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Name:
Robot-Assisted Radical Nephroureterectomy
Description:
Robot-Assisted Radical Nephroureterectomy
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T00H19M58S
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https://cadmoreoriginalmedia.blob.core.windows.net/77cff50f-c1e4-423a-8775-3643947afb93/Robot-Assisted Radical Nephroureterectomy.mp4?sv=2019-02-02&sr=c&sig=xA6i0dYLWszquKcFtyldeG81LwFOhSWb6TavF7xLLd8%3D&st=2026-04-04T21%3A30%3A42Z&se=2026-04-04T23%3A35%3A42Z&sp=r
Upload Date:
2023-10-19T00:00:00.0000000
Transcript:
Language: EN.
Segment:1 TROCAR CONFIGURATION AND DOCKING.
[MUSIC PLAYING]
SPEAKER: Radical nephroureterectomy with ipsilateral bladder cuff excision remains the gold standard for managements of high risk upper tract urothelial carcinoma involving the proximal ureter and/or pelvicalyceal system. And in the three decades since Clayman and colleagues described the first laparoscopic radical nephroureterectomy, minimally invasive approaches continue to see ongoing evolution and increasing utilization.
SPEAKER: And largely with the advent of the da Vinci XI platform here in the United States, we've seen a recent surge in utilization of the robot-assisted approach. The robotic approach to radical nephroureterectomy is indeed our preferred approach, as it affords a reduction in perioperative morbidity and improved convalescence. And again, with the adoption of the da Vinci XI platform, it does so with excellent technical ergonomics and streamlined operating room logistics as compared to the prior SI platform.
SPEAKER: In this video, we will review our step-by-step technique for transperitoneal robot assisted radical nephroureterectomy using a single docking approach with the da Vinci XI platform. This is a representative image of positioning for a right sided procedure. Specifically after induction of general endotracheal anesthesia in the supine position, the patient is repositioned into a modified lateral decubitus position with a 45 degree angle between the patient's back and the operating room table.
SPEAKER: Prior to repositioning from supine, it is important to confirm that the break in the bed is positioned at the upper margin of the iliac crest, as the bed will later be flexed to approximately 30 degrees as shown in order to elevate and expand the ipsilateral flank. We tend to support the patient's back in this position with a gel roll. However, a beanbag positioner is a reasonable alternative. The patient's dependent leg should be flex at the knee and supported at the knee as well as the ankle with foam padding.
SPEAKER: Pillows are placed between the legs to support the non-dependent leg which is aligned in a neutral extended position. The dependent arm is supported by foam padding on an arm board. And the arm board should be angled slightly-- set flat if possible in order to maximize working space for the bedside assistant as well as the robotic arms.
SPEAKER: The non-dependent arm is unsupported in a neutral position by pillows. And after confirming that all pressure points have been carefully padded, the patient is secured with the safety strap as well as 2inch cloth tape. This figure illustrates our standard approach to poor configuration for left sided procedures. Generally, we first establish pneumoperitoneum using a Veress needle transumbilically.
SPEAKER: Once pneumoperitoneum has been established, a total of four 8 millimeter robotic trocars are placed in an oblique line such that the lower ports are angled more medially. And this is done in order to maximize instrument triangulation in a working room during the pelvic portion of the operation. Ideally, all robotic ports are spaced approximately 6 to 8 centimeters apart. And care should be taken that the most superior port is at least 2 centimeters below the costal margin.
SPEAKER: Finally, we prefer to place a 12 millimeter assistant trocar in the midline. This is generally approximately 3 to 4 centimeters above the umbilicus. For this trocar, we'd prefer to use a valveless trocar system such as the AirSeal system. And this can help to stabilize pneumoperitoneum as well as to optimize visualization by maximizing smoke evacuation.
SPEAKER: Again, we generally prefer to place this port in the midline as this will be our preferred site of specimen extraction. And ideally, it is placed at a level above the umbilicus that will maximize triangulation with the robotic instruments during both the retroperitoneal as well as the pelvic portions of the operation. Robotic instrumentation for left sided procedures is shown on the right. And notably, we will commence with the nephrectomy portion of the operation.
SPEAKER: Thus, the camera will be initially placed in the second most superior robotic trocar as shown in the third degree down configuration. The bipolar forceps utilized in the surgeon's left robotic arm or arm one as shown here are either the Maryland bipolar forceps or the fenestrated bipolar graspers depending on surgeon preference. This is a representative intraoperative photo of left sided trocar configuration using the approach described.
SPEAKER: Trocar configuration and instrumentation for robotic right sided radical nephroureterectomy is shown here. And this very much mirrors the described approach for the left side with the one exception being that a 5 millimeter trocar can be optionally placed in a subxiphoid position to allow for later use of an atraumatic grasper such as a Babcock to retract the liver.
SPEAKER: The robot is docked from behind the patient's back perpendicular to the operating room table, and instruments are inserted as shown.
Segment:2 INSTILLATION OF INTRAVESICAL CHEMOTHERAPY.
SPEAKER: Following radical nephroureterectomy for a upper tract urothelial carcinoma, a single postoperative prophylactic dose of intravesical chemotherapy is associated with a decreased risk of subsequent bladder cancer recurrence.
SPEAKER: But despite this, the reported utilization remains poor. And while we await the results of ongoing prospective trials, retrospective data does seem to suggest a similar benefit with a single intraoperative dose of intravesical chemotherapy at the time of radical nephroureterectomy. Thus, based on this, our practice is to instill a single dose of intravesical chemotherapy immediately following patient positioning or robot docking.
SPEAKER: Specifically, the chemotherapy solution is instilled in retrograde fashion. The catheter's clamped, and the operation proceeds. Then following a 60 minute dwell time, the catheter's unclamped, and the agent is allowed to drain, following which the catheter's hand irrigated by the circulating nurse. We prefer administering introvesical chemotherapy early in the operation as described, as it allows for adequate dwell time and drainage as a surgeon commences with the nephrectomy portion of the operation and long prior to dissection of the distal ureter and extravesical bladder cuff excision.
Segment:3 MOBILIZATION OF IPSILATERAL COLON.
SPEAKER: The robotic portion of the operation begins with medialization of the ipsilateral colon. In this left sided case, the peritoneum approximately 2 centimeters lateral to the descending colon is incised with the monopolar scissors. Carrying this plane of dissection distally towards the pelvic inlet will help not only to facilitate exposure during the renal hilar dissection but also during the mid and distal ureteral dissection later in the operation.
SPEAKER: One can see that the mesenteric fat has a characteristically golden yellow color as compared to the more pale yellow color of the anterior layer of Gerota's fascia underneath. Not shown here for right-sided cases, the dissection should be carried cephalad following the contour of the liver and laterally to completely mobilize the coronary ligament of the liver. Now again, the left side once the splenic flexure has been medialized, later, exposure of the left renal hilum can be further optimized by division of the splenorenal and splenophrenic ligaments.
SPEAKER: Specifically, this will allow for the spleen, descending colon, as well as the underlying tail and body of the pancreas to passively fall further medially. Next to the colon, the mesocolon are further dissected medially. And it is critical to maintain the plane of dissection immediately on Gerota's fascia and avoid airing medially in order to avoid inadvertent injury to the nearby pancreas, which can be seen here.
SPEAKER: Again, not shown for right-sided cases, the second part of the duodenum must be Kocherized in order to completely expose the inferior vena cava.
Segment:4 EARLY URETERAL LIGATION.
SPEAKER: Next, attention is turned to developing the tail of Gerota's as well as early identification and ligation of the ureter. The fourth robotic arm can be used to elevate the tail of Gerota's anteriorly to facilitate a two-handed dissection to create and broaden a window between the tail of Gertota's above and psoas fascia below or posteriorly.
SPEAKER: In this case, both the ureter and gonadal vein are identified. And the ureter's litigated with a large Hem-o-lok clip, as this theoretically reduces the risk of distal tumor migration during dissection and manipulation of the proximal upper tract. [MUSIC PLAYING]
Segment:5 RENAL HILAR DISSECTION AND DIVISION.
SPEAKER: Again, the tail of Gerota's and the kidney can be progressively retracted anteriorly with the fourth robotic arm, thereby, lifting the kidney and placing the hilum on stretch.
SPEAKER: And as shown here in the left, the ureter and gonadal vein are bluntly developed intralaterally as the dissection proceeds cephalad. Next, an approximately 2 to 3 centimeters segment of the main renal artery is identified and skeletonized, following which it is divided with a laparoscopic linear vascular stapler. And this is a standard 30 millimeter load.
SPEAKER: Finally, a short segment of the superior aspect of the left renal vein is dissected free, flowing which the left renal vein is divided with the final staple load. Certainly, en bloc ligation and division with a single staple load across both the artery and the vein is a very reasonable alternative to controlling the renal artery and vein, in this case individually.
Segment:6 ADRENAL GLAND PRESERVATION AND COMPLETE RENAL MOBILIZATION.
SPEAKER: Next, following the satisfactory division of the renal hilum, we proceed with mobilizing the kidney, starting medially and carrying this cephalad. And in doing so, unless there's preoperative radiographic evidence of direct adrenal involvement by tumor or gross intraoperative findings to suggest the same, we proceed with an adrenal sparing approach. And a plane is established between the upper pole of the kidney and adjacent paranephric fat infralaterally and the adrenal supramedially.
SPEAKER: This plane is deepened until the retroperitoneum is reached and then carried supralaterally, thereby completely freeing the adrenal gland from the upper pole. Placing the fourth robotic arm between the posterior aspect of the kidney above and the psoas below can help to elevate the kidney and expose the remaining upper pole attachments. And depending on surgeon preference, there are a number of ways to facilitate this dissection in an efficient hemostatic manner, including use of a 10 millimeter laparoscopic ligature device via the assistant port as was previously shown or use of a robotic vessel sealer inserted in place of the monopolar scissors.
SPEAKER: Again, using a combination of the monopolar scissors as well as a bipolar sealing device, the remaining superior and lateral attachments of the kidney are divided.
Segment:7 RETROPERITONEAL LYMPHADENECTOMY.
SPEAKER: In patients undergoing robot assisted radical nephroureterectomy for high risk upper tract urothelial carcinoma specifically involving the proximal two thirds of the upper tract, we will next proceed with retroperitoneal lymphadenectomy.
SPEAKER: And generally here in the left, this will include the paraaortic packet down to the level of the aortic bifurcation. The lymph node dissection is carried out primarily by blunt dissection with occasional monopolar cautery. Large lymphatics can be controlled with hemoclips. And depending on surgeon preference, a bipolar vessel sealer such as the robotic vessel sealer in this case can be used to control smaller vessels and lymphatics coursing into the nodal packets.
SPEAKER: Once the lymph node dissection is complete, the specimens can be stored in the upper abdomen. However, especially in high risk cases such as in patients with radiographic or intraoperative findings concerning for lymph node metastasis, a separate 10 millimeter Endo Catch bag can be used to entrap the lymphadenectomy specimens at this point, with the Endo Catch bag strings secured externally via the system port.
Segment:8 URETERAL DISSECTION AND INSTRUMENT RECONFIGURATION.
SPEAKER: Once excellent hemostasis has been confirmed in the retroperitoneum and hemostatic agents such as Surgicel has been applied, we proceed with carrying the ureteral dissection distally. In this case, the final attachments at the tail of Gerota's are divided using a ligature device. As the dissection is carried distally, the lateral attachment to the sigmoid colon must be divided.
SPEAKER: And here in this female patient, the infundibulopelvic ligament here in the left is divided to facilitate exposure of the underlying ureter. Note that once the lateral peritoneum has been sized, the dissection can be frequently carried digitally underneath the ovary and ovarian ligament, as can be seen here. And in many cases like this one, thanks to the extended reach of the Da Vinci XI platform, one could actually carry out complete distal ureteral dissection with adequate ergonomics and visualization, particularly with the camera positioned in the 30 degree up configuration as needed without actually needing to reconfigure the robotic camera and instruments to optimize for the pelvic dissection.
SPEAKER: However, we routinely advocate for camera hopping or instrument reconfiguration to optimize the setup for the transition to the pelvic dissection, as it can be performed very rapidly, usually in less than 60 seconds, without the need to undock and almost invariably improves the ergonomics and visualization for the pelvic portion of the operation. Specifically to do this, the camera and all instruments are moved one port inferiorly, while the fourth arm and ProGrasp forceps is moved from the lowest port up to the most cephalad port, as can be seen here.
SPEAKER: After instrument reconfiguration, ureteral dissection is carried distally. The peritoneum posterior to the bladder, medially anterior to the ureter is incised to further facilitate carrying the dissection disability. Though it is not routinely required and not shown here, access and visualization to the distal ureter can be further optimized by dividing the vas deferens in the male patient or the round ligament of the uterus in the female patient.
SPEAKER: Even less commonly required, the medial umbilical ligament can also be divided just superiorly and medially to the ureter to allow further contralateral mobilization of the bladder and thereby facilitate exposure of the distal ureter. But again, this is very uncommonly required. As the dissection proceeds distally to the level of the medial umbilical ligament, care should be taken to prospectively identify the superior vesical artery, which runs immediately anteriorly and perpendicularly to the ureter at this location.
SPEAKER: Occasionally, the ureter can be dissected out from underneath the superior vesical artery. However, most commonly, as can be seen here, we prefer to prospectively identify and via the superior vessel pedicle, so that it is not inadvertently evulsed as well as to improve exposure. In this case, the pedicle is generously bipolar and divided. However, it could also be managed with Hem-o-lok clips or a vessel sealer such as the robotic vessel sealer or the ligature device.
SPEAKER: Again, visualization of the superior vesical pedicle should serve as a landmark that the dissection is nearing the bladder. And following division of the superior vesical pedicle, one can see that the exposure and access to the UVJ will be optimized. Though it was not required in this specific case, rotation of the robotic endoscope to a third degree upward configuration can occasionally be helpful to improve visualization in this location as well as for bladder cuff excision.
SPEAKER: Dynamic countertraction is applied by the surgeon's left hand, as the ureter is further freed distally.
Segment:9 EXTRAVESICAL BLADDER CUFF EXCISION.
SPEAKER: At this point, we proceed with extravesical bladder cuff excision. As the UVJ is approached, the splaying detrusor fibers can be seen as the ureter enters the UVJ. And again, as previously described, the chemotherapy has already been drained.
SPEAKER: The bladder has been irrigated and confirmed to be maximally decompressed prior to proceeding. Once the bladder cuff has been circumferentially transected, the small cystotomy tends to spring anteriorly and medially, therefore limiting exposure for subsequent bladder closure. Therefore, after making a small initial cystotomy superiorly and medially and at most only hemitransecting the bladder cuff, a suture is placed full thickness through the superior margin of the cystotomy.
SPEAKER: Some surgeons prefer to place a dedicated stay suture at this location, such as to a 2-0 Vicryl on a UR-6 needle. However, recently, we have transitioned to actually starting the bladder repair at this point. This is done with a 3-0 V-Loc suture. And ultimately, the bladder will be closed in a single layer. After placing two or three throws with the suture, the needle driver is removed.
SPEAKER: The scissors are replaced. And we proceed with the remaining bladder cuff excision, as the suture can later be used to retract and expose the cystotomy when the closure is ultimately completed. Finally, the bladder cuff excision is completed, and the specimen is freed in its entirety. This specific example is of a patient with a tumor in the left renal pelvis.
SPEAKER: Patients undergoing robot assisted radical nephroureterectomy for more distal ureteral tumors or even ureteral vesical junction tumors, such as in this example, a larger cystotomy, again superiorly and medially, allows one to actually visualize the ureteral orifice intravesically, as can be seen here on the right. This can next be circumscribed and provides a reference for the dissection distally to confirm that the ipsilateral ureteral orifice and entire intramural ureteral tunnel has been excised.
SPEAKER:
Segment:10 SPECIMEN ENTRAPMENT.
SPEAKER: Once the specimen is freed in its entirety, we proceed with entrapping the specimen. To do this, we prefer removing the 12 millimeter port in the midline. And through the same incision, a 15 millimeter Endo Catch bag is inserted. Once the specimen is entrapped, it is stored in the upper abdomen.
SPEAKER: And the drawstring is secured externally with a hemostat, following which the 12 millimeter assisted port is replaced alongside the drawstring.
Segment:11 BLADDER CLOSURE.
SPEAKER: Finally, once a specimen has been freed in its entirety and entrapped, we proceed with bladder closure. There are several appropriate methods of bladder closure, depending on surgeon preference. And generally, this should be done in one or two layers with absorbable suture.
SPEAKER: Though not shown here, Lapra-Ty clips can be thoughtfully used to improve efficiency by eliminating the need for not tying. And as previously alluded to, we prefer to continue our previously placed 3-0 V-Loc suture to perform a one layer bladder closure, approximating the bladder mucosa and underlying detrusor. As the closure progresses, the immediately preceding suture exit can be retracted to optimize exposure of the remaining defect and prevent retraction.
SPEAKER: To further reinforce the closure, we transition the same suture to reapproximate the serosa and peritoneum overlying the posterior [INAUDIBLE]. Though, again, this can be done with a separate absorbable suture in running fashion depending on surgeon preference. Finally, after completion of the repair, the circulating nurse fills the bladder with approximately 100 to 200 cc's of sterile saline via the urethral catheter in order to confirm closure integrity.
SPEAKER: Lastly, we proceed with drain placement, specimen extraction, and closure. Specimen extraction is performed in standard fashion via the midline incision. Enclosure is performed in standard fashion. Additional details can be found in the accompanying text. [MUSIC PLAYING]
Segment:1 TROCAR CONFIGURATION AND DOCKING.
[MUSIC PLAYING]
SPEAKER: Radical nephroureterectomy with ipsilateral bladder cuff excision remains the gold standard for managements of high risk upper tract urothelial carcinoma involving the proximal ureter and/or pelvicalyceal system. And in the three decades since Clayman and colleagues described the first laparoscopic radical nephroureterectomy, minimally invasive approaches continue to see ongoing evolution and increasing utilization.
SPEAKER: And largely with the advent of the da Vinci XI platform here in the United States, we've seen a recent surge in utilization of the robot-assisted approach. The robotic approach to radical nephroureterectomy is indeed our preferred approach, as it affords a reduction in perioperative morbidity and improved convalescence. And again, with the adoption of the da Vinci XI platform, it does so with excellent technical ergonomics and streamlined operating room logistics as compared to the prior SI platform.
SPEAKER: In this video, we will review our step-by-step technique for transperitoneal robot assisted radical nephroureterectomy using a single docking approach with the da Vinci XI platform. This is a representative image of positioning for a right sided procedure. Specifically after induction of general endotracheal anesthesia in the supine position, the patient is repositioned into a modified lateral decubitus position with a 45 degree angle between the patient's back and the operating room table.
SPEAKER: Prior to repositioning from supine, it is important to confirm that the break in the bed is positioned at the upper margin of the iliac crest, as the bed will later be flexed to approximately 30 degrees as shown in order to elevate and expand the ipsilateral flank. We tend to support the patient's back in this position with a gel roll. However, a beanbag positioner is a reasonable alternative. The patient's dependent leg should be flex at the knee and supported at the knee as well as the ankle with foam padding.
SPEAKER: Pillows are placed between the legs to support the non-dependent leg which is aligned in a neutral extended position. The dependent arm is supported by foam padding on an arm board. And the arm board should be angled slightly-- set flat if possible in order to maximize working space for the bedside assistant as well as the robotic arms.
SPEAKER: The non-dependent arm is unsupported in a neutral position by pillows. And after confirming that all pressure points have been carefully padded, the patient is secured with the safety strap as well as 2inch cloth tape. This figure illustrates our standard approach to poor configuration for left sided procedures. Generally, we first establish pneumoperitoneum using a Veress needle transumbilically.
SPEAKER: Once pneumoperitoneum has been established, a total of four 8 millimeter robotic trocars are placed in an oblique line such that the lower ports are angled more medially. And this is done in order to maximize instrument triangulation in a working room during the pelvic portion of the operation. Ideally, all robotic ports are spaced approximately 6 to 8 centimeters apart. And care should be taken that the most superior port is at least 2 centimeters below the costal margin.
SPEAKER: Finally, we prefer to place a 12 millimeter assistant trocar in the midline. This is generally approximately 3 to 4 centimeters above the umbilicus. For this trocar, we'd prefer to use a valveless trocar system such as the AirSeal system. And this can help to stabilize pneumoperitoneum as well as to optimize visualization by maximizing smoke evacuation.
SPEAKER: Again, we generally prefer to place this port in the midline as this will be our preferred site of specimen extraction. And ideally, it is placed at a level above the umbilicus that will maximize triangulation with the robotic instruments during both the retroperitoneal as well as the pelvic portions of the operation. Robotic instrumentation for left sided procedures is shown on the right. And notably, we will commence with the nephrectomy portion of the operation.
SPEAKER: Thus, the camera will be initially placed in the second most superior robotic trocar as shown in the third degree down configuration. The bipolar forceps utilized in the surgeon's left robotic arm or arm one as shown here are either the Maryland bipolar forceps or the fenestrated bipolar graspers depending on surgeon preference. This is a representative intraoperative photo of left sided trocar configuration using the approach described.
SPEAKER: Trocar configuration and instrumentation for robotic right sided radical nephroureterectomy is shown here. And this very much mirrors the described approach for the left side with the one exception being that a 5 millimeter trocar can be optionally placed in a subxiphoid position to allow for later use of an atraumatic grasper such as a Babcock to retract the liver.
SPEAKER: The robot is docked from behind the patient's back perpendicular to the operating room table, and instruments are inserted as shown.
Segment:2 INSTILLATION OF INTRAVESICAL CHEMOTHERAPY.
SPEAKER: Following radical nephroureterectomy for a upper tract urothelial carcinoma, a single postoperative prophylactic dose of intravesical chemotherapy is associated with a decreased risk of subsequent bladder cancer recurrence.
SPEAKER: But despite this, the reported utilization remains poor. And while we await the results of ongoing prospective trials, retrospective data does seem to suggest a similar benefit with a single intraoperative dose of intravesical chemotherapy at the time of radical nephroureterectomy. Thus, based on this, our practice is to instill a single dose of intravesical chemotherapy immediately following patient positioning or robot docking.
SPEAKER: Specifically, the chemotherapy solution is instilled in retrograde fashion. The catheter's clamped, and the operation proceeds. Then following a 60 minute dwell time, the catheter's unclamped, and the agent is allowed to drain, following which the catheter's hand irrigated by the circulating nurse. We prefer administering introvesical chemotherapy early in the operation as described, as it allows for adequate dwell time and drainage as a surgeon commences with the nephrectomy portion of the operation and long prior to dissection of the distal ureter and extravesical bladder cuff excision.
Segment:3 MOBILIZATION OF IPSILATERAL COLON.
SPEAKER: The robotic portion of the operation begins with medialization of the ipsilateral colon. In this left sided case, the peritoneum approximately 2 centimeters lateral to the descending colon is incised with the monopolar scissors. Carrying this plane of dissection distally towards the pelvic inlet will help not only to facilitate exposure during the renal hilar dissection but also during the mid and distal ureteral dissection later in the operation.
SPEAKER: One can see that the mesenteric fat has a characteristically golden yellow color as compared to the more pale yellow color of the anterior layer of Gerota's fascia underneath. Not shown here for right-sided cases, the dissection should be carried cephalad following the contour of the liver and laterally to completely mobilize the coronary ligament of the liver. Now again, the left side once the splenic flexure has been medialized, later, exposure of the left renal hilum can be further optimized by division of the splenorenal and splenophrenic ligaments.
SPEAKER: Specifically, this will allow for the spleen, descending colon, as well as the underlying tail and body of the pancreas to passively fall further medially. Next to the colon, the mesocolon are further dissected medially. And it is critical to maintain the plane of dissection immediately on Gerota's fascia and avoid airing medially in order to avoid inadvertent injury to the nearby pancreas, which can be seen here.
SPEAKER: Again, not shown for right-sided cases, the second part of the duodenum must be Kocherized in order to completely expose the inferior vena cava.
Segment:4 EARLY URETERAL LIGATION.
SPEAKER: Next, attention is turned to developing the tail of Gerota's as well as early identification and ligation of the ureter. The fourth robotic arm can be used to elevate the tail of Gerota's anteriorly to facilitate a two-handed dissection to create and broaden a window between the tail of Gertota's above and psoas fascia below or posteriorly.
SPEAKER: In this case, both the ureter and gonadal vein are identified. And the ureter's litigated with a large Hem-o-lok clip, as this theoretically reduces the risk of distal tumor migration during dissection and manipulation of the proximal upper tract. [MUSIC PLAYING]
Segment:5 RENAL HILAR DISSECTION AND DIVISION.
SPEAKER: Again, the tail of Gerota's and the kidney can be progressively retracted anteriorly with the fourth robotic arm, thereby, lifting the kidney and placing the hilum on stretch.
SPEAKER: And as shown here in the left, the ureter and gonadal vein are bluntly developed intralaterally as the dissection proceeds cephalad. Next, an approximately 2 to 3 centimeters segment of the main renal artery is identified and skeletonized, following which it is divided with a laparoscopic linear vascular stapler. And this is a standard 30 millimeter load.
SPEAKER: Finally, a short segment of the superior aspect of the left renal vein is dissected free, flowing which the left renal vein is divided with the final staple load. Certainly, en bloc ligation and division with a single staple load across both the artery and the vein is a very reasonable alternative to controlling the renal artery and vein, in this case individually.
Segment:6 ADRENAL GLAND PRESERVATION AND COMPLETE RENAL MOBILIZATION.
SPEAKER: Next, following the satisfactory division of the renal hilum, we proceed with mobilizing the kidney, starting medially and carrying this cephalad. And in doing so, unless there's preoperative radiographic evidence of direct adrenal involvement by tumor or gross intraoperative findings to suggest the same, we proceed with an adrenal sparing approach. And a plane is established between the upper pole of the kidney and adjacent paranephric fat infralaterally and the adrenal supramedially.
SPEAKER: This plane is deepened until the retroperitoneum is reached and then carried supralaterally, thereby completely freeing the adrenal gland from the upper pole. Placing the fourth robotic arm between the posterior aspect of the kidney above and the psoas below can help to elevate the kidney and expose the remaining upper pole attachments. And depending on surgeon preference, there are a number of ways to facilitate this dissection in an efficient hemostatic manner, including use of a 10 millimeter laparoscopic ligature device via the assistant port as was previously shown or use of a robotic vessel sealer inserted in place of the monopolar scissors.
SPEAKER: Again, using a combination of the monopolar scissors as well as a bipolar sealing device, the remaining superior and lateral attachments of the kidney are divided.
Segment:7 RETROPERITONEAL LYMPHADENECTOMY.
SPEAKER: In patients undergoing robot assisted radical nephroureterectomy for high risk upper tract urothelial carcinoma specifically involving the proximal two thirds of the upper tract, we will next proceed with retroperitoneal lymphadenectomy.
SPEAKER: And generally here in the left, this will include the paraaortic packet down to the level of the aortic bifurcation. The lymph node dissection is carried out primarily by blunt dissection with occasional monopolar cautery. Large lymphatics can be controlled with hemoclips. And depending on surgeon preference, a bipolar vessel sealer such as the robotic vessel sealer in this case can be used to control smaller vessels and lymphatics coursing into the nodal packets.
SPEAKER: Once the lymph node dissection is complete, the specimens can be stored in the upper abdomen. However, especially in high risk cases such as in patients with radiographic or intraoperative findings concerning for lymph node metastasis, a separate 10 millimeter Endo Catch bag can be used to entrap the lymphadenectomy specimens at this point, with the Endo Catch bag strings secured externally via the system port.
Segment:8 URETERAL DISSECTION AND INSTRUMENT RECONFIGURATION.
SPEAKER: Once excellent hemostasis has been confirmed in the retroperitoneum and hemostatic agents such as Surgicel has been applied, we proceed with carrying the ureteral dissection distally. In this case, the final attachments at the tail of Gerota's are divided using a ligature device. As the dissection is carried distally, the lateral attachment to the sigmoid colon must be divided.
SPEAKER: And here in this female patient, the infundibulopelvic ligament here in the left is divided to facilitate exposure of the underlying ureter. Note that once the lateral peritoneum has been sized, the dissection can be frequently carried digitally underneath the ovary and ovarian ligament, as can be seen here. And in many cases like this one, thanks to the extended reach of the Da Vinci XI platform, one could actually carry out complete distal ureteral dissection with adequate ergonomics and visualization, particularly with the camera positioned in the 30 degree up configuration as needed without actually needing to reconfigure the robotic camera and instruments to optimize for the pelvic dissection.
SPEAKER: However, we routinely advocate for camera hopping or instrument reconfiguration to optimize the setup for the transition to the pelvic dissection, as it can be performed very rapidly, usually in less than 60 seconds, without the need to undock and almost invariably improves the ergonomics and visualization for the pelvic portion of the operation. Specifically to do this, the camera and all instruments are moved one port inferiorly, while the fourth arm and ProGrasp forceps is moved from the lowest port up to the most cephalad port, as can be seen here.
SPEAKER: After instrument reconfiguration, ureteral dissection is carried distally. The peritoneum posterior to the bladder, medially anterior to the ureter is incised to further facilitate carrying the dissection disability. Though it is not routinely required and not shown here, access and visualization to the distal ureter can be further optimized by dividing the vas deferens in the male patient or the round ligament of the uterus in the female patient.
SPEAKER: Even less commonly required, the medial umbilical ligament can also be divided just superiorly and medially to the ureter to allow further contralateral mobilization of the bladder and thereby facilitate exposure of the distal ureter. But again, this is very uncommonly required. As the dissection proceeds distally to the level of the medial umbilical ligament, care should be taken to prospectively identify the superior vesical artery, which runs immediately anteriorly and perpendicularly to the ureter at this location.
SPEAKER: Occasionally, the ureter can be dissected out from underneath the superior vesical artery. However, most commonly, as can be seen here, we prefer to prospectively identify and via the superior vessel pedicle, so that it is not inadvertently evulsed as well as to improve exposure. In this case, the pedicle is generously bipolar and divided. However, it could also be managed with Hem-o-lok clips or a vessel sealer such as the robotic vessel sealer or the ligature device.
SPEAKER: Again, visualization of the superior vesical pedicle should serve as a landmark that the dissection is nearing the bladder. And following division of the superior vesical pedicle, one can see that the exposure and access to the UVJ will be optimized. Though it was not required in this specific case, rotation of the robotic endoscope to a third degree upward configuration can occasionally be helpful to improve visualization in this location as well as for bladder cuff excision.
SPEAKER: Dynamic countertraction is applied by the surgeon's left hand, as the ureter is further freed distally.
Segment:9 EXTRAVESICAL BLADDER CUFF EXCISION.
SPEAKER: At this point, we proceed with extravesical bladder cuff excision. As the UVJ is approached, the splaying detrusor fibers can be seen as the ureter enters the UVJ. And again, as previously described, the chemotherapy has already been drained.
SPEAKER: The bladder has been irrigated and confirmed to be maximally decompressed prior to proceeding. Once the bladder cuff has been circumferentially transected, the small cystotomy tends to spring anteriorly and medially, therefore limiting exposure for subsequent bladder closure. Therefore, after making a small initial cystotomy superiorly and medially and at most only hemitransecting the bladder cuff, a suture is placed full thickness through the superior margin of the cystotomy.
SPEAKER: Some surgeons prefer to place a dedicated stay suture at this location, such as to a 2-0 Vicryl on a UR-6 needle. However, recently, we have transitioned to actually starting the bladder repair at this point. This is done with a 3-0 V-Loc suture. And ultimately, the bladder will be closed in a single layer. After placing two or three throws with the suture, the needle driver is removed.
SPEAKER: The scissors are replaced. And we proceed with the remaining bladder cuff excision, as the suture can later be used to retract and expose the cystotomy when the closure is ultimately completed. Finally, the bladder cuff excision is completed, and the specimen is freed in its entirety. This specific example is of a patient with a tumor in the left renal pelvis.
SPEAKER: Patients undergoing robot assisted radical nephroureterectomy for more distal ureteral tumors or even ureteral vesical junction tumors, such as in this example, a larger cystotomy, again superiorly and medially, allows one to actually visualize the ureteral orifice intravesically, as can be seen here on the right. This can next be circumscribed and provides a reference for the dissection distally to confirm that the ipsilateral ureteral orifice and entire intramural ureteral tunnel has been excised.
SPEAKER:
Segment:10 SPECIMEN ENTRAPMENT.
SPEAKER: Once the specimen is freed in its entirety, we proceed with entrapping the specimen. To do this, we prefer removing the 12 millimeter port in the midline. And through the same incision, a 15 millimeter Endo Catch bag is inserted. Once the specimen is entrapped, it is stored in the upper abdomen.
SPEAKER: And the drawstring is secured externally with a hemostat, following which the 12 millimeter assisted port is replaced alongside the drawstring.
Segment:11 BLADDER CLOSURE.
SPEAKER: Finally, once a specimen has been freed in its entirety and entrapped, we proceed with bladder closure. There are several appropriate methods of bladder closure, depending on surgeon preference. And generally, this should be done in one or two layers with absorbable suture.
SPEAKER: Though not shown here, Lapra-Ty clips can be thoughtfully used to improve efficiency by eliminating the need for not tying. And as previously alluded to, we prefer to continue our previously placed 3-0 V-Loc suture to perform a one layer bladder closure, approximating the bladder mucosa and underlying detrusor. As the closure progresses, the immediately preceding suture exit can be retracted to optimize exposure of the remaining defect and prevent retraction.
SPEAKER: To further reinforce the closure, we transition the same suture to reapproximate the serosa and peritoneum overlying the posterior [INAUDIBLE]. Though, again, this can be done with a separate absorbable suture in running fashion depending on surgeon preference. Finally, after completion of the repair, the circulating nurse fills the bladder with approximately 100 to 200 cc's of sterile saline via the urethral catheter in order to confirm closure integrity.
SPEAKER: Lastly, we proceed with drain placement, specimen extraction, and closure. Specimen extraction is performed in standard fashion via the midline incision. Enclosure is performed in standard fashion. Additional details can be found in the accompanying text. [MUSIC PLAYING]
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