Editing Nephroureterectomy (section)

== Robotic-Assisted Laparoscopic Nephroureterectomy ==

=== Contraindications ===
# '''Contraindications to laparoscopic surgery'''
# '''History of extensive abdominal or pelvic surgery'''
# '''Morbid obesity'''
# '''Extremely large tumor'''

=== Advantages ===
to robotic approach
* Reduced blood loss, less pain, and shorter hospital stays

=== Steps of procedure ===
* '''Equipment'''
** Laparoscopic lens: 30 or 0 degrees
** Laparoscopic staplers (12 mm)/Hem-o-Loks (10 mm)
*** If vascular stapler, open staple height of 2.5mm, either 45mm or 60 mm length depending on size of renal vessels
** Sutures
*** Bladder cuff closure
**** 3-0 V-lock on CV-23 (15 cm)
*** Closing
**** 0 Vicryl on UR6 x 2 (port site fascial closure, if needed)
**** 3-0 Vicryl on UR6 x 2 (peritoneal closure of extraction site)
**** 1-0 Vicryl on UR6 x 2 (fascial closure of extraction site)
**** 4-0 monocryl on PS-Z (skin closure)
*** Rescue stitches
**** 4-0 Prolene on RB1 (in case of vascular injury), cut to 10cm
**Specimen Retrieval Pouch
*** Endo Catch™ II 15 mm specimen pouch
**** Can hold 1000 mL[2]
*'''Venous thromboembolism prophylaxis'''
** Compression stockings
** Heparin
*'''Antibiotics'''
**2g cefazolin (TMP-SMX, if penicillin allergic)[https://pubmed.ncbi.nlm.nih.gov/31441676/]
*'''Position:''' 60° ipsilateral (tumor side up) flank with 15° Trendelenburg (head down) tilt.[https://pubmed.ncbi.nlm.nih.gov/24661639/][https://www.youtube.com/watch?v=R4YDeL5_s3E]
* '''Surgical plan'''
**'''Number of ports: 5 (6 if right-sided)''' (variations possible, depending on patient characteristics, surgeon preference, and institution equipment)
***4 x 8mm robotic ports + 1 x 12mm assistant port
** '''Location of ports:'''
*** General considerations for robotic port placement
**** Port placement through the rectus muscle risks damage to the epigastric vessels.[https://www.auanet.org/documents/education/blus-handbook.pdf]
***** The epigastric vessels travel near the lateral edge of the rectus muscles in the lower abdomen and travel closer to the midline in the upper abdomen where they join the internal mammary arteries.[https://www.auanet.org/documents/education/blus-handbook.pdf]
***** Generally if trocars are not placed in the midline, they should be placed at least 6cm lateral to the midline to prevent epigastric injury.[https://www.auanet.org/documents/education/blus-handbook.pdf]
**** >8 cm distance is recommended between robotic ports[https://www.laparoscopyhospital.com/docking-in-robotic-surgery.html]
***** 10-20 cm distance should be maintained between the ports and target anatomy
****** 10 cm distance from TA is good but 20 cm distance is better
***Configuration 1[https://www.youtube.com/watch?v=R4YDeL5_s3E]:
****Oblique straight line, with most inferior port in midline below umbilicus, and most superior port along costal margin at midclavicular line
****Assistant 1 (12 mm): superior to umbilicus, in midline
***Configuration 2[https://pubmed.ncbi.nlm.nih.gov/26970451/] (see Figure in link)
****Camera/Port 3 (8 mm): 3 cm lateral to the umbilicus
**** Port 1 (8 mm): 8 cm superior to camera port, lateral to rectus sheath
**** Port 2 (8 mm): inferior to camera port, on the same line as Port 1
****Port 4 (8 mm): 15 cm lateral to the camera port and 2 cm caudal to the lower pole of the kidney
**** Assistant 1 (12 mm): 5 cm superior to umbilicus, in midline
*** Configuration 3[https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4483175/] (see [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4483175/figure/Fig2/ Right-sided Figure] and [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4483175/figure/Fig3/ Left-sided Figure])
****Oblique straight line, starting with a robotic port located two finger breadths below the costal margin, just lateral to the rectus muscle. Minimum of 6-8cm between the ports.
****Assistant 1 (12 mm): between the two most cephalad robotic ports, closer to the midline
***Configuration 4
****Straight line along the lateral boarder of the ipsilateral rectus sheath, with 6-8 cm between the ports
****Assistant 1 (12 mm): between the two most cephalad robotic ports, in the midline
***If right-sided, additional 5 mm trocar placed just inferior to xiphoid process for liver traction. Use Allis clamp to hold on abdominal wall and retract liver away from surgical field. 
****Depending on liver anatomy, liver retractor may need to be placed in contralateral side.
***Ports are shifted laterally towards the site of disease in obese patients
** '''Step by step:'''
*** '''General anesthesia and insertion of lines.''' Use naso/orograstric tube for gastric decompression during case.
***'''Patient positioning, antiseptic preparation, draping.''' 
**** After induction of general anesthesia...
**** Trim hair overlying operative site, if needed
**** '''If cystoscopy first'''
***** Position patient in lithotomy and perform cystoscopy.
***** Optional: Use a bugbee electrode to cauterize the orifice and the intramural ureter on the tumor bearing side to aid as a marker in the final robotic excision of the distal ureter.[https://pubmed.ncbi.nlm.nih.gov/26970451/]
***** Insert foley catheter +/- instill intravesical gemcitabine.
**** '''If no cystoscopy/after cystoscopy''', 
***** Slide patient up/down table so that ASIS is at/below the break.
***** Slide patient laterally to tumor side of table and roll patient so that the anterior abdomen is placed on the contralateral edge of the table. This allows a greater degree of freedom for the robotic arms without interference from the table.  Position patient in ipsilateral (tumor side up), modified flank/lateral decubitus.
***** Axillary roll should be placed (under the upper chest, at a level inferior to the tip of the scapula, rather than under the axillary region[8]) to prevent neuropraxia.
****** An axillary roll is not required if the patient is tilted at the 45° angle and not lying directly on his or her axilla[9].
***** Use gel rolls, rolled blankets, or a bean bag to support the back.
***** Bottom leg flexed. Top leg straight. Pillows between legs.
***** Secure the patient to the table with wide cloth tape.
***** Optional: Flex table (hyperextend abdomen) slightly. Slight Trendelenburg to level table parallel to floor.
***** Contralateral arm is positioned perpendicular to the torso on a padded arm rest, and the ipsilateral arm is positioned straight on the patient's side OR flexed at the elbow and rested over the chest over pillows.
***** Meticulous foam pad soft tissue and bony sites, including the head and neck, axilla, hip, knee, and ankle, along with careful ergonomically neutral positioning of the neck, arms, and legs
***** Prepare surgical area and drape to expose umbilicus, xiphoid, costal margin, and ASIS.
*** '''Abdominal access with transumbilical Veress needle.''' Apply penetrating towel clamps superior and inferior of umbilicus. With fingers under clamp, gently lift (as excessive elevation can cause separation of the abdominal layers and increase risk of pre-peritoneal placement). Insert Veress needle at 90 degrees. Feel or hear (usually) 2 (corresponding to the penetration of the abdominal fascia and parietal peritoneum) clicks/pops (the protective sheath clicking when it recoils), indicating that the abdominal cavity has been entered.
**** If transumbilical unsuccessful (3 attempts) or contraindicated (presence of umbilical pathology such as adhesions or herniations, peri-umbilical scars, aortic pulsations, thin patient), consider
***** In middle of ASIS and umbilicus and translate this point superiorly to the level of the umbilicus
***** In middle of ASIS and umbilicus and translate this point slightly laterally[https://pubmed.ncbi.nlm.nih.gov/34345564/]
****** If not transumbilical entry, consider: use cautery/knife to make incision at planned entry point. Dissect down through fat to expose fascia. Use Kocher clamp to lift up on fascia. Insert Veress needle.
***** In patients with potential of significant abdominal adhesions, consider open (Hassan) entry
*** '''Test Veress needle and insufflate, if appropriate.''' Aspirate and inspect for blood or fecal content. If negative, inject saline for drop test (though not reliable). Aspirate the needle again. If successful on initial testing, gently advance the needle 0.5cm. Turn on insufflation to high flow (no need to begin at low flow because the size of the Veress needle limits flow to 1.5-2L/min) and evacuate initial air in tubing that is not CO2. Connect gas tubing to needle. Check for 3 consecutive pressure readings below 10mmHg. If pressure >10 mm, withdraw needle slightly. If pressure decreases <10 mm, this indicates that needle tip was against an intra-abdominal structure such as the intestine or omentum. If the pressure remains ≥10 mm Hg, the needle is not properly placed. Achieve pneumoperitoneum to 15 (or 20; 20 facilitates port placement by increasing abdominal resistance, but have to remember to decrease after ports inserted) mm Hg.
*** '''Outline landmarks:''' Use marking pen to outline lateral border of rectus, costal margin, 10th rib, ASIS, (+/- xiphoid if right-sided)
*** '''Outline port sites.''' Use marking pen to denote transverse incisions for ports based on chosen configuration. Start by marking superior port.
*** '''Insert assistant port.''' The visual trocar is used to insert the assistant port. Use knife to make a 12 mm transverse incision at the site of the assistant port. With the camera inside the visual trocar, carefully advance the trocar. Twisting is more important than pushing. Once inside the abdomen, remove canula and open valve (should hear air coming out when opening valve on port). Switch gas to this port. Insert camera.
*** '''Inspect abdomen.''' Check that no injury made during insertion of Veress needle. Check for adhesions that may interfere with port placement.
*** '''Insert remaining ports.''' Transilluminate abdominal wall to avoid large abdominal wall vessels. Begin insertion of most superior port (facilitates visualization). Use knife to make transverse incision. Twist port into incision under vision. Repeat steps for other ports. On right side, setup liver retractor with laparoscopic locking Allis grasper through 5-mm subxiphoid port. Once all ports are positioned, AirSeal is installed and activated and the pneumoperitoneum is reduced to 12-15 mm Hg for the procedure.
*** '''Dock robot'''
**** If Xi
***** Dock robot perpendicular to the bed, over the backside of the patient
*****Attach camera port to robot. Insert and attach camera, +/- target camera. Hold camera port steady and allow robot to adjust. Attach remaining ports to robot.
*****For nephrectomy and lymphadenectomy part
******Robot arm 4 holds Port 1 (monopolar curved scissors)
******Robot arm 1 holds Port 2 (fenestrated bipolar forceps)
******Robot arm 2 holds Port 4 (Prograsp forceps)
******Robot arm 3 holds Port 3/camera
*** '''Medialize bowel to expose retroperitoneum.''' Incise peritoneum at line of Toldt down to sigmoid. The bowel mesentery is bright yellow in color while the retroperitoneal fat is dull yellow. Use blunt and sharp dissection to develop plane anterior to Gerota fascia and posterior to the mesocolon. Release attachments to the spleen (splenocolic and splenorenal) and liver (hepatorenal) as needed.
**** Medial retraction by the assistant facilitates this step.
****Line of Toldt should be divided at the junction between mesocolon and Gerota's fascia.
*****If hole made in mesocolon, repair with absorbable suture.
**** Thin pulsatile vessels belong to the mesentery and should not be divided. If there is undue bleeding, the plane is most likely wrong and needs revision
****'''On the right side, goal is to identify the IVC;''' there is no need for extensive mobilization of the bowel to expose the renal hilum.
***** '''Caution: To avoid duodenal injury, use minimal cautery during the medialization of the duodenum'''
****Take care to leave the kidney attached laterally to avoid unnecessary mobilization into the operative field.
*** '''Identify ureter and gonadal vein'''. Retract Gerota's fascia and lower pole tissues anteriorly to allow identification of the gonadal vein, ureter and psoas muscle. The mid-ureter is identified along the anterior aspect of the psoas, just inferior to the lower pole of the kidney. If too inferior, ureter will be medial and goal is to get under it so better to approach closer to lower pole. Once the ureter is identified, dissect a plane medial and parallel to the ureter +/- gonadal vein.
**** At times, especially early in the experience, the psoas tendon or the iliac artery may be confused with the ureter. It is important to look for the peristalsis of the ureter in case of confusion.
**** '''The gonadal vein is an important anatomic landmark when proceeding toward the renal hilum;''' the renal vein can be identified by tracing the gonadal vein proximally to its insertion in the
***** Renal vein, on the left side
***** Inferior vena cava just caudal to the hilum, on the right side
**** '''On the right side, the gonadal vein is kept medially toward the vena cava, whereas on the left side, the gonadal vein is lifted along with the left ureter to expose the lower margin of the left renal hilum.'''
**** '''Proximally, the gonadal vessels are medial to the ureter. The gonadal vessels descend laterally and cross anterior to the ureter, “water under the bridge”''', '''a third of the way to the bladder.'''
***** '''On the left side, the gonadal vessels cross the left ureter after running parallel to it for a small distance'''
***** On the left side, be careful not to confuse the IMV for the gonadal vein. The IMV will be in the mesocolon, the gonadal vein will be in the retroperitoneal space
**** The gonadal artery is usually found just below the lower pole and if needed, can be ligated and divided.
***'''Ligate ureter'''. Once ureter identified, isolate ureter and place a Hem-o-Lok clip on it below the level of tumor.
***'''Dissect ureter towards bladder.''' While leaving the ureter attached to the kidney, continue distal dissection of the ureter towards the bladder. The superior vesical pedicle may be encountered on the way and can be preserved. Continue dissecting towards the intramural ureter by incising the surrounding detrusor muscle until tenting of the bladder urothelial mucosa is seen. Filling the bladder can help identify the distal extent of the ureter.
***'''Partial transection of ureter/bladder cuff.''' Once ureter dissected to level of ureteric orifice, partially transect ureter on anterior surface. 
***'''Place stay sutures.''' Two 3-0 absorbable stay sutures are placed laterally and medially, prior to excision of the bladder urothelial mucosa.
***'''Complete transection of ureter/bladder cuff.''' Incise the bladder mucosa circumferentially around the ureteric orifice.  The entire distal ureter with surrounding bladder cuff is released.
***'''Closure of cystotomy.''' The previously placed absorbable stay sutures are used to close the cystotomy. Pressure test closure by instillating 250 mL of sterile saline through the urethral catheter. If leak is identified, place additional sutures as needed.
***'''Obtain hemostasis.'''
*** '''+/- instill intravesical chemotherapy.''' Instill intravesical gemcitabine and clamp Foley catheter. Foley catheter to be unclamped in 1 hour.
*** '''+/- Reposition robot.'''
****If configuration 1: Release all robotic arms. Position the robotic crane to the lower pelvis. Swap the second and third robotic arms so that the camera is now in Port 4 and the robotic arm 2 on port 3. The second port continues to hold the fenestrated bipolar forceps. Move the Prograsp forceps to Port 1 and the monopolar curved scissors to Port 3 (previous camera port).
****If configuration 2: Switch camera to the second caudal trocar. Re-target camera
****If configuration 4: Switch camera to the second caudal trocar. Re-target camera. Rotate robotic instruments such that Prograsp forceps is in the most cranial port, fenestrated bipolar in the 2nd most cranial port, and monopolar scissors in the caudal port.
***'''Mobilize upper pole.'''
**** '''On the left side, mobilize the spleen completely to avoid potential splenic injury.''' Be careful of splenic artery and pancreas. When developing space between spleen and kidney, use left hand under spleen to protect spleen. Use hand over hand motion. For efficiency, develop this space completely, before continuing to mobilize the colon.
**** '''On the right side, the right triangular ligament may be divided to lift the liver off the upper pole.'''
*****On the right lobe of the liver, the anterior and posterior layers of the coronary ligament of the liver join to form the right triangular ligament.[https://www.kenhub.com/en/library/anatomy/liver-ligaments]
***** The falciform ligament runs along the anterior surface of the liver. Superiorly, the falciform ligament is attached to the visceral aspect of the anterior abdominal wall.[https://www.kenhub.com/en/library/anatomy/liver-ligaments]
***'''Dissect along psoas towards renal hilum.''' Use the 4th arm to elevate the ureter +/- gonadal vein. Develop the plane superiorly towards the renal hilum,  anterior to the psoas muscle. A few small ureteric vessels may be encountered which can be divided by the use of energy devices. The traction on the ureter is constantly re-positioned as one works towards the hilum.
***'''Identify and dissect renal hilum'''. Dissect the renal hilum meticulously to clearly delineate the vascular structures. During hilar dissection it is important to place the kidney on stretch to improve identification and to facilitate dissection of the hilar vessels.
****'''Caution: be careful not to miss early arterial branching''' that is more common on the right side, especially if a venous occlusion is planned, as this may lead to kidney congestion and may result in more bleeding.
****If needed, the left gonadal vein can be ligated and divided to increase mobility of the renal vein and potentially improve exposure of the renal artery.
****If left side, lumbar veins may be seen and these should be preserved, if possible.
***'''Ligate and divide renal vessels'''. After dissection of hilar vessels complete, ligate vessels with 10 mm Hem-o-Lok clips (2 on the stay side, 1 on the go side) or vascular staples (open staple height of 2.5mm, either 45mm or 60 mm length). Ligate/divide the artery/arteries first, and then the vein.
****If multiple veins, can ligate some to clear space even if all arteries not ligated as long as there is some collateral venous outflow
****'''Caution: ensure that artery is renal artery, NOT superior mesenteric artery'''
****If vessels are difficult to isolate, consider en bloc stapling.
***** A meta-analysis of 595 patients who underwent en bloc ligation during nephrectomy found that[https://pubmed.ncbi.nlm.nih.gov/27457261/]
******No patients developed an arteriovenous fistula with an average postoperative follow-up of 26 months.
****** Procedure duration reduced with en bloc nephrectomy
******No difference in blood loos or complications
***'''Complete kidney dissection.''' Any remaining attachments of the upper pole of the kidney are completely dissected with a combination of cautery and blunt dissection. Adrenal sparing surgery is recommended, when feasible. The plane is carried laterally to completely free the kidney; first complete peritoneal incision and then blunt dissection can be used to free most of the remaining attachments. Be careful of diaphragm at superior lateral part of kidney.
*** '''Place specimen in bag.''' The specimen (kidney, ureter and bladder cuff) should be free from all surrounding structures. A laparoscopic entrapment sac is introduced by the assistant through the 12 mm assistant trocar; the specimen is placed in the sac.
***'''Obtain hemostasis.''' Reduce the insufflation pressure to 5 mm Hg and inspect the renal bed and pelvis for hemostasis.
***'''Lymphadenectomy.''' Consider lymphadenectomy if high grade and T2/T3 or bulky disease and preoperative radiographic study of abnormal or suspicious lymphadenopathy.
****For right-sided UTUC of the renal pelvis and proximal ureter, hilar, para-caval and interaortocaval lymph nodes are sampled.
****For left sided UTUC of renal pelvis and proximal ureter, hilar, para-aortic and interaortocaval lymph nodes are dissected.
****For distal UTUC, ipsilateral pelvic lymph node dissection is performed focusing on obturator, external iliac, internal iliac and common iliac nodal packets.
****Nodal packets are submitted separately and uniquely labeled for pathologic analysis.
****For proximal and renal pelvic tumors, LND is typically performed after nephrectomy. However, for distal UTUC, the some prefer to perform lymph node dissection after bladder cuff excision and subsequent closure. In these cases, the distal ureter and bladder cuff are appropriately placed in specimen bag to avoid contact with other intraabdominal organ
***'''Obtain hemostasis.'''
***'''Undock robot.'''
***'''Delver specimen.'''  and removed from an incision extended medially (to avoid injury to the inferior epigastric vessels) from the lower quadrant port site to form either a Gibson or Pfannensteil incision (more cosmetic).
**** Gibson: 3 cm above and parallel to the inguinal ligament.§
**** Pfannenstiel: transverse lower abdominal incision, superior to the pubic ridge. Dissection is made through the skin and subcutaneous fat; the anterior rectus sheath is divided transversely. The rectus muscle is open vertically in the midline sparing the muscle fibers from being divided. The peritoneum is then entered through a vertical incision. Be careful of branches from the inferior epigastric branches as well as the superficial epigastric.§
*****See [https://www.acog.org/education-and-events/simulations/scog013/module step by step instructions for Pfannenstiel incision]
**** Care must be taken to make a large enough incision to prevent disruption of the specimen; this enables proper histopathological examination.
*** '''First layer closure of extraction site.''' Use 3-0 Vicryl to reapproximate peritoneum and then 1-0 Vicryl to reapproximate fascia.
***'''Re-insufflate abdomen to verify hemostasis and extraction site closure.''' Ensure no bowel taken with abdominal closure.
*** '''Insert Jackson-Pratt drain through inferior robotic port.'''
***'''Closure.''' Use 1-0 Vicryl to reapproximate fascia at extraction site to complete second layer closure. All 12-mm incisions are closed with 0-Vicryl suture by using the Carter-Thomason device (Inlet Medical Inc., Eden Prairie, MN, USA).