(UroToday.com) At the third World Congress of Endourology and Uro-Technology, WCET 2024, a plenary discussion was dedicated to Urothelial Cancer, with a particular emphasis on Cystectomy and Nephroureterectomy. The session featured a panel of three experts, moderated by a leading authority in the field. Among the panelists, Dr. Ravi Munver and Dr. Jeffery Nix were invited to provide a comprehensive comparison of the XI versus SP robotic approaches for managing nephroureterectomy and bladder cuff excision.
Dr. Ravi Munver began his presentation by disclosing his professional affiliations, including roles as a consultant for PROCEPT BioRobotics and a speaker for Boston Scientific. His objectives for the session were clear: to provide an overview of the epidemiology of Upper Tract Urothelial Carcinoma (UTUC), trace the historical evolution of nephroureterectomy procedures, and delve into the surgical steps and various approaches, including the benefits of robotic-assisted surgery.
He highlighted the epidemiology of UTUC, noting that over 550,000 new cases of urothelial carcinoma are diagnosed globally each year, with 27,500 to 55,000 of these involving the upper tract. In the United States alone, approximately 7,000 new cases of UTUC are reported annually. Dr. Munver explained that renal pelvis tumors account for 8% of kidney tumors and 5-10% of all urothelial tumors, while ureteral tumors represent 1% of urinary tract tumors. He also pointed out the highest incidence of these cancers is observed in patients aged 70-90 years, particularly in the Balkan countries, where aristolochic acid nephropathy is prevalent. Moreover, the condition is twice as common in men as in women.
Dr. Munver then traced the historical milestones in the surgical management of this aggressive disease, from the first open nephroureterectomy in 1898 to the advent of laparoscopic techniques in 1991, and the introduction of robotic surgery in 2006. He simplified the surgical procedure into three main steps: radical nephrectomy, distal ureterectomy with bladder cuff excision, and regional lymphadenectomy based on the grade and stage of the disease. Traditionally, open nephroureterectomy has been the gold standard, involving one large incision or two moderate-sized incisions. He also discussed the various techniques for ureterectomy with bladder cuff excision and adrenal gland management, emphasizing that the adrenal gland is typically left in situ unless there is direct involvement by the disease.
Transitioning to the advantages of robotic assistance, Dr. Munver highlighted how robotic surgery improves upon the laparoscopic approach by offering several trocar configurations, superior anastomosis, and suturing capabilities. However, he noted that robotic surgery does have limitations, particularly in patients with morbid obesity, complex vascular anatomy, or abnormal conditions such as horseshoe kidney and adhesions.
Dr. Munver continued by discussing the evolution of robotic surgery from 1999 to 2014, emphasizing that significant improvements in robotic systems only began in 2006 when the devices became less bulky. This advancement allowed surgeons more workspace, culminating in the world's first robotic nephroureterectomy. He then delved into a detailed comparison between the Da Vinci Si and Xi systems. He pointed out that the Si system's positioning requirements added to the operative time, as the robot had to be docked laterally to the patient's flank with table angulation. This setup required the surgeon to first perform the nephrectomy and then reposition the robot to access the bladder and distal ureter.
In contrast, the Da Vinci Xi system, with its enhanced maneuverability and multi-quadrant abdominal access, significantly streamlined the procedure. The Xi system's angled trocar configuration allowed for dual camera placement, enabling efficient nephrectomy and distal ureterectomy with bladder cuff excision. Dr. Munver illustrated these points with a video montage showcasing his cases, highlighting the benefits of the Xi system in terms of shorter hospital stays, reduced blood loss, decreased major complications, and lower positive surgical margins. He also noted that robotic surgery minimizes the length and number of incisions required for specimen extraction compared to laparoscopic surgery.
Dr. Munver then presented a well-organized table summarizing the results of a meta-analysis, which highlighted the advantages of each surgical approach. The analysis clearly demonstrated that the benefits traditionally associated with laparoscopic surgery are increasingly favoring the use of robotic techniques. He concluded his talk by emphasizing the key advantages of the Xi system, stating that single docking saves time and effort, precise targeting improves access to the kidney, ureter, and bladder, and no additional trocars are required. He also noted the system's flexibility, allowing surgeons to choose between transperitoneal or retroperitoneal approaches, its facilitation of lymphadenectomy, the ability to perform running sutures for a watertight bladder closure, and its widespread familiarity, making it applicable to nearly every clinical scenario.
The podium was then passed to Dr. Jeffery Nix, who discussed the advantages of single-port robot-assisted nephroureterectomy and bladder cuff excision. Dr. Nix disclosed his role as a consultant for Intuitive Surgical before diving into the technical aspects of the procedure. He began by addressing the challenges of the Transperitoneal Approach, particularly when using a single-port system. Dr. Nix highlighted that the Transperitoneal Approach is more difficult with a single port compared to a multi-port system, especially in obese patients, where abdominal fat can obscure the camera, leading to frequent loss of visualization. He explained that accessing the kidneys from the midline is more challenging with this approach, which limits the effectiveness of single-port surgery in these cases.
Given these limitations, Dr. Nix suggested that the retroperitoneal flank approach might be more suitable for single-port procedures. However, he noted that this method also has its challenges, particularly when accessing the pelvis for distal ureter dissection. He pointed out that the retroperitoneal approach is more feasible in certain situations, such as in female patients with a larger pelvis or when the kidneys are smaller in size. He illustrated this point with a case example involving a patient with an end colostomy after a sigmoid resection, where accessing the bladder cuff was easier.
Dr. Nix continued by discussing the advantages of the lower anterior approach, which he recommended as a preferred option due to its ability to minimize setup issues while providing wider access to both kidneys, the distal ureter, and the bladder cuff. He emphasized that with this approach, the ureters are quickly exposed with only a few dissection cuts, which can expedite the procedure. Dr. Nix mentioned that he does not have a strict preference for performing the nephrectomy or ureterectomy first.
He then shifted the focus to the differences in hilar views between the lower anterior and retroperitoneal approaches. In the lower anterior approach, the renal arteries and veins are minimally offset, lying directly on top of each other, which can simplify the process. Dr. Nix shared that he uses Endo GIA staples for securing the hilum, as the single-port system does not yet have its own stapling arm. He also mentioned that he personally handles the stapling, rather than delegating it to his bedside assistant.
During the session, an audience member inquired about the bladder cuff portion of the procedure. Dr. Nix responded that he does not observe significant differences between the single-port and multi-port techniques in this regard. The session concluded with a thorough understanding of the challenges and advantages associated with single-port robotic surgery, particularly in nephroureterectomy and bladder cuff excision.
Presented by:
- Ravi Munver, MD, FACS, Vice Chair of Urology, Director of Minimally Invasive & Robotic Urologic Surgery, Director of Robotic Fellowship at Hackensack University Medical Center, New Jersey, USA
- Jeffery W. Nix, MD, MHSA, FACS, Professor and Director of Minimally Invasive & Robotic Urologic Surgery at University of Alabama at Birmingham, Alabama, USA.
Written by: Seyedamirvala Saadat, Research Specialist at Department of Urology, University of California Irvine, @Val_Saadat on X during the 2024 World Congress of Endourology and Uro-Technology: August 12 -16, 2024, Seoul, South Korea
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