Robot-assisted Complete Urinary Tract Exenteration for Multifocal Urothelial Carcinoma: Perioperative Management in...

Complete urinary tract exenteration (CUTE) is an extremely radical procedure for multifocal urothelial carcinoma (UC) involving the bilateral upper urinary tract and the bladder, inevitably requiring postoperative hemodialysis. However, reports on robot-assisted CUTE are limited, and its perioperative safety has not been sufficiently established. The role of perioperative management in this highly invasive procedure remains unclear. This study aimed to report two patients with multifocal UC who underwent robot-assisted CUTE without preexisting dialysis, with perioperative management including hemodialysis initiation.

Two non-dialysis patients with multifocal UC underwent robot-assisted CUTE following neoadjuvant chemotherapy, as postoperative renal failure was inevitable. Patient 1 received gemcitabine plus cisplatin, whereas Patient 2 initially received gemcitabine plus cisplatin, but was subsequently switched to gemcitabine plus carboplatin due to renal dysfunction developing. Both patients achieved a partial response. Given concerns regarding perioperative hemodynamic instability associated with this highly invasive procedure, an arteriovenous shunt was not created preoperatively; instead, jugular catheter-based dialysis access was used, with a planned arteriovenous shunt to be created at a later stage. Surgery was performed using the da Vinci Xi system with two re-docking procedures. The operative times were 461 and 456 min, and estimated blood losses were 90 and 22 ml. Both patients required postoperative blood transfusion. Hemodialysis was initiated on postoperative day 1. No major perioperative complications occurred, and the patients were discharged on postoperative days 21 and 18.

Robot-assisted CUTE may be a feasible surgical option for selected non-dialysis patients with multifocal UC. This approach may enable a safe transition to postoperative dialysis and favorable recovery, while allowing for complete surgical resection with acceptable perioperative outcomes. Further studies are necessary to define its clinical role.