ABSTRACT
Objective This study is to investigate the safety,feasibility and efficacy of the complete retroperitoneal robotic nephroureterectomy in treatment of upper urinary tract tumors.Methods Three patients underwent complete retroperitoneal robotic nephroureterectomy due to the upper urinary epithelial tumor from August to October in 2017 in our institution.The 3 patients' demographics and tumor characteristics,including age,gender,body mass index (kg/m2),ASA score,Charlson comorbidity index,tumor laterality and diameter (cm),were 48/75/68 years old,male/female/female,22.9/20.8/21.3,2/2/2,0/2/1,left/right/left,3.2/2.0/1.4,respectively.All patients had complained about the hematuria and accepted the abdominal CT and CTU examination,preoperatively.All patients were diagnosed localized upper urinary tract malignant tumors based on these images.The tumor of case 1 located in the renal pelvis.The tumor of case 2 located in the upper segment of the ureter.The tumor of case 3 located in the lower segment of the ureter.The operations were performed under general anesthesia,and patients were positioned in full flank.A total of five ports were used in the procedure and placed in the following order.The initial port (Port 1) was a robotic camera port,which was placed 3 cm above the intersection of the mid axillary line and the iliac crest.The next three ports (Port 2 to Port 4) were all 8 mm robotic instrument ports and placed at the intersection of posterior axillary line and costal margin,3 cm above the intersection of anterior axillary line and costal margin,and 4 cm medial and inferior to anterior superior iliac spine.The fifth port (Port 5) was a 12 mm assistant port and placed at 3 cm medial and superior to anterior superior iliac spine.Our completely robotic technique did not require patient repositioning and port reassignment,but redocking of the robotic arms was needed.Nephrectomy was performed according to the routine retroperitoneal laparoscopic procedure.Once the remainder of the kidney was mobilized,the dissection was directed down the pelvis to mobilize the distal segment of the ureter.The bladder defect was then closed by Endo-GIA stapler or absorbable sutures.Results All procedures were successful and smooth,with no intraoperative or postoperative complications.Operative duration (min) and estimated blood loss (ml) was 245/270/239,100/100/100,respectively.Postoperative pain measured by the visual analog pain scale(VASP) at day 1,day 2,day 3 was 5/4/4,4/3/3,2/2/1,respectively.Time off oral intake (d),duration of drainage (d),active time post-operation (h) and hospital stay (d) was 2/2/2,3/2/3,24/32/32,3/2/4,respectively.Intravesical chemotherapy was performed within 24 h after the operation.Postoperatively,the urinary catheter was left in place for 2 weeks.Pathological examination confirmed papillary urothelial carcinoma in all cases.Conclusions The initial experience shows that the complete retroperitoneal robotic nephroureterectomy is a safe,feasible and efficacious procedure,but in this early stage the clinical indications should be strictly controlled.
ABSTRACT
Objective To study the clinic features and risk factors of bladder cancer occurrence after radical nephroureterectomy of urothelial carcinoma of the upper tract.Methods 61 cases of urothelial carcinoma of the upper tract from March 2013 to December 2013 in Beijing Friendship Hospital are retrospectively studied.31 patients are male,while the other 30 patients are female.Age of them ranges from 43 to 90 years old,and the average age is 69 years old.17 patients are accompanied with diabetes.32 patients are accompanied with hypertension.12 patients have the history of chronic nephrosis.7 patients have the history of renal transplation operation.47 patients have the symptom of hematuresis.16 patients have the symptom of lumbago.Body mass index ＜ 18.5 kg/m2 2 cases,18.5 ～ 22.9 kg/m2 25 cases,23.0 ～ 24.9 kg/m2 10 cases,25.0 ～ 29.9 kg/m2 20 cases,≥ 30.0 kg/m2 4 cases.25 patients' serum creatinine is abnormal,while the other 36 patients'is normal.36 patients have left tumors,while the other 25 patients have right tumors.39 patients have hydronephrosis before operation.25 patients go through ureteroscopy.11 patients have the concurrence of bladder cancer preoperatively.25 patients have renal pelvic carcinoma,while the other 36 patients have carcinoma of ureter.14 patients have multiple tumors,while the other 47 patients just have single tumors.The size of tumor ranges from 0.5cm to 8.0cm,and the average size is 2.9cm.27 patients have the cauliflower-like tumors,while the other 34 patients have other shaped tumors.28 cases have the positive results of cytology,while the other 33 cases donl have.6 patients go through cystoscopic operation of ureterovesical junction,while the other 55 patients go through open operation of ureterovesical junction.Kaplan Meier analysis is used to find univariate risk factors of the bladder cancer occurrence postoperatively,and Log-rank test is used after that.Cox regression analysis is used to identify the independent risk factor from all the univariate risk factors.Results Time of surgery ranges from 2.0 hours to 7.5 hours,and the average time is (4.9 ± 1.2) hours.39 patients' tumors are equal or greater than T2 stage,while the other 22 patients'tumors are less than T2 stage.2 patients have Ⅰ grade tumors,40 patients have Ⅱ grade tumors,and the other 19 patients have Ⅲ grade tumors.12 patients go through systematic chemotherapy,while the other 49 patients don l.23 patients go through intravesical instillation postoperatively,while the other 38 donl.Follow-up time of 61 cases ranges from 22 months to 31 months,and the average time is (27.3 ± 2.7) months.3 to 30 months after radical nephroureterectomy,21 cases(34.4％) have bladder cancer occurrence.4 of patients who have concurrence of bladder cancer preoperatively go through the occurrence of bladder cancer(57.1％,4/7),and 17 of patients who dont have concurrence of bladder cancer preoperatively go through the occurrence of bladder cancer(3 1.5％,17/54).8 of patients with multiple tumors go through the occurrence of bladder cancer(57.1％,4/7),while 13 of patients with a single tumor go through the occurrence of bladder cancer(27.7％,13/47).18 of patients who have tumors equal or greater than T2 stage have the occurrence of bladder cancer(46.2％,18/39),while 3 of patients who have tumors less than T2 stage have the occurrence of bladder cancer(13.6％,3/ 22).3 of patients with postoperative intravesical instillation have the occurrence of bladder cancer(13.0％,3/23),while 18 of patients without postoperative intravesical instillation have the occurrence of bladder cancer(47.4％,18/38).Single factor analysis shows that preoperative concurrence of bladder cancer(P =0.003),multiple tumors (P =0.044),T stage (P =0.023) and postoperative intravesical instillation (P =0.002) have significant influence on the occurrence of bladder cancer.And Cox proportional hazards regression model analysis shows that the preoperative concurrence of bladder cancer (RR =2.860,P =0.024,regression coefficient =1.051) and postoperative intravesical instillation (RR =0.201,P =0.011,regression coefficient =-1.065) are significantly related to the occurrence of bladder cancer after radical nephroureterectomy.Conclusions The preoperative concurrence of bladder cancer and postoperative intravesical instillation are the independent risk factors of the bladder cancer occurrence after radical nephroureterectomy.And the preoperative concurrence of bladder cancer is a risk factor,while the postoperative intravesical instillation is a protective factor.