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

摘要

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 patient was placed in a supine position, with a small bump under the flank, and left arm remained open (Fig. 1). A lower anterior access was performed by making a single 6-cm incision approximately at the McBurney point (one-third lateral of the line between the umbilicus and the superior anterior iliac spine, Fig. 2). After sweeping off the subcutaneous fat, the anterior fascia was identified and opened. Blunt dissection proceeded through the external, transverse, and internal oblique muscles to the retroperitoneal fat. Finger dissection created space moving from lateral to medial, freeing the retroperitoneal space as much as possible up to the kidney while avoiding opening the peritoneum. The wound retractor of the SP 10-cm Access-Port (Intuitive Surgical Inc.) was introduced under the posterior fascia, and the Access-Port globe was connected. A ‘side-car’ technique for the assistant port was used, introducing a 12-mm AirSeal® (ConMed Corp., Utica, NY, USA) trocar through the same skin incision and a separate fascial incision under digital control (Fig. 3). Finally, docking of the da Vinci SP System was performed by pointing the boom towards the contralateral shoulder. Surgery began with the camera positioned below, monopolar scissors in port number 3 (right side), bipolar forceps in port number 1 (left side), and Cadiere forceps in port number 2 (above). This setup allows consistent upward retraction by using the Cadiere forceps. The first step was identification of the psoas muscle, which serves as a primary landmark. The psoas was traced cranially, and the inferior cava vein immediately identified medially (in a left side case, the aorta is instead seen). The ureter was then identified and secured with a Hem-o-lok® clip (Weck Closure Systems, Research Triangle Park, NC, USA) to prevent tumour seeding during kidney manipulation in case of pelvic and proximal ureteric tumours. By smoothly progressing cranially, while lifting the lower pole of the kidney upward, the renal pedicle was soon identified. Both artery and vein were dissected. The artery was controlled by using three M-size Hem-o-lok clips (Weck Closure Systems). The vein was subsequently secured with a 35-mm laparoscopic stapler. Once hilar control was achieved, attention was directed towards the bladder. Utilising the ‘Relocate Mode’, the ureter was tracked downward towards the pelvis without need for rep