Supplementary Material for: Optimized patient positioning and port placement for robot-assisted laparoscopic radical nephroureterectomy in distal ureteral carcinoma: a technical case report

Background: Robot-assisted laparoscopic radical nephroureterectomy (RANU) is increasingly utilized in the management of upper tract urothelial carcinoma. However, detailed techniques for addressing distal ureteral carcinoma, particularly those involving partial cystectomy and pelvic lymph node dissection (PLND), remain limited, primarily due to challenges related to surgical positioning and port placement.
Case Presentation: We report the case of a 69-year-old woman diagnosed with cT2N1M0 left distal ureteral carcinoma, extending into the bladder. She received neoadjuvant chemotherapy followed by RANU. To optimize surgical positioning and port placement, we employed a modified lateral decubitus position during the nephrectomy phase and subsequently rotated the operating table for optimal pelvic access. This enabled effective partial cystectomy and PLND with addition of only one extra robotic port.
Outcomes: The total operative time was 4 h and 21 min, with a robotic console time of 3 h and 17 min. Estimated blood loss was minimal at 13 mL. There were no complications or transfusions required.
Conclusion: Our modified RANU technique, utilizing optimized patient surgical positioning and port placement, enabled safe and effective performance of facilitated partial cystectomy and PLND in a patient with invasive distal ureteral carcinoma. This approach offers a valuable option for challenging cases and warrants further investigation.

背景：机器人辅助腹腔镜根治性肾输尿管切除术（Robot-assisted laparoscopic radical nephroureterectomy，RANU）在上尿路尿路上皮癌的临床管理中应用日益普及。然而，针对远端输尿管癌的精细化手术技术，尤其是涉及部分膀胱切除术与盆腔淋巴结清扫术（pelvic lymph node dissection，PLND）的相关术式仍较为有限，这主要归因于手术体位与套管针置入所面临的技术挑战。
病例介绍：本研究报告1例69岁女性患者，经诊断为cT2N1M0期左侧远端输尿管癌，癌组织已侵犯膀胱壁。患者先接受新辅助化疗，随后行机器人辅助腹腔镜根治性肾输尿管切除术。为优化手术体位与套管针置入方案，术者在肾切除阶段采用改良侧卧位，之后旋转手术台以获得最佳盆腔手术暴露视野。该方案仅需额外增设1个机器人手术套管针，即可顺利完成部分膀胱切除术与盆腔淋巴结清扫术。
结果：总手术时长为4小时21分钟，机器人控制台操作时长为3小时17分钟。估计失血量极少，仅为13mL。术中未出现任何并发症，亦无需输血干预。
结论：本研究改良的机器人辅助腹腔镜根治性肾输尿管切除术技术，通过优化患者手术体位与套管针置入方案，可为侵袭性远端输尿管癌患者安全且高效地实施部分膀胱切除术与盆腔淋巴结清扫术。该术式为疑难病例提供了极具价值的可选治疗方案，值得开展进一步研究与探索。