Clinical Data
The research is approved by Ethics Committee of Yantai Yuhuangding Hospital, and patients have signed the informed consent allowing us do this research. 64 patients with UTUC were selected from September 2019 to March 2021. 29 patients underwent robotic-assisted radical nephroureterectomy with excision of bladder cuff as robotic group, and 35 patients underwent laparoscopic radical nephroureterectomy with excision of bladder cuff as laparoscopic group, which were all operated by one same surgical team.
There were 15 males and 14 females aged between 56 and 84 years in robotic group. And 17 males and 18 females aged from 59 to 78 years were enrolled in laparoscopic group. 22 patients visited doctor because of painless gross hematuria symptoms in robotic group, and there were 23 patients in laparoscopic group. All patients were diagnosed by computed computed tumor-graphic urography (CTU) and magnetic resonance urography (MRU) to ensure the tumor location and tumor size before surgery. In robotic group, 12 patients were left lesions and 17 patients were right lesions, 19 had renal pelvis tumors while 10 patients had ureteral tumors higher than the crossing of the common iliac artery. In laparoscopic group, 14 patients were left lesions and 21 patients were right lesions, 23 had renal pelvis tumors while 12 patients had ureteral tumors higher than the crossing of the common iliac artery. And patients were also accepted cystoscopy to eliminated possibility of bladder tumor. Renal dynamic imaging and glomerular filtration rate (GFR) tests were adopted to evaluate contralateral renal function. And American Society of Anesthesiologists (ASA) score was 2.38±0.62 in robotic group, which was not statistical difference compared with laparoscopic group (2.49±0.56). There was not statistically significant difference in general conditions as gender, age, BMI, hematuria symptom, tumor size, tumor location, tumor stage and ASA between two groups (P>0.05).
Excluding criteria
Patients were excluded as following criteria: patients who suffered bilateral renal and ureter tumor, tumor with node metastasis, tumor located in the ureter lower than the crossing of the common iliac artery, bladder carcinoma, simultaneous pelvis or ureter tumor were not counted.
Surgical Technique
Robotic Group
A catheter was inserted into the urethra after general anesthesia. With the lesion side up, firstly, the patient kept lateral decubitus position in 70°. And the waist bridge was raised when the patient’s navel located in the middle of operating bed. Then the assistant sterilized operation region and connected the equipment.
On the first step (taking UTUC at the right side as an example, Fig. 1A), the initial 12 mm camera port (port A) was placed just lateral to musculus rectus abdominis and parallel to the navel level. The first 8 mm working port (port B) was placed 2cm below the costal margin lateral to the musculus rectus abdominis to ensure enough working space. The second working port (port C) was placed about 2 cm above to the anterior superior iliac spine. A 12 mm assistant port (port D) was placed above the navel to avoide interference in the step two. The robot was docked over the back of the patient on the head side (Fig.1B). After entering the abdominal cavity, we incised the paracolic sulci and posterior peritoneum to find ureter (Fig. 2A). As the right side, to expose renal hilum, we usually followed the ureter to find it. On the left side, we followed the ureter and gonadal vein to find the renal hilum and expose renal vein and artery as the gonadal vein inserted renal vein. Once the renal hilum was identified, the renal vein was dissociated with other connective tissue and clipped with three Hem-o-lock clips. The distal vein between two hem-o-lock clips was cut with scissors to identify and release the renal artery, which was processed in a similar way (Fig. 2B). In order to prevent bleeding and lymphatic leakage, bipolar fulguration and clips were crucial. As soon as the renal hilum was controlled, the ureter was clipped below the primary tumor site with a hem-o-lock clip to prevent the tumor from spreading during renal mobilization and excision of the kidney. Then kidney and perirenal fat were completely free without adrenal gland. As we finished the isolation of the kidney and upper ureter, the second step exposing the lower ureter and vesico-ureteric junction was carried out. On the second step, one experienced circuit nurse changed the patient’s position from 70° to 50°, as the adjustment of the patient’s position could improve the comfort of the surgical operation. The third working port (port E) was placed about 5cm below to the navel after nephrectomy (Fig. 1C). Then the robot was changed on the foot side over the back of patient (Fig. 1D). And the assistant changed the robotic working arms from port B and port C to port C and port E, while the camera port was stable. Afterwards, lower ureter was continued to be dissected till the level of the vesico-ureteric junction. The goal of the second step was to dissect the distal ureter, vesico-ureteric junction, and bladder cuff clearly. Periureteric lymphatics and blood vessels to the ureter were fulgurated with bipolar energy to prevent bleeding and seepage. Then pulling the ureter (Fig. 2C) appears the bladder wall to cephalic side and cutting the bladder wall (Fig. 2D,2E). Then the distal ureter and bladder cuff were removed (Fig. 2F). And bladder opening was closed in a running fashion using the previously placed barbed suture in a double layer (Fig. 2G,2H). Bladder closure was checked with instillation of saline through the catheter, to observe the presence or absence of urine leakage. This was an extremely important step if postoperative intravesical chemotherapy was contemplated to prevent recurrence. Then the kidney and ureter were placed in specimen bag with a diameter of 130mm. The pneumoperitoneum pressure was change to 5mmHg to observe the active bleeding of wound. A 6 cm (5-7cm)-wide incision in the midline inferior to the navel was made to take out the surgical specimens. After pulling out the trocar B, a F20 porous drainage tube was placed at the pelvic cavities. The incision on the abdominal wall was sutured, stapled, or adhered.
Laparoscopic Group
After general anesthesia, the patient was placed in lateral decubitus position with lesion side up. The assistant finished disinfection and placed the ports. Port a was placed lateral of the navel, port b was placed in the intersection point of navel level and anterior axillary line, port c was placed at lateral to musculus rectus abdominis above navel and port d was placed blow port a (Fig. 3). Firstly, the renal hilus should be found through dissociate connected tissue. After clipping and cutting the renal vein and artery, the kidney was completely freed. Then the ureter was clamped by hem-o-lock and dissociated as possible as we could. Then they change their position from head side to foot side, which was beneficial to remove the distal ureter dissection and connected bladder wall. And the bladder was sutured with 2-0 barbed suture. Bladder closure was checked by instilling saline. If urine leakage was not observed, the drainage tube was placed and the incision was closed step by step.
Follow Up
All patients followed until March 2021 received intravesical instillation therapy 2 weeks after surgery, once a week for 4~8 times and then once a month for a total of 1 year. According to EUA guidelines, all patients underwent cystoscopy once 3 months for 1 year, thereafter once a year. And CTU examination was performed at intervals of every 6 months for 2 years after surgery, and then once annually.
Statistical analysis
The corresponding indicators of the two groups were recorded and compared, and then the data were analyzed by using the SPSS 25.0 software. Continuous variables were analyzed by T test, while categorical variables were analyzed by chi-square test or Fisher’s exact test. As P-value less than 0.05, we considered the comparation of two group was statistically significant difference