In patients with transitional cell cancer in which the tumor is in the distal (lower) part of the ureter, with no involvement of the bladder, it may be possible to treat the cancer by performing a robotic distal ureterectomy with reimplant. This procedure is similar to the ureteral reimplantation performed to treat ureteral strictures (blockages in the ureter due to scar tissue or other causes), except that the lower ureter is removed with a small piece of bladder where the ureter inserts into the bladder, prior to the reimplantation. The advantage of this approach is that by removing only the distal ureter and reimplanting the healthy, non-cancerous portion of the ureter, the kidney is spared.
As with other ureteral procedures, robotic surgery is very well-suited for distal ureterectomy. The enhanced precision and visualization offered by the da Vinci Si surgical system facilitates the delicate dissection and suturing of the ureter and bladder required in this procedure. Depending on the nature of the tumor, a pelvic lymph node dissection may also be done as part of the surgical treatment—another procedure requiring careful dissection of tissue, in which robot-assisted surgery offers advantages to the surgeon. In addition, since robotic distal ureterectomy is minimally invasive, the patient will experience less post-operative pain and scarring and have a faster recovery.
In this procedure, the patient is anesthesized and four ports are placed in the abdomen using quarter-inch incisions. The robot’s camera and three instrument arms are then inserted into the ports. The surgeon uses these instruments to free up the lower ureter and bladder from their surrounding structures. Once isolated, the ureter is clipped to prevent urine spilling and the ureter along with the bladder cuff is excised and placed in a bag for later extraction. The opening of the bladder is then sutured closed,
The surgeon then reimplants the remaining portion of the ureter into the bladder by creating a new opening in the bladder and suturing the ureter to this opening. In some cases, if the positions of the bladder and ureter are putting tension on this sutured connection (which can impede the healing process), the surgeon may utilize a psoas hitch—in which the bladder is partially cut free from its attachments, then sutured (“hitched”) to the psoas tendon, bringing it closer to the ureter—and/or a Borai flap procedure, where the surgeon creates a new, tongue-like flap of bladder tissue that is then stretched towards the ureter and sutured shut.
Less post-operative discomfort and scarring. Traditionally, distal ureterectomy is performed using an open incision measuring 5 to 8 inches. Robotic surgery allows the same operation to be performed with 4 quarter-inch incisions, resulting in less post-operative pain and minimal scarring.
Less blood loss. Using this minimally invasive robotic technique with its improved visualization, better control of instruments, and the ability to perform precise suturing, blood loss can be minimized compared to the open technique.
Shorter hospital stay and faster recovery. Most patients undergoing robot-assisted distal ureterectomy leave the hospital in 1 to 3 days versus 4 to 6 days for open surgery, and are able to resume normal activities within 1 to 2 weeks, compared to 4 to 6 weeks for open surgery.
The greater precision and visualization offered by the da Vinci Si enhances the surgeon’s ability to perform certain parts of the procedure, including dissection of the ureter at the point where it enters the bladder, suturing of the bladder, and the suturing required for reimplantation of the ureter.
Our surgeons at NYU Langone’s Robotic Surgery Center have extensive experience with this surgical approach, and have published and presented their technique both nationally and internationally. Our initial results have been excellent, and for many surgeons this procedure is now the preferred technique to manage transitional cell carcinoma of the distal ureter.