title: Robotic nephroureterectomy: a simplified approach requiring no patient repositioning or robot redocking.
abstract: BACKGROUND
  Robotic technology is increasingly adopted in urologic surgery and a variety of techniques has been described for minimally invasive treatment of upper tract urothelial cancer (UTUC).
  
  
  OBJECTIVE
  To describe a simplified surgical technique of robot-assisted nephroureterectomy (RANU) and to report our single-center surgical outcomes.
  
  
  METHODS
  Patients with history of UTUC treated with this modality between April 2010 and August 2013 were included in the analysis. Institutional review board approval was obtained. Informed consent was signed by all patients.
  
  
  METHODS
  A simplified single-step RANU not requiring repositioning or robot redocking. Lymph node dissection was performed selectively.
  
  
  METHODS
  Descriptive analysis of patients' characteristics, perioperative outcomes, histopathology, and short-term follow-up data was performed.
  
  
  CONCLUSIONS
  The analysis included 31 patients (mean age: 72.4±10.6 yr; mean body mass index: 26.6±5.1kg/m(2)). Twenty-six of 30 tumors (86%) were high grade. Mean tumor size was 3.1±1.8cm. Of the 31 patients, 13 (42%) had pT3 stage disease. One periureteric positive margin was noted in a patient with bulky T3 disease. The mean number of lymph nodes removed was 9.4 (standard deviation: 5.6; range: 3-21). Two of 14 patients (14%) had positive lymph nodes on final histology. No patients required a blood transfusion. Six patients experienced complications postoperatively, with only one being a high grade (Clavien 3b) complication. Median hospital stay was 5 d. Within the follow-up period, seven patients experienced bladder recurrences and four patients developed metastatic disease.
  
  
  CONCLUSIONS
  Our RANU technique eliminates the need for patient repositioning or robot redocking. This technique can be safely reproduced, with surgical outcomes comparable to other established techniques.
  
  
  RESULTS
  We describe a surgical technique using the da Vinci robot for a minimally invasive treatment of patients presenting with upper tract urothelial cancer. This technique can be safely implemented with good surgical outcomes.
authors.affiliation: Center for Robotic and Image Guided Surgery, Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, OH, USA.
authors.forename: Homayoun
authors.initials: H
authors.lastname: Zargar
authors.affiliation: Center for Robotic and Image Guided Surgery, Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, OH, USA.
authors.forename: Jayram
authors.initials: J
authors.lastname: Krishnan
authors.affiliation: Center for Robotic and Image Guided Surgery, Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, OH, USA.
authors.forename: Riccardo
authors.initials: R
authors.lastname: Autorino
authors.affiliation: Center for Robotic and Image Guided Surgery, Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, OH, USA.
authors.forename: Oktay
authors.initials: O
authors.lastname: Akca
authors.affiliation: Center for Robotic and Image Guided Surgery, Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, OH, USA.
authors.forename: Luis Felipe
authors.initials: LF
authors.lastname: Brandao
authors.affiliation: Center for Robotic and Image Guided Surgery, Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, OH, USA.
authors.forename: Humberto
authors.initials: H
authors.lastname: Laydner
authors.affiliation: Center for Robotic and Image Guided Surgery, Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, OH, USA.
authors.forename: Dinesh
authors.initials: D
authors.lastname: Samarasekera
authors.affiliation: Center for Robotic and Image Guided Surgery, Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, OH, USA.
authors.forename: Oliver
authors.initials: O
authors.lastname: Ko
authors.affiliation: Center for Robotic and Image Guided Surgery, Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, OH, USA.
authors.forename: Georges-Pascal
authors.initials: GP
authors.lastname: Haber
authors.affiliation: Center for Robotic and Image Guided Surgery, Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, OH, USA.
authors.forename: Jihad H
authors.initials: JH
authors.lastname: Kaouk
authors.affiliation: Center for Robotic and Image Guided Surgery, Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, OH, USA. Electronic address: steinr@ccf.org.
authors.forename: Robert J
authors.initials: RJ
authors.lastname: Stein
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D002295:Carcinoma, Transitional Cell / Q000473:pathology / Q000601:surgery*; D015331:Cohort Studies; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D007680:Kidney Neoplasms / Q000473:pathology / Q000601:surgery*; D007902:Length of Stay; D008297:Male; D008875:Middle Aged; D009392:Nephrectomy / Q000379:methods; D061646:Operative Time; D056888:Patient Positioning / Q000379:methods*; D012189:Retrospective Studies; D065287:Robotic Surgical Procedures / Q000009:adverse effects / Q000379:methods*; D016896:Treatment Outcome; D014516:Ureteral Neoplasms / Q000473:pathology / Q000601:surgery*; D013520:Urologic Surgical Procedures / Q000295:instrumentation / Q000379:methods
keywords: Robotic nephroureterectomy; Surgical technique; Upper tract urothelial cancer