Robotic Surgery: A Minimally Invasive Solution for Distal Ureteral Cancer?
"Discover how robot-assisted surgery offers a precise and feasible approach to treating distal ureteral cancer while improving recovery times and potentially enhancing outcomes."
Traditional treatment for upper urinary tract urothelial carcinoma, involving the renal pelvis and ureter, has typically been radical nephroureterectomy due to the cancer's tendency to spread and reoccur. However, for low-risk urothelial tumors in the upper urinary tract, more conservative approaches, such as endoscopic or percutaneous methods, have emerged. These aim to preserve kidney function, especially in patients with only one kidney, bilateral tumors, or compromised kidney filtration.
The Boari flap technique, dating back to 1894, offers a solution for replacing sections of the distal ureter using a bladder flap. It's particularly useful for extensive benign lesions in the mid or distal ureter, facilitating tension-free connections when simpler reimplantation methods aren't viable. Laparoscopic surgery has made this technique less invasive, yielding results comparable to open surgery while minimizing patient recovery time.
While laparoscopic Boari flap procedures are documented for benign conditions and, less frequently, for cancerous ureteral lesions, robot-assisted approaches are even rarer. This article presents a case of distal ureteral urothelial carcinoma treated with robot-assisted distal ureterectomy and Boari flap reconstruction, highlighting the procedure's feasibility and precision.
Robot-Assisted Ureterectomy: How Does It Work and What Are the Benefits?
A 55-year-old male patient, a heavy smoker, presented with right renal colic and intermittent hematuria, revealing a distal ureteral tumor. After careful consideration and the patient's reluctance towards radical surgery, a robot-assisted distal ureterectomy with Boari flap reconstruction was performed using the da Vinci S-HD system.
- Mobilization and Fixation: The bladder was extensively mobilized and secured to the right psoas muscle to reduce tension.
- Flap Creation: An anterior flap with a wide base was created on the bladder to reach the ureter without tension.
- Anastomosis: The ureter was spatulated on its ventral side and connected to the bladder flap using separated sutures.
- Stenting and Closure: A double J ureteral catheter was placed, and the bladder was closed with continuous sutures.
- Leak Test and Drainage: The bladder's closure was tested with 300 ml of saline solution. A Jackson-Pratt drain was placed in the pelvis, and a 20 Fr Foley catheter was inserted.
The Future of Ureteral Cancer Treatment: Is Robotic Surgery the Answer?
Urothelial tumors of the upper urinary tract, affecting the renal pelvis and ureter, are rare, accounting for a small percentage of renal and urothelial cancers. Radical nephroureterectomy remains the standard treatment due to the risk of multifocality, recurrence, and aggressive behavior. However, conservative management, including ureteroscopic or percutaneous approaches, has shown promise in select cases.
Robot-assisted laparoscopic surgery for distal ureteral reimplantation is emerging as a safe and effective technique. While the Boari flap procedure has been performed laparoscopically with favorable results in benign ureteral conditions, its application in oncologic cases, particularly with robotic assistance, is limited but growing.
The presented case supports that robot-assisted Boari flap is technically feasible and potentially more precise than traditional laparoscopy. Further studies with larger patient cohorts and longer follow-up periods are needed to fully evaluate the oncological outcomes of this innovative approach.