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

Abbreviations

EBL

estimated blood loss

LND

lymph node dissection

(RA)NU

(robot‐assisted) nephroureterectomy

SP

single port

UTUC

upper tract urothelial carcinoma

Introduction

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.

Patient and Methods

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.

Surgical Technique

The patient was placed in a supine position, with a small bump under the flank, and left arm remained open (Fig. 1).

Fig. 1.

Patient position for a supine anterior retroperitoneal access approach.

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).

Fig. 2.

Skin incision at the McBurney point.

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).

Fig. 3.

The SP ‘Access‐Port’ and ‘Side‐car’ positioned AirSeal trocar.

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 repositioning the patient or re‐docking the robot. The distal part of the ureter was dissected until reaching the bladder. Once the detrusor muscle was identified and confirmed, a V‐Loc™ (Covidien, Medtronic plc, Dublin, Ireland) 2/0 barbed stay suture was placed to allow easy identification of the bladder opening after the bladder cuff excision. A complete two‐layer reconstruction of the bladder was performed. Bladder closure was confirmed to be watertight by injecting 200 mL saline through the Foley catheter. As last step, the nephrectomy was completed by freeing the kidney after ‘relocating’ again towards the kidney. The specimen was removed through the wound protector without using an Endo Catch™ bag (Medtronic plc). No drain was placed.

Results

The incision and docking time was 14 min, and console time was 105 min, resulting in a total operative time of 119 min. The intraoperative EBL was 100 mL. No intra‐ or postoperative complications were reported. The patient was discharged on the first postoperative day. The haemoglobin level at discharge was 121 g/L compared to the preoperative value of 124 g/L. The creatinine level at discharge was 135.25 μmol/L (1.53 mg/dL), compared to the preoperative creatinine level of 83.98 μmol/L (0.95 mg/dL). The pain score was 1.2 (out of 10) at the time of discharge. No narcotics were used in postoperative care.

Pathology showed a high‐grade urothelial cancer with negative margins.

To date, at our Institution, we have performed eight RANU procedures using the new da Vinci SP platform. In our series of eight patients, the postoperative outcomes were notably favourable. The average EBL during surgery was 130 mL, with no patient requiring a blood transfusion. The mean console time was 108 min and a bladder‐cuff resection was performed in all cases. Additionally, three patients underwent locoregional lymph node dissection (LND), none of whom developed a lymphocele. No major complications were recorded, and all patients were discharged on the first postoperative day with a Foley catheter, which was removed after 7 days following cystography. No abdominal drain was placed in any patient. Pathological reports confirmed that no patients had positive surgical margins.

Discussion

A SP RANU is a safe and reproducible multi‐quadrant procedure that can be performed by using a lower anterior retroperitoneal approach.

The Xi RANU is an established minimally invasive treatment for UTUC. While a retroperitoneal approach is explored for multiport RANU, it is mainly performed transperitoneally due to technical multiport constraints. The Xi procedure still faces internal clashing and suboptimal working angles moving from the kidney to the bladder. The SP platform, designed for narrow spaces like the retroperitoneum and pelvis and allowing multi‐quadrant surgery could optimise RANU.

We used the novel supine anterior retroperitoneal access technique by Pellegrino et al. [5], which enables the maintenance of the patient in a supine position throughout, avoiding repositioning and re‐docking. This allowed rapid, precise Access Port placement. Transitioning from the renal quadrant to the bladder cuff was streamlined and efficient, utilising the advanced functionality of the da Vinci SP system's ‘Relocate Mode’, with bed‐side assistance optimising instrument settings during this phase.

To our knowledge, this represents the first reported European case of RANU using a retroperitoneal approach with the da Vinci SP robotic platform. In our experience, the SP platform overcomes limitations in confined surgical spaces such as the retroperitoneum. Postoperative pain was minimal, with no need for narcotics. The lower reported pain scores in retroperitoneal surgery, compared to transperitoneal, are likely due to avoiding peritoneal membrane irritation, which is highly innervated and sensitive to distension caused by pneumoperitoneum, and surgical incisions. Additional benefits include faster recovery and decrease surgical trauma. From a surgical perspective, the retroperitoneal approach utilising the SP platform presents notable benefits, including enhanced control of hilar structures, reduced blood loss, fewer surgical complications, and diminished postoperative discomfort. Evaluating the potential cost reduction associated with shorter hospital stays warrant further investigation.

In our opinion, LND appears feasible with this approach, offering easy access to locoregional lymph nodes, including the iliac, para‐aortic, para‐caval, and hilar nodes. It may be advisable to avoid this technique in patients with extensive lymph node involvement due to the limited operative field and potential difficulties in managing the aspiration system.

This technique has not shown significant limitations. However, in obese patients, the procedure becomes more challenging due to the excess fat, which further reduces the already limited operative field. Retroperitoneal adhesions caused by inflammation, such as in patients with a history of UTIs or pyelonephritis related to stones, could present the greatest limitation due to the difficulties in creating the retro‐pneumoperitoneum.

Conclusions

Here, we detailed the surgical steps and showed the safety and feasibility of SP RANU procedure via a supine anterior retroperitoneal access. This procedure offers key advantages for both the surgeon (allowing a completely retroperitoneal multi‐quadrant surgery) and, above all, the patient (more natural position during the surgery, minimising skin incision and postoperative pain, shortening the hospitalisation time).

As the SP system is increasingly adopted worldwide, SP RANU has to potential to become a competitive player in the surgical armamentarium for the treatment of UTUC. A comparative analysis with multiport Xi RANU should be the focus of future clinical research.

Disclosure of Interests

The authors declare that they have no disclosure of interest.

Data accessibility

https://zenodo.org/records/13767816.

Supporting information

Video S1. Single Port Robotic Nephroureterectomy via Supine Anterior Approach: step by step technique.