Radical Nephroureterectomy (RNUx) is the gold standard for treatment of high-risk upper-tract urothelial carcinoma (UTUC). While the open approach has historically been the standard of care, the emergence of minimally-invasive approaches, specifically robotics, has provided Urologists with a new way to treat patients with high-risk UTUC requiring surgical intervention. This review article provides a comprehensive narrative on the subject.1
Aside from the clear advantages of minimally-invasive surgery that include decreased peri-operative morbidity (e.g. reduced intra-operative blood loss and incision-related complications), reduced hospital stays, and shorter return to activities of daily living. The robotic approach to RNUx offers a unique advantage of combining upper and lower tract (i.e. multi-quadrant) access without needing to re-position the patient, re-dock the robot, or create additional incisions.
However, this was not always the case as initial minimally-invasive techniques involved hybrid surgery with pure laparoscopy for upper tract extirpation (e.g. nephroureterectomy), requiring repositioning and docking of the robot for lower tract reconstruction (e.g. bladder cuff excision, cystotomy repair).2 The evolution of robotics addressed this limitation, where modified positioning and increased surgical efficiency (e.g. increased freedom of robotic arms, etc.) with the development of the da Vinci Xi eliminated the need to re-position and re-dock, effectively creating a unified approach appropriately termed “single-docking.”3,4
The open approach to RNUx either requires a larger single incision or two separate incisions to achieve the same access. While pure laparoscopy may also circumvent the morbidity associated with an open-approach, it has been shown to have inferior oncological outcomes, likely attributed to technical limitations during bladder cuff excision and cystotomy reconstruction, instead depending upon endoscopic repair that confers greater intravesical recurrence risk.5 Technical limitations of pure laparoscopic or endoscopic repairs risk leaving the ureteral stump that portends poor oncologic outcomes.6 The performance of template-based lymph node dissection, which likely confers a survival advantage, may also be technically challenging using standard laparoscopy. Lymph node dissection is technically feasible with the robotic approach and allows for greater yield and more meticulous dissection given three-dimensional visualization, magnification, and EndoWrist technology. Amongst the minimally invasive approaches, robotics provide superior functional benefits without sacrificing oncological outcomes when compared to the open approach.3,7 To date there is only one series in the literature that has reported oncologic outcomes of robotic-assisted laparoscopic nephroureterectomy,8 however long-term outcome data is still needed.
Ultimately, the robotic approach to RNUx allows achievement of the “pentafecta” which includes radical nephrectomy, ureterectomy with early clipping to prevent downward seeding, lymph node dissection, bladder cuff excision and closure, and instillation of intravesical chemotherapy. Currently, at Wake Forest Baptist Medical Center we have an ongoing multicenter prospective trial evaluating the effects of gemcitabine for intravesical therapy during RNUx (NCT04398368).
This narrative review highlights the inherent advantages of the robotic approach. “Single-docking” obviates the need for intraoperative re-positioning, which allows performance of multi-quadrant surgery in a minimally invasive fashion. Compared to the current standard open approach, robotic RNUx has been shown to offer potentially equivocal oncological outcomes but with the advantages of minimally invasive surgery. While studies showing long-term oncologic outcome data are still needed, the current data is promising in support of robotic RNUx as the new standard of care for high risk UTUC where surgery is indicated.
Written by: Raymond Xu MD,1 Sumit Saini MD,1 Parth Thakker MD,1 Ram Anil Pathak MD,2 & Ashok Kumar Hemal MD1- Wake Forest University School of Medicine, Winston-Salem, NC
- Mayo Clinic, Jacksonville, FL
References:
- Saini S, Pathak RA, Hemal AK. Robotic nephroureterectomy in the management of upper tract urothelial cancer: inching toward standard of care? Int Urol Nephrol. 2022 Aug;54(8):1777-1785.
- Hu JC, Silletti JP, Williams SB (2008) Initial experience with robot-assisted minimally-invasive nephroureterectomy. J Endourol 22(4):699–704. https:// doi. org/ 10. 1089/ end. 2007. 0333
- Hemal AK, Stansel I, Babbar P, Patel M (2011) Robotic-assisted nephroureterectomy and bladder cuff excision without intraoperative repositioning. Urology 78(2):357-364. https://doi.org/10.1016/j.urology.2010.12.075
- Patel MN, Hemal AK. Does Advancing Technology Improve Outcomes? Comparison of the Da Vinci Standard/S/Si to the Xi Robotic Platforms During Robotic Nephroureterectomy. J Endourol. 2018 Feb;32(2):133-138.
- Xylinas E, Rink M, Cha EK, Clozel T, Lee RK, Fajkovic H, Comploj E, Novara G, Margulis V, Raman JD, Lotan Y, Kassouf W, Fritsche HM, Weizer A, Martinez-Salamanca JI, Matsumoto K, Zigeuner R, Pycha A, Scherr DS, Seitz C, Walton T, Trinh QD, Karakiewicz PI, Matin S, Montorsi F, Zerbib M, Shariat SF, Upper Tract Urothelial Carcinoma Collaboration (2014) Impact of distal ureter management on oncologic outcomes following radical nephroureterectomy for upper tract urothelial carcinoma. Eur Urol 65(1):210–217.
- Pathak RA, Hemal AK. Fate of residual ureteral stump in patients undergoing robot-assisted radical nephroureterectomy for high-risk upper tract urothelial carcinoma. Transl Androl Urol. 2020 Apr;9(2):856-862.
- Zeuschner P, Vollmer SG, Linxweiler J, Wagenpfeil G, Wagenpfeil S, Saar M, Siemer S, Stöckle M, Heinzelbecker J (2021) Robotassisted versus open radical nephroureterectomy for urothelial carcinoma of the upper urinary tract: a retrospective cohort study across ten years. SurgOncol 16(38):101607. https:// doi. org/ 10.1016/j. suronc. 2021. 101607
- 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 Dec;194(6):1561-6.
- Pathak RA, Hemal AK. Techniques and Outcomes of Robot-assisted Nephro-ureterectomy for Upper Tract Urothelial Carcinoma. Eur Urol Focus. 2018 Sep;4(5):657-661.