharmacy, Sciences and Technology from Targu Mures

Abstract and Figures

Introduction and importance Upper tract urothelial carcinoma (UTUC) is a highly systemic aggressive disease with a tendency of rapid lymph node invasion and metastasis presenting poor oncologic outcomes. Ureteral localization of tumors leads to hydronephrosis and early invasion of the muscle wall, being categorized as high risk tumors. Case presentation A 70 years old female was diagnosed with lower left ureteral urothelial tumor associated with hydronephrosis and paraaortic and iliac enlarged lymph nodes. The disease was stratified as high risk upper tract urothelial carcinoma. Treatment consisted in en bloc radical nephroureterectomy, bladder cuff excision and wide lymph node dissection using a combined robotic and 3D laparoscopic approach. Clinical discussion Surgical challenges are surpassed by the use of minimal invasive approaches that offer precise dissection and tissue manipulation with a fast postoperative recovery and early adjuvant oncologic treatment. Comprehensive and complete lymph node dissection along with precise bladder cuff excision offers improved staging, possibly impacting disease prognosis. Conclusion En bloc minimal invasive radical nephroureterectomy, bladder cuff excision and wide lymph node dissection offer improved surgery time and lymph node dissection, better management of distal ureteral and bladder cuff excision, watertight cystorrhaphy and optimal disease staging. The experience of the main surgeon with 3D laparoscopy was used in the hereby case to optimize operatory time for the renal step of the surgery. The gentle and precise movements of the Da Vinci robot allowed an accurate en bloc dissection (pN2, N4+/15) with implications in staging and possibly also in oncologic outcomes.
Content may be subject to copyright.
International Journal of Surgery Case Reports 92 (2022) 106902
Available online 1 March 2022
2210-2612/© 2022 Published by Elsevier Ltd on behalf of IJS Publishing Group Ltd. This is an open access article under the CC BY-NC-ND license
(http://creativecommons.org/licenses/by-nc-nd/4.0/).
Case report
Robotic and 3D laparoscopic radical nephroureterectomy with en bloc
specimen excision (kidney, ureter, bladder cuff excision and extended
lymphadenectomy) Case report
Octavian Sabin Tataru
a
,
1
, Eliza Cristina Bujoreanu
b
,
1
, Bogdan Ovidiu Coste
c
,
*
,
Teodor Traian Maghiar
c
, Bogdan Petrut
b
,
d
,
e
a
I.O.S.U.D., George Emil Palade University of Medicine and Pharmacy, Sciences and Technology of Targu Mures, Department of Urology, Targu Mures, Romania
b
Prof. Dr. I. Chiricuta" Institute of Oncology, Department of Urology, Cluj-Napoca, Romania
c
Pelican Hospital- Medicover Group, Department of Urology, Oradea, Romania
d
Iuliu Hatieganu" University of Medicine and Pharmacy, Department of Urology, Cluj-Napoca, Romania
e
ESUT- EAU section of Uro-Technology Training Group, Romania
ARTICLE INFO
Keywords:
Upper tract urothelial carcinoma
Radical robotic nephroureterectomy
Lymph node dissection
3D laparoscopy
En bloc excision
Case report
ABSTRACT
Introduction and importance: Upper tract urothelial carcinoma (UTUC) is a highly systemic aggressive disease with
a tendency of rapid lymph node invasion and metastasis presenting poor oncologic outcomes. Ureteral locali-
zation of tumors leads to hydronephrosis and early invasion of the muscle wall, being categorized as high risk
tumors.
Case presentation: A 70 years old female was diagnosed with lower left ureteral urothelial tumor associated with
hydronephrosis and paraaortic and iliac enlarged lymph nodes. The disease was stratied as high risk upper tract
urothelial carcinoma. Treatment consisted in en bloc radical nephroureterectomy, bladder cuff excision and wide
lymph node dissection using a combined robotic and 3D laparoscopic approach.
Clinical discussion: Surgical challenges are surpassed by the use of minimal invasive approaches that offer precise
dissection and tissue manipulation with a fast postoperative recovery and early adjuvant oncologic treatment.
Comprehensive and complete lymph node dissection along with precise bladder cuff excision offers improved
staging, possibly impacting disease prognosis.
Conclusion: En bloc minimal invasive radical nephroureterectomy, bladder cuff excision and wide lymph node
dissection offer improved surgery time and lymph node dissection, better management of distal ureteral and
bladder cuff excision, watertight cystorrhaphy and optimal disease staging. The experience of the main surgeon
with 3D laparoscopy was used in the hereby case to optimize operatory time for the renal step of the surgery. The
gentle and precise movements of the Da Vinci robot allowed an accurate en bloc dissection (pN2, N4+/15) with
implications in staging and possibly also in oncologic outcomes.
1. Introduction
Urothelial cancer (UC) is the fourth most common cancer [1]. The
upper urinary tract (UTUCs) tumors account for 510% of UC [1]. Tu-
mors in the kidney cavities (pyelocaliceal) are approximately 50% more
common as ureteral tumors [2]. The rst laparoscopic nephroureter-
ectomy (LNU) was performed and published by Clayman, in 1991 [3].
Since then, advancements in technology placed LNU as a safe surgical
treatment in UTUCs. Oncological outcomes after LNU or open radical
nephroureterectomy (RNU) tend to be similar [2], with robotic radical
nephroureterectomy (RRNU) offering advantages over LNU in terms of
improved rates of lymph node dissection (LND) and short-term
morbidity [4]. Veccia et al. [5], reported RRNU to be safe, providing
the advantages of a minimally invasive approach without endangering
oncologic outcomes, with further evidence from a systematic review
suggesting that RRNU is being equivalent with LNU [6]. In a multicenter
study, Roscigno et al. [7], found that pN+is an independent predictor of
cancer specic survival (CSS) (p <0.001), therefore LND should
* Corresponding author at: General Eremia Grigorescu nr. 89, 400305 Cluj-Napoca, Romania.
E-mail addresses: coste_bogdan@yahoo.com (B.O. Coste), bogdan.petrut@umfcluj.ro (B. Petrut).
1
Tataru Octavian Sabin and Bujoreanu Eliza Cristina contributed equally to this paper.
Contents lists available at ScienceDirect
International Journal of Surgery Case Reports
journal homepage: www.elsevier.com/locate/ijscr
https://doi.org/10.1016/j.ijscr.2022.106902
Received 1 December 2021; Received in revised form 25 February 2022; Accepted 27 February 2022
International Journal of Surgery Case Reports 92 (2022) 106902
2
improve the staging of the disease and establish the role of adjuvant
chemotherapy in such patients. The hereby paper presents the case of a
patient diagnosed with left ureteral distal urothelial cancer with latero-
aortic and left iliac lymph node masses that underwent left en bloc
radical Da Vinci X robotic nephroureterectomy with bladder cuff exci-
sion and extended lymph node dissection with the aid of 3D laparos-
copy. The case was managed by a tumor board and no neoadjuvant
treatment was given. The surgical technique and the analysis of peri/
postoperative data are highlighted and oncologic management with 16
months follow-up data noted.
2. Presentation of case
A 70 years old female patient presented to our Department with gross
haematuria, left nephralgia and lower left ureteral urothelial tumor
associated with hydronephrosis and periureteral enlarged lymph nodes.
Preoperative computed tomography (CT- abdomen, pelvis and tho-
rax) conrmed the left distal ureteral tumor (20/17 mm) associated with
grade III hydronephrosis (Fig. 1) and enlarged paraaortic and left
external iliac lymph nodes. No distant metastases were noted. The dis-
ease is stratied as high risk UTUC, according to EAU Guidelines [2].
Laboratory examinations showed values within normal range: He-
moglobin level (11.1 g/dl), platelets level (381,000/
μ
l), leukocytes level
(8180/
μ
l), Ca (9.2 mg/dl), K (3.81 mmol/l), Na (142 mmol/l), serum
creatinine (1.05 mg/dl), serum urea (39.3 mg/dl). Urine analysis pre-
sented no pathological ndings except hematuria and urine culture was
negative. Karnofsky Performance status was 80 points, ECOG 1. The
patient presented no medical/surgical/toxicological history. Analgesic
medication was self-administered 34 times per week. The family his-
tory did not reveal any relevant genetic or psychosocial elements.
Informed consent has been obtained from the patient to use medical
data and images. This work has been reported in line with the SCARE
2020 criteria [8].
2.1. Surgical technique
2.1.1. Operating table position and port placement
The patient was placed in a ank position, with the table angled in
the middle to expose the lumbar area. Trocar placement was performed
for the initial step of 3D laparoscopic radical nephrectomy with cranial
access ports and then adjusted for the Da Vinci® X robotic approach
(Fig. 2).
2.1.2. Radical robotic nephroureterectomy
2.1.2.1. Radical 3D laparoscopic nephrectomy. After the descending
colon was mobilized (Fig. 3.1) along the white line of Toldt, from the
splenic exure to the left iliac vessels, the retroperitoneum was accessed
and the left lumbar ureter identied (Fig. 3.2). The dissection of the
ureter advanced cranially with the en bloc excision of a latero- aortic
lymph node mass (Fig. 3.3, 3.4, 3.5) and continued with the dissection of
the renal pedicle. The renal artery followed by the renal vein were
clipped and sectioned (Fig. 3.6, 3.7) and then the kidney was dissected
from surrounding tissues (Fig. 3.8) and placed in an Endobag
(Fig. 3.9).
2.1.3. Robotic distal ureter dissection, lymph node dissection, bladder cuff
excision and cystorrhaphy
The left ureter was dissected caudal (Fig. 4.1) as it crossed the iliac
vessels and a lymph node was identied medial to the iliac vein (Fig. 4.1,
4.2, 4.3). The lymph node was dissected from the adjacent tissues but
excised from the iliac fossa en bloc with the ureter (Fig. 4.4, 4.5, 4.6).
The surgery continued with the perimeatic cystectomy (Fig. 4.7, 4.8)
and the en bloc excision piece-nephroureterectomy with perimeatic
cystectomy and attached lymph node masses (Fig. 4.9) was placed in 2
Endobags™ – one for the kidney and latero-aortic lymph node mass
(initial step of the surgery 3D laparoscopic) and one for the pelvic
ureter with perimeatic cystectomy and iliac lymph node (second step of
the surgery - Da Vinci X® robot).
The defect in the left wall of the bladder can be observed in Fig. 5.1
along with the inated balloon of the transurethral indwelling catheter
Fig. 1. The Computed Tomography (CT) scan and en bloc excised specimen macroscopic view.
The CT (Computed Tomography) scan images (abdomino-pelvic, contrast enhanced-arterial phase) highlighting the latero-aortic lymph node mass (1.1) and left iliac
lymph node mass in the vicinity of the ureteral tumor on the distal ureter- with upstream ureterohydronephrosis (1.2). The images are presented in coronal (above)
and axial (below) planes.
The en bloc excised specimen (1.3) can be observed with a close-up on pelvic ureter (1.4). The kidney, ureter with perimeatic urinary bladder wall and attached
lymph node masses (latero-aortic and left iliac) are marked.
Symbols on images: K- left kidney, U - left ureter, L1 - latero-aortic lymph node mass, L2 left iliac lymph node mass, DOTTED LINE - perimeatic left bladder wall.
O.S. Tataru et al.
International Journal of Surgery Case Reports 92 (2022) 106902
3
inside it. After a suprapubic catheter was placed, the cystorrhaphy was
performed with a running suture (Fig. 5.2, 5.3, 5.4, 5.5, 5.6) using a
Quill® thread. The en bloc specimen can be observed in Fig. 1.3, 1.4.
2.2. Results
Surgery time and perioperative results are presented in Table 1. The
histopathologic examination revealed ureteral muscle invasive papillary
urothelial carcinoma with lymphovascular invasion and negative sur-
gical margins, G3 high grade tumor pT2N2(4+/15)V1Pn0R0, M0 status
according to imagistic evaluation.
The patient underwent adjuvant oncologic treatment as decided by a
tumor board, with imaging (every 6 months), oncologic and urologic
follow-up. The nephrologic exam showed no signs of renal insufciency.
Chemotherapy was administered 1 month after surgery as follows: 1
cycle of Gemcitabine and Cisplatin with intolerance to Cisplatin and
continued with 4 cycles of Gemcitabine and Carboplatin. External
radiotherapy followed after chemotherapy- 25 sessions, 45GY/28FR/
1.8GY- paraaortic and left iliac vessels anatomic eld.
At present date (16 months postoperative), the patient presents in
good general status, with serum creatinine level in normal range and no
imaging signs of disease recurrence or metastasis, but with moderate
inferior left limb lymphedema (23% added circumferential difference).
The patient reports a good life quality, using compression socks and
lymphatic drainage massages weekly.
3. Discussion
One of the rst described retroperitoneal RRNU was published in
2006 by Rose et al. [9], performed on two patients without conversion.
In order to reduce surgery time and the morbidity after prolonged
anesthesia a combined (3D laparoscopic and robotic) approach was
preferred for the present case. Experiences of different techniques of
distal ureter resection with bladder cuff excision [10] were reviewed in
Fig. 2. Patient positioning and trocar placement.
Trocars placement for the 3D laparoscopic operatory steps: (1), (2) and (3). Robotic trocars placement for the Da Vinci X® operatory steps: (3), (4) and (5). (3)
represents the optic trocar for both approaches.
Fig. 3. 3D laparoscopic left radical nephrectomy and latero-aortic lymphadenectomy.
Symbols on images: C descending colon, K- left kidney, U - left ureter, L1 - latero-aortic lymph node mass, A - renal artery, V renal vein.
O.S. Tataru et al.
International Journal of Surgery Case Reports 92 (2022) 106902
4
emerging studies that compared outcomes of laparoscopic vs. RRNU
[6,1113]. Literature reviews on how to assess the clinical impact of
lymphadenectomy [14], to compare different robotic platforms during
RRNU [15] and different laparoscopic and robotic approaches with the
open approach [16,17] were published. Robotic LND is suited for
dissection of large number of lymph nodes with less morbidity and im-
provements for disease staging [4]. Different techniques were described
for patient positioning (45/60 degree ank position), with a tilted
Trendelenburg position [18] bringing the advantage of a better kidney
exposure that facilitates renal hilum, upper kidney pole access as well as
ureteral dissection. Access ports were placed in a linear conguration to
facilitate access for both the upper pole of the kidney and the urinary
bladder and for pelvic LND to achieve accurate stratication of the
disease, similar to what Taylor et al. [18], previously described. The
distal management and excision of the bladder cuff is performed by the
Da Vinci® systems (X, SI, XI) with improved dissection of the distal
ureter and bladder cuff excision and have advantages because it forgoes
cystoscopy and repositioning, and facilitates LND and cystotomy closure
[10,19]. This patient positioning on the operating table offered the space
needed to quickly dock the robotic platform, therefore without losing
time to readjust the surgical eld.
Lymphadenectomy is advisable in patients with muscle-invasive
UTUCs because the 5 year overall survival and cancer specic mortal-
ity are comparable between patients with N1 and N0 muscle-invasive
UTUCs [14]. In the hereby case, 4 out of the 15 excised lymph nodes
presented malignancy, establishing pT2pN2 staging. The number of
excised lymph nodes shows a high quality excision of the lymph nodes,
helped by the precision of the Da Vinci robot. In a retrospective analysis
of 7278 patients with UTUC treated with RNU, Zhai et al. [20], found
that a higher overall survival (OS) and CSS was associated with LND in
patients with T3-T4 tumors (p <0,05), but not in pT1 and pT2 disease (p
>0,05). A newer systematic review looked into the potential benet of
lymph node dissection and compared CLND, incomplete and no LND.
CLND is as an independent prognostic factor for improved survival, but
did not show signicant survival differences for tumors located in the
ureter. Reviews suggest that RRNU is similar for perioperative and
oncological performance to other surgical techniques (LNU, open
nephroureterectomy), but it may offer a lower overall complication rate
as well as postoperative mortality, such as the results in our case with
grade 1 postoperative (30 days) Clavien-Dindo complications [6].
Template for CLND for lower ureter tumors as described by Campi et al.
[21], involves on the left side the obturatory, external, internal and
common iliac lymph nodes and the para-aortic LND being a controver-
sial topic. Our extended para-aortic LND offers better stratication for
our patient. RRNU seems to be safe and offers the advantages of a
minimally invasive technique respecting oncological principles [5]. It is
well known that there is no consensus regarding the treatment approach
for UTUC patients with nodal involvement, but in selected cases such as
symptomatic patients, EAU guidelines recommend surgery as a pallia-
tive treatment [2]. Nonetheless, Covid-19 is putting its toll on cancer
patients and their need for treatment, therefore UTUCs is considered a
high risk disease and a high priority for patients to have access to
treatment without any delay [22].
Fig. 4. Da Vinci X® robotic left ureterectomy with perimeatic cystectomy and left iliac lymphadenectomy.
Symbols on images: K- left kidney, U - left ureter, UB - urinary bladder, L2 left iliac lymph node mass, A - external iliac artery, V external iliac vein, Ae external
iliac artery, Ai internal iliac artery.
O.S. Tataru et al.
International Journal of Surgery Case Reports 92 (2022) 106902
5
4. Conclusions
This case represents a successful management by a tumor board of a
patient with a high grade ureteral muscle invasive papillary urothelial
carcinoma with lymphovascular invasion pT2N2(4+/15)M0V1Pn0R0
that received adjuvant treatment (chemotherapy and radiotheraphy)
after minimal invasive en bloc excision surgery.
RRNU can offer very good perioperative results, improved surgery
time, and improved LND, better management of distal ureteral and
bladder cuff excision, better watertight cystorrhaphy. Da Vinci X® may
offer better access at the edges of the operatory eld; either we are
talking the bladder or the superior renal pole. Da Vinci X® may need
trocar port translocation with one more trocar in long shaped patients.
Access with only three ports (camera and two instruments) may offer
easier access at the edges of the operatory eld. But in this situation an
assistant with laparoscopic skills may constitute a good advantage. The
en bloc resection of kidney, ureter and lymph nodes helps the surgeon
keeping track in removing all the lymphatic tissue in the designated
areas, keeping the connection of lymph nodes with the ureter and for
better stratication.
The experience of the leading surgeon with 3D laparoscopy was used
to optimize operatory time for the renal step of the surgery, using the
large jaws of the bipolar laparoscopic device. The precision offered by
the Da Vinci X robot allowed an accurate en bloc dissection and intra-
pelvic disease management, possibly inuencing oncologic outcomes.
Consent
Written informed consent was obtained from the patient for publi-
cation of this case report and accompanying images. A copy of the
written consent is available for review by the Editor-in-Chief of this
journal on request.
Sources of funding
This research did not receive any specic grant from funding
agencies in the public, commercial, or not-for-prot sectors.
Ethical approval
This work does not require a deliberation by the ethics committee.
Registration of research studies
Not applicable.
Guarantor
Bogdan Ovidiu Coste accepts full responsibility for the work and had
controlled the decision to publish.
Provenance and peer review
Not commissioned, externally peer-reviewed.
CRediT authorship contribution statement
Tataru Octavian Sabin: Conceptualization, Data curation, Formal
Fig. 5. Da Vinci X® robotic cystorrhaphy.
The cystorrhaphy was performed with a running suture using a Quill® thread.
Symbols on images: UB - urinary bladder.
Table 1
Perioperative results and follow up data.
Results
Total duration of surgery (minutes) 213
Operating room +patient preparation 35
Surgical Time
(3D Laparoscopy +DaVinci® X robot)
160 (50 +110)
Specimen extraction 6
Abdominal wall closure 12
Blood loss (ml) 100
Serum Creatinine levels (postoperative, mg/dl)
3rd day 1.11
6 months 0.98
12 months 1.03
16 months 1.15
Clavien-Dindo (30 days) post operatory complications (grade) I
O.S. Tataru et al.
International Journal of Surgery Case Reports 92 (2022) 106902
6
analysis, Funding acquisition, Investigation, Methodology, Project
administration, Resources, Software, Supervision, Validation, Visuali-
zation, Writing - original draft, Writing - review & editing, nal approval
of the version to be submitted.
Bujoreanu Eliza Cristina: Conceptualization, Data curation, Formal
analysis, Funding acquisition, Investigation, Methodology, Project
administration, Resources, Software, Supervision, Validation, Visuali-
zation, Writing - original draft, Writing - review & editing, nal approval
of the version to be submitted.
Coste Bogdan Ovidiu: Conceptualization, Data curation, Formal
analysis, Funding acquisition, Investigation, Methodology, Resources,
Supervision, Validation, Visualization, Writing - review & editing, nal
approval of the version to be submitted.
Maghiar Teodor Traian: Conceptualization, Data curation, Formal
analysis, Funding acquisition, Investigation, Methodology, Project
administration, Resources, Software, Supervision, Validation, Visuali-
zation, Writing - review & editing, nal approval of the version to be
submitted.
Bogdan Petrut: Leading surgeon, Conceptualization, Data curation,
Formal analysis, Funding acquisition, Investigation, Methodology,
Project administration, Resources, Software, Supervision, Validation,
Visualization, Writing - review & editing, nal approval of the version to
be submitted.
Declaration of competing interest
None. All authors report no conict of interests or nancial ties.
References
[1] R.L. Siegel, K.D. Miller, A. Jemal, Cancer statistics, 2020, CA Cancer J. Clin. 70 (1)
(2020 Jan) 730.
[2] M. Rouprˆ
et, M. Babjuk, M. Burger, O. Capoun, D. Cohen, E.M. Comp´
erat, et al.,
European Association of Urology guidelines on upper urinary tract urothelial
carcinoma: 2020 update, Eur. Urol. 79 (1) (2021 Jan) 6279.
[3] R.V. Clayman, L.R. Kavoussi, R.S. Figenshau, P.S. Chandhoke, D.M. Albala,
Laparoscopic nephroureterectomy: initial clinical case report, J. Laparoendosc.
Surg. 1 (6) (1991 Dec) 343349.
[4] A.P. Kenigsberg, W. Smith, X. Meng, R. Ghandour, L. Rapoport, A. Bagrodia,
Robotic nephroureterectomy vs laparoscopic nephroureterectomy: increased
utilization, rates of lymphadenectomy, decreased morbidity robotically,
J. Endourol. 35 (3) (2021 Mar) 312318.
[5] A. Veccia, A. Antonelli, S. Francavilla, C. Simeone, G. Guruli, H. Zargar, et al.,
Robotic versus other nephroureterectomy techniques: a systematic review and
meta-analysis of over 87,000 cases, World J. Urol. 38 (4) (2020 Apr) 845852.
[6] T. Stonier, N. Simson, S.-M. Lee, I. Robertson, T. Amer, B.K. Somani, et al.,
Laparoscopic vs robotic nephroureterectomy: is it time to re-establish the standard?
Evidence from a systematic review, Arab. J. Urol. 15 (3) (2017 Sep) 177186.
[7] M. Roscigno, S.F. Shariat, V. Margulis, P. Karakiewicz, M. Remzi, E. Kikuchi, et al.,
Impact of lymph node dissection on cancer specic survival in patients with upper
tract urothelial carcinoma treated with radical nephroureterectomy, J. Urol. 181
(6) (2009 Jun) 24822489.
[8] R.A. Agha, T. Franchi, C. Sohrabi, G. Mathew, A. Kerwan, SCARE Group, The
SCARE 2020 guideline: updating consensus Surgical CAse REport (SCARE)
guidelines, Int. J. Surg. Lond. Engl. 84 (2020 Dec) 226230.
[9] K. Rose, S. Khan, H. Godbole, J. Olsburgh, P. Dasgupta, GUYS and St. Thomas
Robotics Group, Robotic assisted retroperitoneoscopic nephroureterectomy – rst
experience and the hybrid port technique, Int. J. Clin. Pract. 60 (1) (2006 Jan)
1214.
[10] A.E. Braun, A. Srivastava, F. Maffucci, A. Kutikov, Controversies in management of
the bladder cuff at nephroureterectomy, Transl. Androl. Urol. 9 (4) (2020 Aug)
18681880.
[11] W.R. Lai, B.R. Lee, Techniques to resect the distal ureter in robotic/laparoscopic
nephroureterectomy, Asian J. Urol. 3 (3) (2016 Jul) 120125.
[12] E. Mullen, K. Ahmed, B. Challacombe, Systematic review of open versus
laparoscopic versus robot-assisted nephroureterectomy, Rev. Urol. 19 (1) (2017)
3243.
[13] R. Campi, J. Cotte, F. Sessa, T. Seisen, R. Tellini, D. Amparore, et al., Robotic
radical nephroureterectomy and segmental ureterectomy for upper tract urothelial
carcinoma: a multi-institutional experience, World J. Urol. 37 (11) (2019 Nov)
23032311.
[14] N.H. Azawi, K.D. Berg, A.K.M. Thamsborg, C. Dahl, J.V. Jepsen, B. Kroman-
Andersen, et al., Laparoscopic and robotic nephroureterectomy: does
lymphadenectomy have an impact on the clinical outcome? Int. Urol. Nephrol. 49
(10) (2017 Oct) 17851792.
[15] M.N. Patel, A.K. Hemal, Does advancing technology improve outcomes?
Comparison of the Da vinci standard/S/Si to the xi robotic platforms during robotic
nephroureterectomy, J. Endourol. 32 (2) (2018 Feb) 133138.
[16] H. Lee, H.J. Kim, S.E. Lee, S.K. Hong, S.-S. Byun, Comparison of oncological and
perioperative outcomes of open, laparoscopic, and robotic nephroureterectomy
approaches in patients with non-metastatic upper-tract urothelial carcinoma, PLoS
One 14 (1) (2019), e0210401.
[17] R. De Groote, K. Decaestecker, A. Larcher, S. Buelens, E. De Bleser, F. DHondt, et
al., Robot-assisted nephroureterectomy for upper tract urothelial carcinoma:
results from three high-volume robotic surgery institutions, J. Robot. Surg. 14 (1)
(2020 Feb) 211219.
[18] B.L. Taylor, D.S. Scherr, Robotic nephroureterectomy, Urol. Clin. N. Am. 45 (2)
(2018 May) 189197.
[19] H. Ye, X. Feng, Y. Wang, R. Chen, C. Zhang, W. Zhang, et al., Single-docking
robotic-assisted nephroureterectomy and extravesical bladder cuff excision
without intraoperative repositioning: the technique and oncological outcomes,
Asian J. Surg. 43 (10) (2020 Oct) 978985.
[20] T.-S. Zhai, L. Jin, Z. Zhou, X. Liu, H. Liu, W. Chen, et al., Effect of lymph node
dissection on stage-specic survival in patients with upper urinary tract urothelial
carcinoma treated with nephroureterectomy, BMC Cancer 19 (1) (2019 Dec 12)
1207.
[21] R. Campi, A. Minervini, A. Mari, G. Hatzichristodoulou, F. Sessa, A. Lapini, et al.,
Anatomical templates of lymph node dissection for upper tract urothelial
carcinoma: a systematic review of the literature, Expert. Rev. Anticancer. Ther. 17
(3) (2017 Mar) 235246.
[22] R. Campi, D. Amparore, U. Capitanio, E. Checcucci, A. Salonia, C. Fiori, et al.,
Assessing the burden of nondeferrable major uro-oncologic surgery to guide
prioritisation strategies during the COVID-19 pandemic: insights from three italian
high-volume referral centres, Eur. Urol. 78 (1) (2020 Jul) 1115.
O.S. Tataru et al.
ResearchGate has not been able to resolve any citations for this publication.
Article
Full-text available
Introduction: The SCARE Guidelines were first published in 2016 and were last updated in 2018. They provide a structure for reporting surgical case reports and are used and endorsed by authors, journal editors and reviewers, in order to increase robustness and transparency in reporting surgical cases. They must be kept up to date in order to drive forwards reporting quality. As such, we have updated these guidelines via a DELPHI consensus exercise. Methods: The updated guidelines were produced via a DELPHI consensus exercise. Members were invited from the previous DELPHI group, as well as editorial board member and peer reviewers of the International Journal of Surgery Case Reports. The expert group completed an online survey to indicate their agreement with proposed changes to the checklist items. Results: 54 surgical experts agreed to participate and 53 (98%) completed the survey. The responses and suggested modifications were incorporated to the 2018 guideline. There was a high degree of agreement amongst the SCARE Group, with all SCARE Items receiving over 70% scores 7-9. Conclusion: A DELPHI consensus exercise was completed, and an updated and improved SCARE Checklist is now presented.
Article
Full-text available
The coronavirus 2019 (COVID-19) pandemic has led to an unprecedented emergency scenario for all aspects of health care, including urology. At the time of writing, Italy was the country with the highest rates of both infection and mortality. A panel of experts recently released recommendations for prioritising urologic surgeries in a low-resource setting. Of note, major cancer surgery represents a compelling challenge. However, the burden of these procedures and the impact of such recommendations on urologic practice are currently unknown. To fill this gap, we assessed the yearly proportion of high-priority major uro-oncologic surgeries at three Italian high-volume academic centres. Of 2387 major cancer surgeries, 32.3% were classified as high priority (12.6% of radical nephroureterectomy, 17.3% of nephrectomy, 33.9% of radical prostatectomy, and 36.2% of radical cystectomy cases). Moreover, 26.4% of high-priority major cancer surgeries were performed in patients at higher perioperative risk (American Society of Anesthesiologists score ≥3), with radical cystectomy contributing the most to this cohort (50%). Our real-life data contextualise ongoing recommendations on prioritisation strategies during the current COVID-19 pandemic, highlighting the need for better patient selection for surgery. We found that approximately two-thirds of elective major uro-oncologic surgeries can be safely postponed or changed to another treatment modality when the availability of health care resources is reduced. Patient summary: We used data from three high-volume Italian academic urology centres to evaluate how many surgeries performed for prostate, bladder, kidney, and upper tract urothelial cancer can be postponed in times of emergency. We found that approximately two-thirds of patients with these cancers do not require high-priority surgery. Conversely, of patients requiring high-priority surgery, approximately one in four is considered at high perioperative risk. These patients may pose challenges in allocation of resources in critical scenarios such as the current COVID-19 pandemic.
Article
Full-text available
Background: /Objective: Currently there are few report of oncologic outcomes following robotic-assisted radical nephroureterectomy (RRNU) based on long-term follow-up. To evaluate the therapeutic effect of RRNU for upper tract urothelial carcinoma (UTUC), a technique of single-docking RRNU was described and its oncological outcomes was evaluated. Patients and methods: The data of 29 patients underwent RRNU for UTUC of Ta-T3 from July 2013 to June 2016 was analyzed. The data of 131 patients of UTUC underwent laparoscopic radical nephroureterectomy (LRNU) over the same period was analyzed as control. Kaplan-Meier analysis and Cox regression were used for prognosis evaluation. Results: The median follow-up time was 40.5 and 40.4 months in RRNU cohort and LRNU cohort. No difference in 5-year intravesical recurrence-free survival (IVRFS) (88.0% vs. 85.5%, p = 0.611) or distant metastasis-free survival (93.1% vs.96.7%, p = 0.323) between RRNU cohort and LRNU cohort. The 5-year retroperitoneal recurrence-free survival and cancer-specific survival (CS) were lower in RRNU cohort than in LRNU cohort (77.3% vs. 87.7%, and 71.2% v.s. 84.7%, respectively). Conclusion: The single-docking RRNU is an effective treatment for UTUC, avoiding the re-docking of patient-side cart or the intraoperative reposition of patient, and bringing equivalent 5-year IVRFS compared to LRNU. However, the lower 5-year retroperitoneal recurrence-free survival and CS in RRNU cohort warned the concern of higher chance of local tumor spillage during RRNU. The noninferiority of RRNU to LRNU still needed the confirmation of large sample sized, prospective randomized controlled study.
Article
Full-text available
Background: We aimed to estimate the stage-specific impact of lymph node dissection (LND) on survival for upper urinary tract urothelial carcinoma (UTUC) patients treated with nephroureterectomy (NU). Methods: Overall, 7278 UTUC patients undergoing NU within the SEER database from 2004 to 2015 were identified. Kaplan-Meier plots illustrated overall survival (OS) and cancer-specific survival (CSS) rates according to LND status. Multivariable Cox regression analyses assessed the effect of LND on OS and CSS rates stratified by pathological tumor stage. Results: LND was performed in 26.9% of patients, and in 18.6, 23.3, 31.2 and 45.9% for pT1, pT2, pT3 and pT4 patients, respectively (P < 0.001). In multivariable Cox regression analyses, LND was associated with a higher OS or CSS in UTUC patients with pT3 and pT4 disease (all P < 0.05), but failed to achieve independent predictor status in patients with pT1 and pT2 disease (all P > 0.05). LND with 1 to 3 regional lymph nodes removed was prone to a higher OS or CSS only in pT4 compared to no LND (both P < 0.01). LND with 4 or more regional lymph nodes removed predisposed to a higher OS or CSS in pT3 or pT4 (all P < 0.05). Conclusions: The beneficial effect of LND especially LND with 4 or more regional lymph nodes removed on survival was evident in pT3/4 patients. LND can be considered for pT3 and pT4, for pT1/2 remains to be seen, both of which will be verified by further prospective studies.
Article
Full-text available
Purpose To perform a systematic review and meta-analysis of the literature inherent robotic nephroureterectomy (RNU) and to compare its outcomes with those of other nephroureterectomy (NU) techniques. Methods A systematic literature search was performed up to April 2019 using PubMed, Embase®, and Web of Science. The Preferred Reporting Items for Systematic Review and Meta-analysis Statement was followed for study selection. The following data were extracted for each study: baseline features, surgical outcomes, oncological outcomes, and survival outcomes. Stata® 15.0 was used for statistical analysis. Results Literature search identified 80 studies eligible for the meta-analysis and overall 87,291 patients were included in the analysis: open NU (ONU; n = 45,601), hand-assisted laparoscopic NU (HALNU; n = 442), laparoscopic NU (LNU n = 31,093), and RNU (n = 10,155). RNU was more likely to be performed in those patients with multifocal tumor location (proportion: 0.19; 95% CI 0.14, 0.24) and high-grade disease (proportion: 0.70; 95% CI 0.53, 0.68). The lowest EBL was recorded in the RNU group (weighted mean (WM) 163.31 mL; 95% CI 88.94, 237.68), whereas the highest was in the ONU group (414.99 mL; 95% CI 378.52, 451.46). Operative time was shorter for ONU (224.98 mL; 95% CI 212.26, 237.69). RNU had lower rate of intraoperative complications (0.02; 95% CI 0.01, 0.05). ONU showed higher odds of transfusions (0.20; 95% CI 0.15, 0.25). LOS was statistically significantly shorter for the RNU group (5.35 days; 95% CI 4.97, 5.82). HALNU seemed to present lower risk of PSM (0.02; 95% CI − 0.01, 0.05), and lower risk of recurrence (0.22; 95% CI 0.15, 0.30), metastasis (0.07; 95% CI 0.05, 0.10), and cancer-related death (0.03; 95% CI 0.01, 0.06). ONU showed the lowest 5 years cancer specific survival (proportion: 0.77; 95% CI 0.74, 0.80). No correlation was found between the surgical technique and recurrence-free and cancer-specific survival. Conclusions Evidence regarding RNU for the treatment of UTUC is increasing but it remains quite sparse and of low quality. Despite this, RNU seems to be safe, and to offer the advantages of a minimally invasive approach without impairing the oncological outcomes. Nevertheless, ONU, HALNU, and LNU still represent a valid, and commonly used surgical treatment option. As RNU becomes more popular, and concerns related to its use remain, the best surgical technique for NU remains to be determined.
Article
Full-text available
Purpose To report a multi-institutional experience on robotic radical nephroureterectomy (RNU) and segmental ureterectomy (SU) for upper tract urothelial carcinoma (UTUC). Methods Data were prospectively collected from patients with non-metastatic UTUC undergoing robotic SU or RNU at three referral centers between 2015 and 2018. Transperitoneal, single-docking robotic RNU followed established principles. Bladder cuff excision (BCE) was performed with robotic or open approach. Techniques for SU included: ureteral resection and primary uretero-ureterostomy; partial pyelectomy and modified pyeloplasty; ureteral resection with BCE and direct- or psoas hitch-ureteroneocystostomy. We retrospectively evaluated the technical feasibility, and peri-operative and oncologic outcomes after robotic RNU/SU. Results 81 patients were included. No case required conversion to open surgery. Early major (Clavien–Dindo grade > 2) complications were reported in six (7.4%) patients (two after SU, four after RNU). Three patients experienced late major complications (one after SU, two after RNU). Median ΔeGFR at 3 months was − 1 ml/min/1.73 m² after SU and − 15 ml/min/1.73 m² after RNU. Positive surgical margins were recorded in five patients (one after SU, four after RNU). Median follow-up was 21 months and 22 months in the SU and RNU groups, respectively. Three (20%) patients had ipsilateral upper tract recurrence after SU, while five (7.5%) developed metastases after RNU. No case of port-site metastases or peritoneal carcinomatosis was reported. At last follow-up, 67 (82.7%) patients were alive without evidence of disease. Conclusion Robotic SU and RNU are technically feasible and achieved promising peri-operative and oncologic outcomes in selected patients with non-metastatic UTUC.
Article
Introduction and Objective: Robotic radical nephroureterectomy (RRNU) may offer advantages over laparoscopic radical nephroureterectomy (LRNU). The purpose of this study is to evaluate the overall survival (OS) of patients with upper tract urothelial carcinoma (UTUC) who underwent RRNU vs LRNU and identify factors that account for differences. Methods: The National Cancer Database was queried from 2010 to 2016 for patients with American Joint Committee on Cancer 6th/7th edition Stage I/II/III UTUC. Kaplan-Meier analysis compared LRNU and RRNU OS. Univariate analysis detected differences between the groups. Cox regression determined factors associated with mortality rate. Logistic regression identified predictors of a lymph node dissection (LND) and 90-day mortality rate. Results: A total of 2631 patients met the criteria, 1129 of whom underwent RRNU and 1502 LRNU, with a follow-up of 33 and 35 months, respectively (p = 0.063). RRNU had a median OS of 71.1 vs 62.6 months (p = 0.033). LRNU patients were older (72.7 vs 71.4, p < 0.001) and had no differences in comorbidities, pathologic T stage, or grade. The LRNU cohort was less likely to undergo LND (19% vs 35%, p < 0.001) and had a lower median lymph node yield (3 vs 4, p < 0.001). LRNU patients more likely underwent conversion to an open procedure, had longer hospital stays, and higher 30- and 90-day mortality rates. LRNU was independently associated with mortality rate (p = 0.030). Age, grade, positive margins, pT/pN stage were associated with mortality rate. Younger age, RRNU, surgery at an academic center, and neoadjuvant chemotherapy predicted an LND. Conclusions: RRNU demonstrated increased rates of LND and may offer a short-term morbidity benefit to LRNU. Survival differences may be due to improved characterization of disease through LND.
Article
Upper tract urothelial carcinoma (UTUC) accounts for roughly 5% of urothelial carcinomas. Historically, the gold standard for high-risk or bulky low-risk UTUC was an open radical nephroureterectomy with formal bladder cuff excision (BCE). The development of novel endoscopic, laparoscopic, and robotic techniques has transformed this operation, yet no level I evidence exists at present that demonstrates the superiority of one strategy over another. While new approaches to nephroureterectomy in the last decade have shifted the management paradigm to decrease the morbidity of surgery, controversy continues to surround the approach to the distal ureter and bladder cuff. Debate continues within the urologic community over which surgical approach is best when managing UTUC and how various approaches impact clinical outcomes such as intravesical recurrence, recurrence-free survival (RFS) and disease-specific mortality (DSM). When focusing on the existing treatment algorithm, key metrics of quality include (I) removal of the entire specimen en bloc, (II) minimizing the risk of tumor and urine spillage, (III) R0 resection, and (IV) water-tight closure allowing for early use of prophylactic intravesical chemotherapy. In the absence of robust evidence demonstrating a single superior approach, the urologic surgeon should base decisions on technical comfort and each patient's particular clinical circumstance.
Article
Context The European Association of Urology (EAU) Guidelines Panel on Upper Urinary Tract Urothelial Carcinoma (UTUC) has prepared updated guidelines to aid clinicians in the current evidence-based management of UTUC and to incorporate recommendations into clinical practice. Objective To provide an overview of the EAU guidelines on UTUC as an aid to clinicians. Evidence acquisition The recommendations provided in the current guidelines are based on a thorough review of available UTUC guidelines and articles identified following a systematic search of Medline. Data on urothelial malignancies and UTUC were searched using the following keywords: urinary tract cancer, urothelial carcinomas, upper urinary tract carcinoma, renal pelvis, ureter, bladder cancer, chemotherapy, ureteroscopy, nephroureterectomy, neoplasm, adjuvant treatment, instillation, recurrence, risk factors, and survival. References were weighted by a panel of experts. Evidence synthesis Owing to the rarity of UTUC, there are insufficient data to provide strong recommendations. The 2017 tumour, node, metastasis (TNM) classification is recommended. Recommendations are given for diagnosis and risk stratification as well as for radical and conservative treatment, and prognostic factors are discussed. A single postoperative dose of intravesical mitomycin after nephroureterectomy reduces the risk of bladder tumour recurrence. Kidney-sparing management should be offered as a primary treatment option to patients with low-risk tumour and two functional kidneys. After radical nephroureterectomy, cisplatin-based chemotherapy is indicated in locally advanced UTUC. Conclusions These guidelines contain information on the management of individual patients according to a current standardised approach. Urologists should take into account the specific clinical characteristics of each patient when determining the optimal treatment regimen, based on the proposed risk stratification of these tumours. Patient summary Urothelial carcinoma of the upper urinary tract is rare, but because 60% of these tumours are invasive at diagnosis, an appropriate diagnosis is most important. A number of known risk factors exist.
Article
Each year, the American Cancer Society estimates the numbers of new cancer cases and deaths that will occur in the United States and compiles the most recent data on population‐based cancer occurrence. Incidence data (through 2016) were collected by the Surveillance, Epidemiology, and End Results Program; the National Program of Cancer Registries; and the North American Association of Central Cancer Registries. Mortality data (through 2017) were collected by the National Center for Health Statistics. In 2020, 1,806,590 new cancer cases and 606,520 cancer deaths are projected to occur in the United States. The cancer death rate rose until 1991, then fell continuously through 2017, resulting in an overall decline of 29% that translates into an estimated 2.9 million fewer cancer deaths than would have occurred if peak rates had persisted. This progress is driven by long‐term declines in death rates for the 4 leading cancers (lung, colorectal, breast, prostate); however, over the past decade (2008‐2017), reductions slowed for female breast and colorectal cancers, and halted for prostate cancer. In contrast, declines accelerated for lung cancer, from 3% annually during 2008 through 2013 to 5% during 2013 through 2017 in men and from 2% to almost 4% in women, spurring the largest ever single‐year drop in overall cancer mortality of 2.2% from 2016 to 2017. Yet lung cancer still caused more deaths in 2017 than breast, prostate, colorectal, and brain cancers combined. Recent mortality declines were also dramatic for melanoma of the skin in the wake of US Food and Drug Administration approval of new therapies for metastatic disease, escalating to 7% annually during 2013 through 2017 from 1% during 2006 through 2010 in men and women aged 50 to 64 years and from 2% to 3% in those aged 20 to 49 years; annual declines of 5% to 6% in individuals aged 65 years and older are particularly striking because rates in this age group were increasing prior to 2013. It is also notable that long‐term rapid increases in liver cancer mortality have attenuated in women and stabilized in men. In summary, slowing momentum for some cancers amenable to early detection is juxtaposed with notable gains for other common cancers.