The major difference between robotic radical nephrectomy and robotic radical nephroureterectomy is the dissection of the distal ureter and the management of the intramural portion of the ureter. The surgical steps are essentially the same up to these two convergent points.
Trocar positioning may need to be altered (lower position closer to pelvis) in order to afford dissection of the distal structures. Transperitoneal access allows safe mobilization of the ureter down to the bladder. The patient is initially placed in a medially rotated position for the nephrectomy, and then laterally rotated for the ureterectomy. Trendelenburg positioning aids in the dissection of pelvic structures.
Identification of distal ureter
The crossing points of the distal ureter may be identified in order to aid in the dissection of the distal ureter.
a.Ureter crossing point with gonadal vessels
b.Ureteral crossing point with common iliac artery
c.Ureteral crossing point with umbilical artery (lateral umbilical ligament)
d.Ureteral crossing point with vas deferens
The ureter should be dissected as distally as possible, and clipped in order to avoid intraabdominal seeding.
The intramural portion of the ureter is excised with the pluck technique. Prior to positioning for the nephrectomy, cystoscopy is performed and the ureteral orifice is identified. Using a Collings knife, the ureteral orifice and intramural ureter are excised.
Upon completion of the nephrectomy and ureteral dissection (up to detrusor fibers in the bladder) until the clipped ureter is plucked off the bladder. To close the bladder cuff, a linear endoscopic stapler is used. The risk for stone formation on the clip line should be considered.