Refined step-by-step narrative review of robotic radical nephroureterectomy in the management of upper tract urothelial carcinoma.

Background and objective: Upper tract urothelial carcinoma (UTUC) is a challenging clinical entity to diagnose and manage. Recent advances in robotic technology have permitted optimization of surgical technique in robot-assisted radical nephroureterectomy with bladder cuff excision (RNU/BCE), regional lymphadenectomy, and intra or perioperative instillation of intravesical chemotherapy. This has optimized the management of bulky upper tract disease and high-grade disease not amenable to segmental ureterectomy or nephron-sparing surgery. The purpose of this article is to highlight and review the surgical technique if RNU/BCE and regional lymphadenectomy utilized in our high-volume clinical practice.

Methods: A review of our surgical approach was summarized for this narrative article. This technique has been refined over a course of more than 150 cases and 12 years of local experience with the procedure, as well as through multiple da Vinci^® robotic surgical systems over the years.

Key content and findings: RNU/BCE, regional template-based lymphadenectomy, and intra or perioperative instillation of intravesical chemotherapy is technically feasible and the procedure has been optimized via multiple iterations with a decade of local experience. The appropriate steps are outlined in this review.

Conclusions: RNU/BCE, regional template-based lymphadenectomy, and intra or perioperative instillation of intravesical chemotherapy provides a refined, standardized, efficient approach for management of UTUC in appropriately selected patients. This surgical technique has also been undertaken in elderly patients including those with advanced age (>80 years old) with significant medical co-morbidities due to imperative, symptomatic indications. Further, this approach may be facilely adapted by urologists familiar with all forms of robotic renal surgery.