Retroperitoneal Robot-Assisted Nephroureterectomy: Technical Description and Single Center Experience

Robot-assisted radical nephroureterectomy (RANU) is increasingly used for upper tract urothelial carcinoma (UTUC). The retroperitoneal approach avoids bowel mobilization, but its adoption in robotic surgery remains limited because of the confined working space and technical complexity. We described our step by step retroperitoneal technique and evaluated perioperative outcomes in an initial single center series.

We retrospectively reviewed consecutive patients who underwent intended fully robot assisted retroperitoneal RANU at our institution between July 2022 and September 2025. Patients requiring planned laparoscopic assistance, concomitant radical cystectomy, or upfront transperitoneal surgery were excluded. Patient characteristics, operative variables, unplanned intraoperative deviations from the intended approach, and perioperative complications were assessed.

Forty six patients were included. The median total operative time, insufflation time, and console time were 372, 328, and 268 min, respectively. Median estimated blood loss was 20 mL, and median postoperative hospital stay was 11 days. Unplanned deviation from the intended retroperitoneal robotic approach occurred in four patients (8.8%), with observed contributing factors including massive hydronephrosis, prior urinary tract surgery, recent urinary extravasation, and suspected adjacent organ invasion. Clavien-Dindo grade ≥ 3 complications occurred in four patients (8.8%), including one intraoperative duodenal serosal injury that was repaired immediately. Limitations include the retrospective design, single center setting, small sample size, learning curve effect, and lack of a transperitoneal comparator.

In this initial single center series, retroperitoneal RANU was feasible in selected patients. Our experience suggests that careful preoperative assessment of anatomic complexity and prior surgical history may help identify cases in which completion of the retroperitoneal approach is difficult.