title: Robot-assisted nephroureterectomy and bladder cuff excision without patient or robot repositioning: description of modified port placement and technique.
abstract: BACKGROUND
  Nephroureterectomy (NUx) with full bladder cuff excision is the gold-standard treatment for upper urinary tract urothelial cancer. Although minimally invasive techniques for NUx have demonstrated comparable outcomes to those of the open technique, the robotic technique is limited by the need for intraoperative patient repositioning and robot redocking to manage the distal ureter and bladder cuff. We describe our novel technique of robotic NUx that allows for complete access to the kidney and full bladder cuff excision.
  
  
  METHODS
  This modified technique was performed on a consecutive series of patients undergoing robotic NUx for upper urinary tract urothelial cancer from August 2012 to January 2014. Operative parameters and pathologic data were recorded, and patients were followed up for surveillance. After insufflation, the robotic trocars are placed in a standardized fashion, allowing for a one-time switch of instruments to facilitate distal ureteral dissection and a wide bladder cuff excision without patient repositioning or robot redocking.
  
  
  RESULTS
  Twenty-six patients have undergone NUx using our modified technique. Mean blood loss and operative time were 66 mL and 230 minutes, respectively. There were no intraoperative complications or open conversions, and there were no positive surgical margins. The average follow-up time was 7.8 months (range, 2-17 months), and 4 cases of cancer recurrence in the bladder were identified.
  
  
  CONCLUSIONS
  This novel technique for robotic NUx offers a standardized and easy-to-implement approach for NUx that requires a minimal learning curve for an experienced robotic surgeon, while affording a comparable oncologic control without the need for patient repositioning or additional port placement.
authors.affiliation: 1 Department of Urology, Columbia University Medical Center , New York, New York.
authors.forename: Ketan K
authors.initials: KK
authors.lastname: Badani
authors.forename: Michael B
authors.initials: MB
authors.lastname: Rothberg
authors.forename: Ari
authors.initials: A
authors.lastname: Bergman
authors.forename: Mark V
authors.initials: MV
authors.lastname: Silva
authors.forename: Edan Y
authors.initials: EY
authors.lastname: Shapiro
authors.forename: Alan
authors.initials: A
authors.lastname: Nieder
authors.forename: Trushar
authors.initials: T
authors.lastname: Patel
authors.forename: Akshay
authors.initials: A
authors.lastname: Bhandari
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D016063:Blood Loss, Surgical; D002295:Carcinoma, Transitional Cell / Q000601:surgery*; D015331:Cohort Studies; D015653:Cystectomy / Q000379:methods*; D005260:Female; D006801:Humans; D007680:Kidney Neoplasms / Q000601:surgery*; D007682:Kidney Pelvis; D008297:Male; D008875:Middle Aged; D009392:Nephrectomy / Q000379:methods*; D061646:Operative Time; D056888:Patient Positioning / Q000379:methods*; D065287:Robotic Surgical Procedures / Q000379:methods*; D013525:Surgical Instruments; D014513:Ureter / Q000601:surgery*; D014516:Ureteral Neoplasms / Q000601:surgery*; D001743:Urinary Bladder / Q000601:surgery