Single-port robot-assisted nephroureterectomy via a supine anterior approach: step-by-step technique

Abstract

Radical nephroureterectomy (NU) remains the standard of care for treating non metastatic high-risk upper tract urothelial carcinoma (UTUC) [1]. Robot-assisted NU (RANU) has gained wider adoption over the past few years, especially after the introduction of the da Vinci^® (Intuitive Surgical Inc., Sunnyvale, CA, USA) Xi robotic platform that facilitates multi-quadrant surgical procedures [2]. However, the Xi RANU is mostly performed via a transperitoneal approach [3].

The da Vinci Single Port System (da Vinci SP^®; Intuitive Surgical Inc.) was introduced to the USA market in 2018 [4] and recently received European approval. This novel robotic platform has renewed interest in the retroperitoneal approach for kidney procedures, including RANU [5]. Advantages over multiport systems include smaller incisions, better cosmetic outcomes, reduced surgical trauma, less pain, and faster recovery.

Only very few cases of SP RANU have been reported to date [6, 7]. Here, we describe the detailed surgical technique of SP RANU, demonstrating its feasibility and ease of implementation in a high-volume robotic centre.

Our edited video (Video S1) shows a RANU case performed using the da Vinci SP in May 2024 at our institution. A 70-year-old male with a 2.8-cm pelvis (PUJ) tumour, a Charlson Comorbidity Index of 6, and a body mass index of 29.32 kg/m² was selected. Recorded surgical outcomes included: docking and console time, estimated blood loss (EBL), complications, haemoglobin, creatinine, pain scores at discharge assessed by using a numerical rating scale, and length of stay.

The incision and docking time was 14 min, and console time was 105 min, resulting in a total operative time of 119 min. The intraoperative EBL was 100 mL. No intra- or postoperative complications were reported. The patient was discharged on the first postoperative day. The haemoglobin level at discharge was 121 g/L compared to the preoperative value of 124 g/L. The creatinine level at discharge was 135.25 μmol/L (1.53 mg/dL), compared to the preoperative creatinine level of 83.98 μmol/L (0.95 mg/dL). The pain score was 1.2 (out of 10) at the time of discharge. No narcotics were used in postoperative care.

Pathology showed a high-grade urothelial cancer with negative margins.

To date, at our Institution, we have performed eight RANU procedures using the new da Vinci SP platform. In our series of eight patients, the postoperative outcomes were notably favourable. The average EBL during surgery was 130 mL, with no patient requiring a blood transfusion. The mean console time was 108 min and a bladder-cuff resection was performed in all cases. Additionally, three patients underwent locoregional lymph node dissection (LND), none of whom developed a lymphocele. No major complications were recorded, and all patients were discharged on the first postoperative day with a Foley catheter, which was removed after 7 days following cystography. No abdominal drain was placed in any patient. Pathological reports confirmed that no patients had positive surgical margins.

A SP RANU is a safe and reproducible multi-quadrant procedure that can be performed by using a lower anterior retroperitoneal approach.

The Xi RANU is an established minimally invasive treatment for UTUC. While a retroperitoneal approach is explored for multiport RANU, it is mainly performed transperitoneally due to technical multiport constraints. The Xi procedure still faces internal clashing and suboptimal working angles moving from the kidney to the bladder. The SP platform, designed for narrow spaces like the retroperitoneum and pelvis and allowing multi-quadrant surgery could optimise RANU.

We used the novel supine anterior retroperitoneal access technique by Pellegrino et al. [5], which enables the maintenance of the patient in a supine position throughout, avoiding repositioning and re-docking. This allowed rapid, precise Access Port placement. Transitioning from the renal quadrant to the bladder cuff was streamlined and efficient, utilising the advanced functionality of the da Vinci SP system's ‘Relocate Mode’, with bed-side assistance optimising instrument settings during this phase.

To our knowledge, this represents the first reported European case of RANU using a retroperitoneal approach with the da Vinci SP robotic platform. In our experience, the SP platform overcomes limitations in confined surgical spaces such as the retroperitoneum. Postoperative pain was minimal, with no need for narcotics. The lower reported pain scores in retroperitoneal surgery, compared to transperitoneal, are likely due to avoiding peritoneal membrane irritation, which is highly innervated and sensitive to distension caused by pneumoperitoneum, and surgical incisions. Additional benefits include faster recovery and decrease surgical trauma. From a surgical perspective, the retroperitoneal approach utilising the SP platform presents notable benefits, including enhanced control of hilar structures, reduced blood loss, fewer surgical complications, and diminished postoperative discomfort. Evaluating the potential cost reduction associated with shorter hospital stays warrant further investigation.

In our opinion, LND appears feasible with this approach, offering easy access to locoregional lymph nodes, including the iliac, para-aortic, para-caval, and hilar nodes. It may be advisable to avoid this technique in patients with extensive lymph node involvement due to the limited operative field and potential difficulties in managing the aspiration system.

This technique has not shown significant limitations. However, in obese patients, the procedure becomes more challenging due to the excess fat, which further reduces the already limited operative field. Retroperitoneal adhesions caused by inflammation, such as in patients with a history of UTIs or pyelonephritis related to stones, could present the greatest limitation due to the difficulties in creating the retro-pneumoperitoneum.

Here, we detailed the surgical steps and showed the safety and feasibility of SP RANU procedure via a supine anterior retroperitoneal access. This procedure offers key advantages for both the surgeon (allowing a completely retroperitoneal multi-quadrant surgery) and, above all, the patient (more natural position during the surgery, minimising skin incision and postoperative pain, shortening the hospitalisation time).

As the SP system is increasingly adopted worldwide, SP RANU has to potential to become a competitive player in the surgical armamentarium for the treatment of UTUC. A comparative analysis with multiport Xi RANU should be the focus of future clinical research.

The authors declare that they have no disclosure of interest.

https://zenodo.org/records/13767816.