Urothelial cancer of the upper urinary tract is an uncommon urological malignancy, occurring in 5–10% of all urothelial tumors in the United States [1]. In the case of high-grade urothelial malignancy and/or tumor burden not amenable to minimally invasive procedures such as endoscopic resection and/or laser versus electrocautery fulguration, the gold standard has been open nephroureterectomy with bladder cuff excision . The technique for this has always varied depending on surgeon preference and experience as well as patient’s body habitus such as morbid obesity. This open surgical procedure is generally accomplished through two separate large incisions, one for the nephrectomy, and the other for the distal ureterectomy and bladder cuff excision, each with its associated morbidity. With the advent of laparoscopy and robotic surgery, nephroureterectomy can be performed in a minimally invasive fashion, with comparable oncological outcomes and with decreased morbidity [2]. We will review the technique of minimally invasive nephroureterectomy and, above all, discuss its complications, with particular focus on those associated with distal ureterectomy and bladder cuff excision.

In general, nephroureterectomy is a two-step surgical procedure involving different quadrants of the abdomen and pelvis: nephrectomy and distal ureterectomy with bladder cuff excision . The steps of nephrectomy are well known to urologists and are easily translatable to laparoscopy and robotics. Trocar placement and configuration depend on how the distal ureter is managed, the type of laparoscopic/robotic equipment available, and patient’s body habitus (body mass index). Management of the distal ureter and bladder cuff depends on surgeon preference and experience with minimally invasive techniques. In open surgery, this is performed through a Gibson, Pfannenstiel, or midline incision. To minimize urine spillage into the surgical field, an extravesical technique is typically used in antegrade fashion. If there is concern for tumor involving the ureteral orifice or concomitant bladder tumor, a cystotomy is made as part of the intravesical technique to directly visualize the ureteral orifice and to free up the distal ureter in both directions.

Prior to popularization of the robotic platform, many of the early laparoscopic series utilized a variant of the “pluck” technique to mobilize the distal ureter and the bladder cuff. These techniques were developed because antegrade mobilization of the distal ureter and the bladder cuff, combined with intracorporeal laparoscopic suturing of the bladder defect, require a high degree of laparoscopic experience and finesse. The “pluck” technique relies on transurethral incision around the ipsilateral ureteral orifice and mobilization of the distal ureter from the bladder and perivesical fat. This is then followed by pulling the ureter laparoscopically on gentle traction to “pluck” it away from the bladder. The transurethral techniques described in laparoscopic series included Collins knife [3], cutting wire electrode [4], bipolar plasma “button” electrode [5], and laser excision [6] around the ureteral orifice. To minimize potential subsequent spillage of cancer cells from the ureter, a variety of techniques have been described in the urological literature, which include endoscopic ureteral occlusion techniques such as suture ligation [7], fulguration of the ureteral lumen [7], balloon occlusion [8], and fibrin plug within the ureteral lumen [9].

Although the “pluck” technique is familiar to urologists with experience with transurethral resection, major disadvantages to this technique include the oncological concern of potentially seeding the perivesical fat with cancer cells, as the bladder defect is not closed with this technique and is left to heal by prolonged Foley catheter drainage. It excludes the possibility to instill intravesical chemotherapy immediately after surgery to decrease the rate of intravesical recurrence of bladder tumors because such instillation would potentially flow into the peritoneum and retroperitoneum. In addition, this technique usually required the patient to be placed in dorsal lithotomy position first for the cystoscopic part of the procedure, followed by repositioning, reprepping, and redraping the patient for the nephrectomy part of the procedure.

In an attempt to decrease the difficulty of laparoscopic suturing, different groups have developed variations in the laparoscopic management of the distal ureter and bladder cuff. In one of the earliest case series on laparoscopic nephroureterectomy, McDougall et al. used a titanium stapler to divide the ureter distal to the ureterovesical junction in ten patients [10]. Although the oncological outcomes were not statistically different in their updated case series [11] compared with a group of patients who underwent open nephroureterectomy, a different case series comparing the distal ureterectomy methods during hand-assisted laparoscopic nephroureterectomy found that the stapled cohort had higher than expected positive surgical margin rate at the distal ureter (29%) compared with the other techniques (i.e., “pluck” technique, open distal ureterectomy, and hand-assisted laparoscopic extravesical distal ureterectomy), which had rates less than 10% [12].

An alternative to the stapling technique was with dividing the bladder cuff with LigaSure Atlas (Medtronic, Minneapolis, MN, USA) [13]. Similar to the stapling technique, the LigaSure method seals the bladder defect with no spillage of urine into the operative field. Although this method reportedly had good outcomes with no local recurrence reported with a mean follow-up time of 11.6 months, there is no direct visualization of the ureteral orifice prior to dividing the bladder cuff . A different group reported that out of the 22 patients undergoing this technique, 4 required additional cystorrhaphy to make the closure watertight [14]. One was found to have a remnant ipsilateral ureteral orifice on cystoscopy and underwent transurethral resection with no residual tumors identified.

For urologists facile at laparoscopic suturing, Cho et al. described their technique of placing a curved bulldog clamp on the bladder cuff, dividing the cuff proximal to the clamp, and intracorporeal suturing of the bladder mucosa prior to removing the bulldog clamp [15]. Although this technique prevents urine spillage and allows for visual confirmation of the ureter specimen for the ureteral orifice, it does require advanced laparoscopy techniques for the two-layer cystorrhaphy closure.

With the popularization of the robotic platform, the learning curve for minimally invasive procedures, such as nephroureterectomy, has been decreased. The three-dimensional vision and the articulating wristed instruments facilitate ureteral dissection and intracorporeal suturing in small working spaces. For robotic nephroureterectomy (RNU) , Hemal et al., have published their experience with performing all the steps of the operation without repositioning the patient or redocking the robotic patient-side cart to the patient. This has been done for da Vinci S, Si, and Xi robots (Intuitive Surgical, Sunnyvale, CA, USA) [16, 17]. With the da Vinci S and Si robots, they place the robotic arms in a T-shaped configuration, with the camera trocar in the middle of the port configuration [16]. Upon completion of nephrectomy, the camera position is tilted to the pelvis for the distal ureterectomy. With the da Vinci Xi robot, the four robotic trocars are placed linearly over the pararectus line and can be shifted medially or laterally depending on the patient’s body habitus [17]. As the camera for the da Vinci Xi robot goes through the 8 mm robotic trocar, the camera can be moved from one robotic trocar to another trocar as needed to facilitate visualization during distal ureterectomy.

Alternatively, Darwiche et al. recommended placing the Xi trocars in an oblique straight line and switch the camera to the second most caudal robotic trocar for the distal ureterectomy [18]. Most recently, Argun et al. advocated placing the Xi trocars in a T-shaped configuration [19], similar to the configuration as reported by Hemal et al. [16] using the earlier generation robots.

With the robot, the antegrade approach to the distal ureter is considerably less difficult to perform compared with laparoscopic techniques. To minimize potential cancer cell migration from the ureter to the bladder, the ureter should be clipped distal to the location of the tumor within the upper tract.

Complications in RNU can be divided by anatomical location and organ of interest. This is because nephroureterectomy encompasses an anatomical area from the upper reaches of the upper quadrant to the distal reaches of the true pelvis. The complications associated with the nephrectomy part of the case are identical to those encountered for radical nephrectomy and partial nephrectomy. These complications have been previously described in this book on radical nephrectomy. Complications encountered during distal ureterectomy portion of the RNU are detailed below: