V09-10: Newly established approach of an entirely retroperitoneal robotic nephroureterectomy

Peter Sparwasser*, Stefan Epple, Anita Thomas, Robert Dotzauer, Katharina Böhm, Maximilian Peter Brandt, Kamal Gheith, Rene Mager, Martin Kurosch, Hendrik Borgmann, Thomas Höfner, Axel Haferkamp, Igor Tsaur, Mainz, Germany

Introduction: While several surgical techniques have been established for both open and minimally invasive treatment of upper tract urothelial cancer (UTUC), the procedure of robot-assisted nephroureterectomy (NU) including excision of the bladder cuff has never been reported using only retroperitoneum. We developed a novel port placement and step-by-step technique allowing to perform robot-assisted NU by an unique retroperitoneal approach without relocation of the surgical robot.

Methods: Between February and June 2021 patients with history of UTUC and indication for surgery were treated by robot-assisted NU completely restricted to the retroperitoneal space using a singular trocar placement and a two-step docking without relocation of the surgical robot (DaVinci® Xi). Patient characteristics, perioperative outcomes and short-term follow-up were prospectively analyzed.

Results: This analysis included 5 patients [mean age: 67.4yr; BMI: 28.2kg/m2; Charlson comorbidity index 5.2]. All 5 patients had UTUC with a mean tumor size of 3.02cm (range 0.9-6.0). UTUC was thereby localized to distal ureter in 2 and to kidney in 3 cases.  No positive surgical margins were noted for all patients with UTUC [1 low-grade and 4 high-grade]. Retroperitoneal lymphadenectomy in 3 patients did not reveal positive nodes. No intraoperative adverse events exceeding EAUiaiC classification =2 were observed, while EBL was 200ml (range 100-450). No patient experienced postoperative complications exceeding Clavien Dindo classification =3a. Median hospital stay was 5.4d without any 30d-readmission.

Conclusions: We demonstrate safety and feasibility of the first entire robot-assisted retroperitoneal nephroureterectomy (RRNU) with bladder cuff. This surgical technique is easily reproducible, while surgical outcomes are similar to other established techniques. Prospective research is warranted in order to robustly evaluate its supposed benefits over transperitoneal approaches.

Source of Funding: none