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Table of Contents
ORIGINAL ARTICLE
Year : 2018  |  Volume : 29  |  Issue : 1  |  Page : 38-42

Evaluation of perioperative complications and outcomes of robot-assisted radical nephroureterectomy and bladder cuff excision in a tertiary center


1 Department of Urology, Taipei Veterans General Hospital, Taipei, Taiwan
2 Department of Urology, Taipei Veterans General Hospital; Department of Urology, School of Medicine, Shu-Tien Urological Institute, National Yang-Ming University, Taipei, Taiwan

Date of Web Publication23-Feb-2018

Correspondence Address:
Tzu-Chun Wei
Department of Urology, Taipei Veterans General Hospital, No. 201, Section 2, Shipai Road, Beitou District, Taipei 11217
Taiwan
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/UROS.UROS_7_17

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  Abstract 

Purpose: For patients with localized upper tract urothelial carcinoma (UTUC), radical nephroureterectomy with ipsilateral bladder cuff excision (RNU + BCE) is the standard treatment. In recent years, robot-assisted RNU with BCE (RaRNU + BCE) has been another choice of surgical intervention. This article was aimed to analyze the efficacy and perioperative outcomes regarding RaRNU + BCE through a single institutional experience. Patients and Methods: From March 2012 to November 2015, a total of 54 patients with UTUC were treated with RaRNU + BCE at Taipei Veterans General Hospital. We collected demographic data, histopathological reports, perioperative complications, and oncologic outcomes. Results: A total of 54 patients were included in our study. The mean age was 71.9 ± 9.9 (range 48–88) and the mean body mass index was 23.5 ± 2.9 (range: 16.4–30.8). The mean operating time was 314 min (RaRNU: 133.9 ± 41.4 min and RaBCE: 72.9 ± 25.7 min). The mean first docking time was 26.8 ± 7.7 min and the mean second docking time was 16.5 ± 6.7 min. The mean EBL was 87.7 ml. Pathological stage distribution was 22.2%, 27.8%, 13.0%, 31.5%, and 5.6% in pTa, pT1, pT2, pT3, and pT4, respectively. Complications occurred in 7 cases (13%), with 4 Grade I and 3 Grade II by Clavien-Dindo classification. Positive tumor involvement at bladder cuff was noted in three patients, and the bladder recurrence rate was 29.6%. Local recurrence, lymph node metastasis, and distant metastasis were all noted for two patients, respectively. The cancer-specific and overall survival rate was 98.1% and 96.3%. Conclusions: Our experience showed that RaRNU + BCE is a technically feasible and safe procedure for selected patients with UTUC.

Keywords: Bladder cuff excision, nephroureterectomy, robot, upper tract urothelial carcinoma


How to cite this article:
Tai MC, Chung HJ, Wei TC, Lin TP, Huang EY, Lu SH, Chang YH, L. Lin AT. Evaluation of perioperative complications and outcomes of robot-assisted radical nephroureterectomy and bladder cuff excision in a tertiary center. Urol Sci 2018;29:38-42

How to cite this URL:
Tai MC, Chung HJ, Wei TC, Lin TP, Huang EY, Lu SH, Chang YH, L. Lin AT. Evaluation of perioperative complications and outcomes of robot-assisted radical nephroureterectomy and bladder cuff excision in a tertiary center. Urol Sci [serial online] 2018 [cited 2020 Aug 6];29:38-42. Available from: http://www.e-urol-sci.com/text.asp?2018/29/1/38/226032


  Introduction Top


The incidence of upper tract urothelial carcinoma (UTUC) rises from 1.88 to 2.06 cases per 100,000 person-years in 30 years.[1] In Taiwan, the incidence of UTUC accounts for 23.4%, which is higher than in Western countries.[2] For renal pelvis or ureteral tumor, radical nephroureterectomy with ipsilateral bladder cuff excision (RNU + BCE) is the standard treatment for high-risk UTUC.[3] The first case of laparoscopic RNU + BCE was presented by Clayman et al. in 1991,[4] and good perioperative safety and comparable oncologic outcomes to open RNU + BCE was reported.[5] With the development of technology, the da Vinci robot system (Intuitive Surgical, Sunnyvale, CA, USA) has been widely used in urologic surgery. It can reduce the technical challenges of intracorporeal suturing and learning curve for beginners to laparoscopic urology.[6] In Taipei Veterans General Hospital, robot-assisted RNU with BCE (RaRNU + BCE) has been used to treat patient since 2012. Thus, we presented the efficacy, perioperative, and oncologic outcomes regarding RaRNU + BCE for UTUC.


  Patients and Methods Top


From March 2012 to November 2015, we reviewed the chart of patients receiving RaRNU + BCE for UTUC at Taipei Veterans General Hospital retrospectively. All the cases were done with da Vinci Surgical System Si. The robot was redocked after RNU + BCE, but the position of the patient was not changed. Distant metastasis was excluded while preoperative evaluation, and lymph node dissection was not performed routinely unless enlarged lymphadenopathy had been suspected. We collected demographic data, histopathological reports, perioperative complications, and oncologic outcomes.

Take left side tumor, for example, the patient was placed in the right lateral position after general anesthesia. A 2 cm incision was made at 1 cm left lateral to umbilicus, and pneumoperitoneum was established through Veress needle. A 12 mm trocar was indwelled as a camera port. Another three 8 mm robotic trocars was placed, with the first one on the same umbilical level about 10 cm far away from the first trocar, the second one on the midclavicular line, about 10 cm far away from the first trocar up at the subcostal region, and the third 8 mm trocar also at the midclavicular line down at the level of iliac crest about 10 cm from the first trocar. Another 12 mm assistant trocar was placed at lower midline, about 5 cm lower than umbilicus [Figure 1]. Da Vinci system arms were docked from upper left site first. We identified the ureter first and dissected the ureter toward the renal hilum. The renal artery and vein were ligated by Endo GIA. After radical nephrectomy completed, the da Vinci system was redocked toward distal ureter and bladder cuff. The da Vinci system arms were docked from lower left site and the third arm was switched to the other side [Figure 1]. We dissected the entire intramural ureter and orifice extravesically, and the whole BCE was performed completely intracorporeally. The defect of urinary bladder was repaired with 3-0 Monocryl. Then, we extended the assistant port along the midline to extract the specimen. All surgeries were performed with the da Vinci system successfully.
Figure 1: Ports placement for robotic assisted left-side nephroureterectomy

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  Results Top


A total of 54 patients receiving RaRNU + BCE from a single institute were analyzed. The demographic and perioperative data of the patients were shown in [Table 1] and [Table 2]. The mean age was 71.9 (48–88). Renal pelvis tumor was noted in 29 patients. Concomitant bladder tumor was found in six patients when UTUC was diagnosed by ureterorenoscopy, and transurethral resection of the bladder tumor (TURBT) was performed simultaneously. Only one patient had UTUC during follow-up for bladder cancer. The mean operating time was 314 min (RaRNU: 133.9 min and RaBCE: 72.9 min). The mean first docking time was 26.8 min, and the mean second docking time was 16.5 min. The mean operating time decrease could be noted from the initial twenty procedures to over forty procedures [Table 2]. The mean EBL was 87.7 ml. Pathological stage distribution was 22.2%, 27.8%, 13.0%, 31.5%, and 5.6% in pTa, pT1, pT2, pT3, and pT4, respectively [Table 3]. Only one of the two patients had positive lymph node dissection. There was no patient receiving neoadjuvant chemotherapy. Adjuvant chemotherapy was suggested in twenty patients who had higher pathological stage such as T3, T4, or N1 after combined multidisciplinary meeting, but only 14 of them decided to receive adjuvant chemotherapy with Gemcitabine + Cisplatin (GCGG).
Table 1: Patient demographic and tumor characteristics

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Table 2: Perioperative data

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Table 3: Histopathological data, perioperative complication, and oncologic outcomes

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Complications occurred in seven cases (13%), with 4 Grade I and 3 Grade II by Clavien-Dindo Classification [Table 3]. One patient with multiple abdominal surgeries, including cesarean section twice, appendectomy, and retroperitoneal tumor resection, experienced thermal injury over intestine during enterolysis. Simple suture of the tearing serosa was performed immediately. There was no leakage, and flatus passage was noted at postoperative day 3, with diet intake resumed smoothly. Another patient experienced abdominal pain, nausea, and vomiting at postoperative day 18. Abdominal computed tomography revealed partial intestinal obstruction. Nasogastric tube was inserted for symptoms' relief, and the patient recovered gradually under conservative management. Two patients had blood transfusion during operations. One patient developed fever at postoperative day 12 and prostatitis was diagnosed and treated with oral antibiotics.

The mean (range) follow-up time was 22.6 (1–49) months. Bladder recurrence was noted in 16 patients, 29.6% [Table 3]. There were three patients whose bladder cuff was involved with tumor. One patient had concomitant bladder tumor before RaRNU + BCE but not the other two. Recurrent bladder tumors were diagnosed at postoperative 3 and 8 months, respectively, in these two patients, respectively. In the postoperation cystoscopy, residual ipsilateral ureter orifice could be seen in 4 patients, and 3 of them had recurrent bladder UC during follow-up. However, for those with complete BCE, there was 26% (13/50) bladder recurrence rate.

During follow-up period, two patients had a local recurrence at ipsilateral pelvis or ipsilateral retroperitoneum; two patients had para-aortic lymph node metastasis. All of them received chemotherapy after a while. Two patients had distant lung metastasis confirmed by lung biopsy, and further wedge resection was performed. Only two patients died during follow-up. One died of lymph node metastasis and the other due to system lupus erythematosus. The cancer-specific survival rate was 98.1% and the overall survival rate was 96.3%.


  Discussion Top


For patients with localized UTUC, less blood loss and hospital stay were noted in laparoscopic RNU + BCE than the open method, with no statistical significances in the oncologic outcomes.[7],[8] However, limited instrumentations, a steep learning curve, and difficult reconstructive techniques were still faults in laparoscopic surgery.[6] The da Vinci robotic system (Intuitive Surgical, Sunnyvale, CA, USA) had a three-dimensional vision and EndoWrist instruments to overcome the technical challenge.[9] However, there has still been not enough evidence supporting the efficacy and oncological outcomes of RaRNU + BCE, especially regarding the cost-effectiveness. In the recently published review article by Wu et al., the most case number was 60.[10] In our study, there were 54 patients, which may be the second most RaRNU + BCE numbers among published literature.

In this study, we evaluate our experience for the management of UTUC using a complete robotic approach with redocking but not repositioning. Lymph node dissection was not performed routinely even for patients with invasive UTUC unless enlarged lymph node was noted in the image before the operation. Therefore, lymphadenectomy was done in two patients because of the preoperative suspicion. Only one of the two had positive lymph node. The benefits of lymphadenectomy remain controversial.[11] Moschini et al. presented that only 24.4% of patients received a concomitant lymphadenectomy during laparoscopic RNU and 7.7% had more than eight lymph nodes.[12] Besides, according to 2017 EAU guideline, “To perform a lymphadenectomy in invasive UTUC” was labeled as Grade C recommendation.

Neoadjuvant chemotherapy was not performed. However, adjuvant chemotherapy was indicated for patients with a higher pathological stage such as T3, T4, or N1, even without visible residual tumor in the follow-up image. In our study, adjuvant chemotherapy was suggested in all these 20 patients after combined multidisciplinary meeting, but only 14 of them finally decided to receive GCGG. For patients with UTUC not suitable for surgery initially, chemotherapy was suggested first. If the tumor became more surgically resectable after the chemotherapy, we usually preferred open instead of laparoscopic or robotic surgery since the difficulties during operation were quite anticipated.

The mean follow-up time was 22.6 (1–49) months. A total of 16 patients (29.6%) experienced urinary bladder recurrence and they all received TURBT. There were three patients whose bladder cuff was involved with tumor. One patient had concomitant bladder tumor before RaRNU + BCE, and incomplete TRUBT near the ureter orifice might be the reason. For another two patients with positive BCE, recurrent bladder tumors were diagnosed at postoperative 3 and 8 months, respectively. This could be assumed that occult tumor near the ipsilateral ureter orifice was not found by preoperation cystoscopy. Concerning about the complete resection of bladder cuff, residual ureter orifice could be seen in 4 (7.4%) patients while the postoperation cystoscopy, and 3 of them had recurrent bladder UC during follow-up. For those with complete BCE, there was still 26% (13/50) recurrence rate, perhaps due to either higher pathologic stage UTUC without acceptance of adjuvant chemotherapy or the multifocal character of UC itself.

During follow-up period, total six patients had local recurrence or distant metastasis. Their pathological stage was pT3 and five of them had received adjuvant chemotherapy. In our study, the bladder recurrence rate was 29.6%, with 75% in the incomplete BCE group and 26% in the complete BCE group. Local recurrence, lymph node metastasis, and distant metastasis rate was 3.7%, 3.7%, and 3.7%, respectively. The cancer-specific and overall survival rate was 98.1% and 96.3%. Aboumohamed et al. presented comparable oncologic outcomes between open and laparoscopic data.[13] They prospectively evaluated 65 patients treated with RaRNU + BCE for UTUC between 2008 and 2014. At the mean follow-up of 25.1 months, 27.2% of patients experienced bladder recurrence and 8.3% had regional or retroperitoneal recurrence. Cancer-specific survival rate at 2 years was 92.9%.[13] Yang et al. evaluated twenty patients who received RaRNU + BCE between 2010 and 2013. Three patients developed recurrence in the urinary bladder and four developed metastatic diseases.[9] Our results were similar to previous reports. Complications occurred in seven cases (12.9%), with 4 Grade I and 3 Grade II by Clavien-Dindo classification [Table 3]. Trudeau et al. reported less overall complications in patients treated with RaRNU compared to laparoscopic RNU (11.9% vs. 18.2%, respectively, P < 0.001),[14] and our results lid between these two reports.

Several limitations existed in this study. It was a retrospective study, and the mean follow-up time was only 22.6 months. Besides, we did not compare RaRNU + BCE to laparoscopic or open method. Although we had comparable oncologic outcomes and complication rate, longer follow-up and randomized controlled studies are still necessary to determine the benefit for RaRNU + BCE, especially concerning about the cost-effectiveness.


  Conclusions Top


In the single institute study, completely intracorporeal robot-assisted RNU with ipsilateral BCE showed comparable oncologic outcomes and perioperative complications. Therefore, it is a technically feasible and safe procedure for selected patients with UTUC.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Raman JD, Messer J, Sielatycki JA, Hollenbeak CS. Incidence and survival of patients with carcinoma of the ureter and renal pelvis in the USA, 1973-2005. BJU Int 2011;107:1059-64.  Back to cited text no. 1
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Chen CY, Liao YM, Tsai WM, Kuo HC. Upper urinary tract urothelial carcinoma in Eastern Taiwan: High proportion among all urothelial carcinomas and correlation with chronic kidney disease. J Formos Med Assoc 2007;106:992-8.  Back to cited text no. 2
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Rouprêt M, Babjuk M, Compérat E, Zigeuner R, Sylvester RJ, Burger M, et al. European association of urology guidelines on upper urinary tract urothelial cell carcinoma: 2015 update. Eur Urol 2015;68:868-79.  Back to cited text no. 3
    
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Clayman RV, Kavoussi LR, Figenshau RS, Chandhoke PS, Albala DM. Laparoscopic nephroureterectomy: Initial clinical case report. J Laparoendosc Surg 1991;1:343-9.  Back to cited text no. 4
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Ni S, Tao W, Chen Q, Liu L, Jiang H, Hu H, et al. Laparoscopic versus open nephroureterectomy for the treatment of upper urinary tract urothelial carcinoma: A systematic review and cumulative analysis of comparative studies. Eur Urol 2012;61:1142-53.  Back to cited text no. 5
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Rai BP, Shelley M, Coles B, Somani B, Nabi G. Surgical management for upper urinary tract transitional cell carcinoma (UUT-TCC): A systematic review. BJU Int 2012;110:1426-35.  Back to cited text no. 7
    
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Rai BP, Shelley M, Coles B, Biyani CS, El-Mokadem I, Nabi G, et al. Surgical management for upper urinary tract transitional cell carcinoma. Cochrane Database Syst Rev 2011:CD007349.  Back to cited text no. 8
    
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Yang CK, Chung SD, Hung SF, Wu WC, Ou YC, Huang CY, et al. Robot-assisted nephroureterectomy for upper tract urothelial carcinoma: The Taiwan robot urological surgery team (TRUST) experience. World J Surg Oncol 2014;12:219.  Back to cited text no. 9
    
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Wu WC, Hung SF, Yii SC, Tsai CY, Chung SD. Robot-assisted laparoscopic nephroureterectomy for upper tract urothelial carcinoma (UT-UC). Urol Sci 2017;28:63-5.  Back to cited text no. 10
    
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Alvarez-Maestro M, Rivas JG, Gregorio SA, Guerin CC, Gómez ÁT, Ledo JC, et al. Current role of lymphadenectomy in the upper tract urothelial carcinoma. Cent European J Urol 2016;69:384-90.  Back to cited text no. 11
    
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Moschini M, Foerster B, Abufaraj M, Soria F, Seisen T, Roupret M, et al. Trends of lymphadenectomy in upper tract urothelial carcinoma (UTUC) patients treated with radical nephroureterectomy. World J Urol 2017;35:1541-7.  Back to cited text no. 12
    
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Aboumohamed AA, Krane LS, Hemal AK. Oncologic outcomes following robot-assisted laparoscopic nephroureterectomy with bladder cuff excision for upper tract urothelial carcinoma. J Urol 2015;194:1561-6.  Back to cited text no. 13
    
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Trudeau V, Gandaglia G, Shiffmann J, Popa I, Shariat SF, Montorsi F, et al. Robot-assisted versus laparoscopic nephroureterectomy for upper-tract urothelial cancer: A population-based assessment of costs and perioperative outcomes. Can Urol Assoc J 2014;8:E695-701.  Back to cited text no. 14
    


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