Single-Position Robot-Assisted Laparoscopic Nephroureterectomy for Duplicated Kidneys and Ureters: Technique and Outcomes

Single-Position Robot-Assisted Laparoscopic Nephroureterectomy for Duplicated Kidneys and Ureters: Technique and Outcomes | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Single-Position Robot-Assisted Laparoscopic Nephroureterectomy for Duplicated Kidneys and Ureters: Technique and Outcomes Wei-Cheng Sun, Feng Zhang, Jia-Ning Sun, Xiao-Yan Wang, Gong-Lin Tang, and 4 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-5867796/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Purpose Robot-assisted laparoscopic nephroureterectomy has reached a high level of maturity. However, operating on patients with duplex kidneys presents added challenges, primarily due to the large-scale resection and the need for re-positioning. This study aims to elaborate on the technique and outcomes of single-position robot-assisted nephroureterectomy for duplicated kidneys and ureters. Methods In our department, 23 patients diagnosed with duplicated renal collecting systems were selected. 10 patients underwent single-position robot-assisted laparoscopic nephroureterectomy (single-position group), and 13 had traditional robot-assisted laparoscopic nephroureterectomy (non-single-position group). We systematically collected their demographic data, surgical indications, and perioperative variables, and meticulously evaluated the surgical outcomes. Results All 23 patients underwent successful surgeries without conversion to open procedures. No remarkable differences were detected in the baseline clinical characteristics. The single-position group had a shorter operation time (166.20 ± 21.29 min vs. 208.31 ± 23.30 min, p < 0.001) and drainage tube indwelling time (3.50 ± 0.53 days vs. 4.15 ± 0.69 days, p < 0.05). Additionally, a statistically significant disparity in estimated blood loss (EBL) was noted between the two groups (136.00 ± 18.14 ml vs. 165.77 ± 40.72 ml, p < 0.05). There were no differences in post-operative hospital stays and pre-and post-operative estimated glomerular filtration rate (eGFR), and no recurrence was observed. Conclusion Single-position robot-assisted nephroureterectomy is both a reliable and secure surgical treatment for duplicated renal collecting systems, offering benefits such as reduced operative time, minimal minor complications, less estimated b l ood loss, and a high rate of surgical success. Robotic surgery Nephroureterectomy Duplicated system Single position Technique Figures Figure 1 Figure 2 Figure 3 Introduction The congenital abnormality of duplicated renal collecting systems is somewhat common [ 1 ], affecting 0.7–4.0% of the population, with a higher prevalence in females and often diagnosed during childhood [ 2 ]. Most cases involve upper pole renal dysplasia and reduced function [ 3 ]. For patients with symptomatic non-functioning segments and ectopic ureters, the upper pole heminephrectomy is the normal surgical procedure [ 4 ], with laparoscopic upper pole nephroureterectomy offering a minimally invasive, safe, and efficient treatment option [ 5 ]. As robotic technology becomes increasingly integrated into renal surgeries, its advantages are being progressively acknowledged. The robotic approach is particularly well-suited for nephroureterectomy, offering enhanced visualization around the lower pole vasculature and enabling more precise surgical movements, especially critical in cases requiring reconstruction [ 6 , 7 ]. Traditional nephroureterectomy in duplex kidney patients involves the removal of the dysfunctional upper pole and the duplicated ureter. This extensive resection typically necessitates repositioning during surgery. However, robot-assisted nephroureterectomy performed in a single position eliminates the need for repositioning and re-disinfection, thereby enhancing both safety and efficacy. This study introduces our innovative technique, designed to reduce operative time and expedite patient recovery. Patients and Methods Patients From November 2019 to December 2023, 23 patients (13 males and 10 females) underwent robot-assisted nephroureterectomy in our study. 10 patients underwent robot-assisted laparoscopic nephroureterectomy in a single position (single-position group), while 13 patients had traditional robot-assisted laparoscopic nephroureterectomy (non-single-position group). Among them, 13 patients were asymptomatic upon admission, 10 patients experienced lumbago, and 12 patients presented with hydronephrosis. A dilated upper pole renal and ureter under a duplicate collecting system was discovered by preoperative imaging evaluations performed on all patients, such as intravenous pyelograms (IVU), computed tomography (CT), or magnetic resonance imaging (MRI). Three-dimensional reconstruction was employed to enhance patient counseling, optimize surgical decision-making, and facilitate both pre-and intraoperative planning. We documented the patients' demographics, surgical indications, perioperative variables, and outcomes. Surgical technique Before the robot-assisted nephroureterectomy, patients first experienced 6F ureteral catheters inserted in both ureters via cystoscopy with retrograde ureteropyelography of the lower pole collecting system. One catheter was withdrawn, and the other, which led to the normal operating system, was attached to the Foley catheter. The same highly trained doctors conducted all of the five procedures, using the da Vinci Si surgical apparatus. Patients were positioned in a 70° modified flank orientation (Fig. 2 a), and all surgical procedures were executed via the transperitoneal approach. First of all, a small incision was initially made at port C (4 cm to the right of the navel), with the abdominal wall elevated bilaterally using towel forceps. To create pneumoperitoneum, a Veress needle was placed at the umbilicus. A 12-mm trocar was then placed to supply medial camera viewing. Subsequently, three additional 8-mm robotic arm ports were placed: port B was placed at the outer margin of the right rectus abdominis, 5 cm below the costal margin; port D was placed at 5 cm medially superior to the anterior superior iliac spine; and port E was placed at the midpoint between port C and port D. The 12-mm assistant port A was positioned along the abdominal midline, horizontally between port B and port C, for retraction, suction-irrigation, and suture handling, etc (Fig. 1 and Fig. 2 b). A 5-mm port, located 4 cm below the xiphoid process, accommodated a liver retractor (Fig. 1 ). Subsequently, the robot was docked at a 90° angle. The colon was medially mobilized and both ureters were found following robot docking (Fig. 2 c). The normal ureter was identified with the aid of the ureteral catheter that had previously been implanted. The duplicated kidney and ureter were exposed following dissection of the paracolic groove and Gerota fascia (Fig. 3 a and 3 b), where ureter tortuosity and significant hydronephrosis were noted. The enlarged upper pole ureter was completely dissected, and the lower pole vasculature crossed anteriorly to the upper pole ureter, thus it was carefully protected when the ureters were dissected head to the renal hilum (Fig. 3 c). The upper pole blood vessels were transected after being fastened with hem-o-lok clamps. Selective vascular dissection was performed instead of clamping the hilum to fully specify the vascular architecture of the upper and lower pole components. It was important to make sure that dissection completion posterior to the renal hilum was confirmed before transecting the anomalous ureter. If necessary, bulldog clamps need to be used to clamp down the dissected renal artery. The hydronephrotic kidney was excised along the duplicated renal margin using a harmonic scalpel. Along the line separating the upper and lower pole parts, the hemiphrectomy was performed. The renal incision margin was sutured with absorbable sutures (Fig. 3 d), and oxidized cellulose polymer (Fig. 3 e) or bipolar cautery was used for achieving hemostasis. The robot orientation was adjusted while maintaining the patient’s position. The lateral border of the left rectus abdominis and the port E level intersected at port G, where an extra 8-mm robotic arm port was positioned (Fig. 1 ). The patient’s head was angled at 10–20° downward, and the 70° lateral position was adjusted to 45° by manipulating the operating table. The original robotic arm at port D was relocated to port G, leaving robotic arms in ports E and G. Port D served as an auxiliary slot and accommodated an anti-negative pressure drainage tube. Post-redocking, surgery continued with ports other than port B, and the incision at port B was sutured to maintain pneumoperitoneum integrity (Fig. 2 d). A caudal resection of the nonfunctioning ureter was performed within 1 cm of the bladder (Fig. 3 f). To evaluate the integrity of the collecting system and differentiate the normal ureter, methylene blue was retrogradely administered into the ureteral catheter that had already been placed. The abnormal ureter was resected (Fig. 3 g), and the resected ureteral stump was sealed (Fig. 3 h). After careful examination of the excised kidney wounds showed no active bleeding, the incision was extended approximately 4 cm to the right from port C. After being extracted from the incision, all excised specimens (Fig. 2 e) were sent for a standard pathological analysis. An anti-negative pressure drainage tube was set at port D for abdominal drainage. Finally, intra-abdominal gas was evacuated, trocars were taken out, and layers of closure were applied to the wounds. On the second postoperative day, the drainage tube and Foley catheter were withdrawn, and the ureteral catheter was taken out right away. Statistical analysis All quantitative values are presented as the mean ± standard deviation (SD). Continuous variables were compared via the Student's t-test. For categorical variables, comparison was carried out using the Chi-square test or Fisher's test, as deemed appropriate. All statistical tests were two-tailed, and the significance level was set at p < 0.05 for all tests. The analysis was conducted using SPSS software, version 26.0. Results 23 patients (13 males and 10 females) underwent duplex kidney resection from March 2020 to December 2023. There was no intraoperative conversion to open surgery. 10 patients underwent robot-assisted laparoscopic nephroureterectomy in a single position (single-position group), while 13 patients had traditional robot-assisted laparoscopic nephroureterectomy (non-single-position group). The indications for surgery included hydronephrosis, hydroureter, and a history of lumbago. No remarkable differences were detected in the baseline clinical characteristics. In comparison to the non-single-position group, the single-position group demonstrated a shorter operation time (166.20 ± 21.29 min vs. 208.31 ± 23.30 min, p < 0.001) and a shorter drainage tube indwelling time (3.50 ± 0.53 days vs. 4.15 ± 0.69 days, p < 0.05). Additionally, a statistically significant disparity in estimated blood loss (EBL) was noted between the two groups (136.00 ± 18.14 ml vs. 165.77 ± 40.72 ml, p < 0.05). No differences were observed in post-operative hospital stays, pre-operative estimated glomerular filtration rate (eGFR), and post-operative eGFR (Table 1 ). Table 1 Characteristics of patients in single-position and non-single-position groups. Characteristics single-position group non-single-position group p-value Age (years) 46.70 ± 8.51 45.62 ± 6.27 0.739 BMI (body mass index, kg/m2) 23.25 ± 3.48 22.58 ± 2.52 0.613 Female (n, %) 4 (40.00) 6 (46.15) 0.768 EBL (ml) 136.00 ± 18.14 165.77 ± 40.72 0.031 Operation time (min) 166.20 ± 21.29 208.31 ± 23.30 < 0.001 Drainage tube indwelling time (days) 3.50 ± 0.53 4.15 ± 0.69 0.017 Post-op hospital stays (days) 4.40 ± 0.70 4.92 ± 0.86 0.123 Pre-operative eGFR (mL/min/1.73 m²) 114.40 ± 7.03 110.62 ± 7.37 0.224 Post-operative eGFR (mL/min/1.73 m²) 98.00 ± 13.51 95.77 ± 7.42 0.646 Overall complication 0 1 Recurrence 0 0 One patient in the non-single-position group received blood transfusions (7.69%, Clavien-Dindo grade II) on the first and second postoperative days and developed an infection (7.69%, Clavien-Dindo grade I) during the same period, which was managed with ceftizoxime. All patients underwent excision of the affected kidney and ureter, yielding a subjective surgical success rate of 100% (23/23). In the single-position group, 10 patients were followed up for 3–9 months. In the non-single-position group, 13 patients were followed up for 4–9 months. No recurring hydronephrosis was discovered since all patients were monitored. Discussion One typical anomaly in the urinary system is duplicated renal collecting systems [ 1 ]. These anomalies are frequently unnoticed until adulthood, though obstructions related to the upper polar nephron typically manifest in children. Approximately 60% of affected individuals exhibit no apparent or characteristic clinical symptoms [ 8 , 9 ]. But for those experiencing notable symptoms such as hydronephrosis, dysuria, lumbo-abdominal pain, recurrent urinary tract infections, and persistent vaginal or rectal leakage, the conventional upper-pole nephrectomy is still frequently used, to treat symptomatic duplex systems with inadequately performing superior segments [ 10 ]. Duplicated renal collecting systems represent a frequent urological anomaly. In 1993, Jordan GH and Winslow BH et al. [ 11 ] pioneered the application of laparoscopic techniques for addressing kidney and ureter duplication, highlighting the benefits of laparoendoscopy and establishing the viability of laparoendoscopic upper pole partial nephrectomy for such anomalies. By 2007, Abouassaly R et al. [ 12 ] provided a detailed description of their laparoscopic upper pole partial nephrectomy technique in a cohort of adult patients. They believed that this approach is both safe and effective for treating symptomatic duplicated systems in adults, offering reduced morbidity, swift recovery, and a high success rate. Further advancements were made in 2010 when Patel MN et al. [ 13 ] demonstrated the viability and effectiveness of handling inherited renal abnormalities using robot assistance. In 2012, Mason MD et al. [ 6 ] recognized robot-assisted laparoscopy as ideally suited for upper pole heminephrectomy. This technique boosted the surgeon's movements and ergonomics while simultaneously enhancing vision during the removal of the ureter and upper pole collecting system as it passed through the lower pole vasculature. In individuals who have duplicated renal collecting systems, the presence of an excessively long ureter stump is a significant concern that urologists should acknowledge. Retained long ureteral stumps have been documented to function similarly to diverticula, leading to infections caused by urinary stasis [ 14 ]. This complication, known as distal stump syndrome (DSS), manifests through symptoms including empyema of the stump, recurrent urinary tract infections, and/or urethritis. Approximately 20% of patients experience DSS several months to years following heminephrectomy [ 15 – 17 ]. Managing DSS often requires a secondary and complex distal ureterectomy, challenged by severe inflammation and adhesions [ 18 ]. Despite the potential risks of damaging the normal ureter, the complete resection of the duplicated ureter remains a contentious topic. Some literature indicates that under laparoscopic procedures, duplicated ureters were excised at various points along the iliac vessel or pelvic border [ 12 , 19 – 21 ]. In robot-assisted laparoscopy, studies have reported resections were within 1 cm of the bladder or at the bladder hiatus [ 6 , 7 ]. In our procedures, nonfunctioning ureters were carefully dissected to within 1 cm of the bladder to minimize complications and avoid subsequent operations. Additionally, the need to reposition and perform secondary disinfection during traditional surgeries prolongs both operation and anesthesia duration, potentially worsening patient outcomes and elevating the risk of postoperative infections. The use of a single position in robot-assisted nephroureterectomy eliminates the need for repositioning and resterilization, offering several advantages over conventional procedures: (1) the transperitoneal technique offers enough of surgical space and distinct anatomical features; (2) optimal trocar angles and distances enhance the field of view, unhindered by robotic arms; (3) the procedure comfortably accommodates removal of duplicated kidneys and ureters, allowing precise suturing of the renal incisal edge and ureteral stump; (4) the robotic system ensures greater precision, particularly in dissecting fine blood vessels; (5) vascular complications are better managed due to instrument flexibility; (6) procedural time is reduced by approximately 40 minutes by eliminating repositioning and disinfection; (7) muscle injury was reduced by the larger camera port at the outside of the rectus abdominis, aiding recovery [ 22 ]; (8) complete ureter removal is achieved by modifying the robot and robotic arms position; (9) the accuracy of blood vessel dissection is boosted by utilizing the three-dimensional reconstruction, better preserving renal function by not clamping the renal arteries during all surgical procedures; (10) certain trocars can be reused by adjusting the robot's position, which saves surgery costs and consumables. This report details our single-position robot-assisted nephroureterectomy for managing abnormalities in duplicated renal collecting systems. While single-position surgery is not novel, and lateral recumbency is common nationwide, this study explores maximizing surgical precision and efficiency through robotic assistance. Our findings demonstrate the feasibility and safety of performing duplex kidney resections without altering patient position, with a high success rate. Unavoidably, there are several restrictions on this research. The strength of our findings may be limited by the relatively tiny cohort and short follow-up time, which will be consummated in the future. The short- and long-term effects of maintaining a single position also warrant further investigation. Finally, because this study is retrospective and single-center, it will take longer follow-up and larger sample sizes to validate our findings. Conclusion Single-position robot-assisted nephroureterectomy is both a reliable and secure surgical treatment for duplicated renal collecting systems. Removing the duplicated kidneys and ureters obviates the need for intraoperative repositioning of the patients, and it has the advantages of short operative time, acceptable minor complications, less estimated blood loss, and a high surgical success rate. Large-sample and multi-center studies are still required in the long run. Abbreviations EBL estimated blood loss eGFR estimated glomerular filtration rate IVP intravenous pyelography CT computerized tomography MRI magnetic resonance imaging SD standard deviation DSS distal stump syndrome BMI body mass index. Declarations Ethics approval and consent to participate All procedures used in research involving human subjects were compliant with the 1964 Declaration of Helsinki and its subsequent amendments, as well as the ethical requirements of the national and/or institutional research committees. The Yuhuangding Hospital Ethics Committee gave permission to the project. The informed consent was signed by each participant. Availability of data and materials The data that support the findings of this study are available from the corresponding author by email: [email protected] . Competing interests The authors declare no competing interests. Funding This study was supported by grants from the National Natural Science Foundation of China (No. 81972376), Taishan Scholars Program of Shandong Province (No. tsqn202211379), and Major Science and Technology Project of Shandong Antibody Drug Innovation and Entrepreneurship Community in 2023. Authors’ contributions WCS, FZ, and JNS drafted the manuscript. HWZ operated on the patients. XYW, GLT, XC, CYL, and JDZ collected the materials. All authors read and approved the final manuscript. Acknowledgments Not applicable. References Patel S, Abimbola O, Roy OP (2020) Tortuous Duplicated Collecting System Complicated by Ureterovesical Junction Compression. Curr Urol 14(1):50–53. 10.1159/000499260 Didier RA, Chow JS, Kwatra NS, Retik AB, Lebowitz RL (2017) The duplicated collecting system of the urinary tract: embryology, imaging appearances and clinical considerations. Pediatr Radiol 47(11):1526–1538. 10.1007/s00247-017-3904-z Nicolaou N, Renkema KY, Bongers EMHF, Giles RH, Knoers NVAM (2015) Genetic, environmental, and epigenetic factors involved in CAKUT. Nat Rev Nephrol 11(12):720–731. 10.1038/nrneph.2015.140 Dahl DS (1975) Bilateral complete renal duplication with total obstruction of both lower pole collecting systems. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-5867796","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":405345132,"identity":"577f957c-2818-4630-a14e-73314dd710c4","order_by":0,"name":"Wei-Cheng Sun","email":"","orcid":"","institution":"Binzhou Medical University","correspondingAuthor":false,"prefix":"","firstName":"Wei-Cheng","middleName":"","lastName":"Sun","suffix":""},{"id":405345133,"identity":"8cf9df94-8ce5-42a9-86fb-90f236220da9","order_by":1,"name":"Feng Zhang","email":"","orcid":"","institution":"Binzhou Medical University","correspondingAuthor":false,"prefix":"","firstName":"Feng","middleName":"","lastName":"Zhang","suffix":""},{"id":405345134,"identity":"9529064f-e775-4cf0-b7be-d40a77efbce2","order_by":2,"name":"Jia-Ning Sun","email":"","orcid":"","institution":"Shandong Second Medical University Clinical Medical College","correspondingAuthor":false,"prefix":"","firstName":"Jia-Ning","middleName":"","lastName":"Sun","suffix":""},{"id":405345135,"identity":"880aaa67-2648-42b5-af7c-3b4e345d9cc5","order_by":3,"name":"Xiao-Yan Wang","email":"","orcid":"","institution":"Capital Medical University","correspondingAuthor":false,"prefix":"","firstName":"Xiao-Yan","middleName":"","lastName":"Wang","suffix":""},{"id":405345136,"identity":"5d19bb69-0647-499c-be83-004dbfbd6495","order_by":4,"name":"Gong-Lin Tang","email":"","orcid":"","institution":"Affiliated Yantai Yuhuangding Hospital of Qingdao University","correspondingAuthor":false,"prefix":"","firstName":"Gong-Lin","middleName":"","lastName":"Tang","suffix":""},{"id":405345137,"identity":"922617af-603e-4ed8-9a41-8b8c042a15af","order_by":5,"name":"Xin Chen","email":"","orcid":"","institution":"Affiliated Yantai Yuhuangding Hospital of Qingdao University","correspondingAuthor":false,"prefix":"","firstName":"Xin","middleName":"","lastName":"Chen","suffix":""},{"id":405345138,"identity":"b5ac1cf0-9150-4eaf-95cb-916cbd47dcc9","order_by":6,"name":"Chen-Yue Liu","email":"","orcid":"","institution":"Binzhou Medical University","correspondingAuthor":false,"prefix":"","firstName":"Chen-Yue","middleName":"","lastName":"Liu","suffix":""},{"id":405345139,"identity":"05419dc1-eee0-49b3-8f7d-5aec986d6b1c","order_by":7,"name":"Jun-Dong Zhao","email":"","orcid":"","institution":"Shandong Second Medical University Clinical Medical College","correspondingAuthor":false,"prefix":"","firstName":"Jun-Dong","middleName":"","lastName":"Zhao","suffix":""},{"id":405345140,"identity":"46e376fa-5958-4532-b4f1-35e925128620","order_by":8,"name":"Hong-Wei Zhao","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA40lEQVRIie3Rr4vDMBTA8UAgM+lqX7jRuulAoap/zCuDqu3YXGWPQSKO8/dnVJ5sN5jKfMWJ1kxf5cGxn3ZH27mJfHS+vLyEEMt6Qswvddv+nTyX0rLGNOpPxkAVFRkNhFYzWZukP/FgpIiT0Tg3ZioatRlwsZc3VYsvFojPOUuRFcTV79idTEotV4Z7Lix2FfJvAmafdyckzgAYXKa8JhXCgUhYDEg4k3FezcMlyu2ABGIFjsLr+iFBHJLwch2AKW6PDFgkvHcXX+um+UmL21e2v8fIc/VHd3KHP3bcsizL+tcZjw5NhuYCESUAAAAASUVORK5CYII=","orcid":"","institution":"Affiliated Yantai Yuhuangding Hospital of Qingdao University","correspondingAuthor":true,"prefix":"","firstName":"Hong-Wei","middleName":"","lastName":"Zhao","suffix":""}],"badges":[],"createdAt":"2025-01-20 17:08:17","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-5867796/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-5867796/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":74679923,"identity":"b15ec4d8-5828-4a64-914e-d6de85fbb851","added_by":"auto","created_at":"2025-01-24 15:41:30","extension":"jpeg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":54810,"visible":true,"origin":"","legend":"\u003cp\u003eSchematic illustration of trocar placement and incision sites for specimen extraction in robot-assisted nephroureterectomy: (A) Assistant port: a 12-mm trocar is inserted on the abdominal midline, positioned horizontally between ports B and C; (B) Robotic arm port: an 8-mm trocar is placed at the outer edge of the right rectus abdominis muscle, 5 cm below the costal margin; (C) Camera port: a 12-mm trocar is inserted 4 cm to the right of the umbilicus; (D) Robotic arm port: an 8-mm trocar is placed 5 cm above the medial aspect of the right anterior superior iliac spine; (E) Robotic arm port: an 8-mm trocar is positioned at the midpoint between port C and port D; (F) Liver retractor port: a 5-mm trocar is inserted 4 cm below the xiphoid process; (G) Robotic arm port: an 8-mm trocar is placed at the intersection of the outer edge of the left rectus abdominis muscle with the same horizontal line as port E; (BB) represents the belly button.\u003c/p\u003e","description":"","filename":"floatimage1.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-5867796/v1/d46c5def4f640b6148a3d852.jpeg"},{"id":74679922,"identity":"e066b33e-317b-47c4-8efc-d0b0a72a51cb","added_by":"auto","created_at":"2025-01-24 15:41:30","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":1251761,"visible":true,"origin":"","legend":"\u003cp\u003ePatient positioning and port placement for robot-assisted excision of the right duplex kidney. (a) The patient was placed in the left side position (approximately 70°). (b) Initial trocar placements. (c) Following docking, the robot is utilized to excise the right duplicate kidney. (d) \u0026nbsp;After redocking, the robot is employed to dissection and excision the right duplicate ureter. (e) Specimens of the excised right duplicate kidney and ureter.\u003c/p\u003e","description":"","filename":"floatimage24.png","url":"https://assets-eu.researchsquare.com/files/rs-5867796/v1/7ae6c75b3f441b64d2376d6e.png"},{"id":74680706,"identity":"7964b347-5984-46ff-ab00-b2a12ae80754","added_by":"auto","created_at":"2025-01-24 15:49:30","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":2017806,"visible":true,"origin":"","legend":"\u003cp\u003eIntraoperative procedure. (a) Identification of the duplicatekidney. (b) Identification of the duplicate ureter. (c) Identification and dissection of the upper pole non-functioning segment of the right kidney. (d) Suturing of the renal incisional margin using absorbable sutures. (e) Achievement of hemostasis with oxidized cellulose polymer. (f) Dissection of the non-functioning ureter. (g) Resection of the non-functioning ureter. (h)Closure of the resected ureteral stump.\u003c/p\u003e","description":"","filename":"floatimage32.png","url":"https://assets-eu.researchsquare.com/files/rs-5867796/v1/26d025535acc38acff6b9aa5.png"},{"id":79531688,"identity":"aa156f7c-3484-4b93-b7e4-f46730be4744","added_by":"auto","created_at":"2025-03-30 20:46:25","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":4807715,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-5867796/v1/c2b91d49-b048-471c-9ab3-626ea70498f2.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Single-Position Robot-Assisted Laparoscopic Nephroureterectomy for Duplicated Kidneys and Ureters: Technique and Outcomes","fulltext":[{"header":"Introduction","content":"\u003cp\u003eThe congenital abnormality of duplicated renal collecting systems is somewhat common [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e], affecting 0.7\u0026ndash;4.0% of the population, with a higher prevalence in females and often diagnosed during childhood [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. Most cases involve upper pole renal dysplasia and reduced function [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. For patients with symptomatic non-functioning segments and ectopic ureters, the upper pole heminephrectomy is the normal surgical procedure [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e], with laparoscopic upper pole nephroureterectomy offering a minimally invasive, safe, and efficient treatment option [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. As robotic technology becomes increasingly integrated into renal surgeries, its advantages are being progressively acknowledged. The robotic approach is particularly well-suited for nephroureterectomy, offering enhanced visualization around the lower pole vasculature and enabling more precise surgical movements, especially critical in cases requiring reconstruction [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eTraditional nephroureterectomy in duplex kidney patients involves the removal of the dysfunctional upper pole and the duplicated ureter. This extensive resection typically necessitates repositioning during surgery. However, robot-assisted nephroureterectomy performed in a single position eliminates the need for repositioning and re-disinfection, thereby enhancing both safety and efficacy. This study introduces our innovative technique, designed to reduce operative time and expedite patient recovery.\u003c/p\u003e"},{"header":"Patients and Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003ePatients\u003c/h2\u003e \u003cp\u003eFrom November 2019 to December 2023, 23 patients (13 males and 10 females) underwent robot-assisted nephroureterectomy in our study. 10 patients underwent robot-assisted laparoscopic nephroureterectomy in a single position (single-position group), while 13 patients had traditional robot-assisted laparoscopic nephroureterectomy (non-single-position group). Among them, 13 patients were asymptomatic upon admission, 10 patients experienced lumbago, and 12 patients presented with hydronephrosis. A dilated upper pole renal and ureter under a duplicate collecting system was discovered by preoperative imaging evaluations performed on all patients, such as intravenous pyelograms (IVU), computed tomography (CT), or magnetic resonance imaging (MRI). Three-dimensional reconstruction was employed to enhance patient counseling, optimize surgical decision-making, and facilitate both pre-and intraoperative planning. We documented the patients' demographics, surgical indications, perioperative variables, and outcomes.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eSurgical technique\u003c/h3\u003e\n\u003cp\u003eBefore the robot-assisted nephroureterectomy, patients first experienced 6F ureteral catheters inserted in both ureters via cystoscopy with retrograde ureteropyelography of the lower pole collecting system. One catheter was withdrawn, and the other, which led to the normal operating system, was attached to the Foley catheter.\u003c/p\u003e \u003cp\u003eThe same highly trained doctors conducted all of the five procedures, using the da Vinci Si surgical apparatus. Patients were positioned in a 70\u0026deg; modified flank orientation (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003ea), and all surgical procedures were executed via the transperitoneal approach. First of all, a small incision was initially made at port C (4 cm to the right of the navel), with the abdominal wall elevated bilaterally using towel forceps. To create pneumoperitoneum, a Veress needle was placed at the umbilicus. A 12-mm trocar was then placed to supply medial camera viewing. Subsequently, three additional 8-mm robotic arm ports were placed: port B was placed at the outer margin of the right rectus abdominis, 5 cm below the costal margin; port D was placed at 5 cm medially superior to the anterior superior iliac spine; and port E was placed at the midpoint between port C and port D. The 12-mm assistant port A was positioned along the abdominal midline, horizontally between port B and port C, for retraction, suction-irrigation, and suture handling, etc (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e and Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003eb). A 5-mm port, located 4 cm below the xiphoid process, accommodated a liver retractor (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). Subsequently, the robot was docked at a 90\u0026deg; angle.\u003c/p\u003e \u003cp\u003eThe colon was medially mobilized and both ureters were found following robot docking (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003ec). The normal ureter was identified with the aid of the ureteral catheter that had previously been implanted. The duplicated kidney and ureter were exposed following dissection of the paracolic groove and Gerota fascia (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003ea and \u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003eb), where ureter tortuosity and significant hydronephrosis were noted. The enlarged upper pole ureter was completely dissected, and the lower pole vasculature crossed anteriorly to the upper pole ureter, thus it was carefully protected when the ureters were dissected head to the renal hilum (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003ec). The upper pole blood vessels were transected after being fastened with hem-o-lok clamps. Selective vascular dissection was performed instead of clamping the hilum to fully specify the vascular architecture of the upper and lower pole components. It was important to make sure that dissection completion posterior to the renal hilum was confirmed before transecting the anomalous ureter. If necessary, bulldog clamps need to be used to clamp down the dissected renal artery. The hydronephrotic kidney was excised along the duplicated renal margin using a harmonic scalpel. Along the line separating the upper and lower pole parts, the hemiphrectomy was performed. The renal incision margin was sutured with absorbable sutures (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003ed), and oxidized cellulose polymer (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003ee) or bipolar cautery was used for achieving hemostasis.\u003c/p\u003e\u003cp\u003eThe robot orientation was adjusted while maintaining the patient\u0026rsquo;s position. The lateral border of the left rectus abdominis and the port E level intersected at port G, where an extra 8-mm robotic arm port was positioned (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). The patient\u0026rsquo;s head was angled at 10\u0026ndash;20\u0026deg; downward, and the 70\u0026deg; lateral position was adjusted to 45\u0026deg; by manipulating the operating table. The original robotic arm at port D was relocated to port G, leaving robotic arms in ports E and G. Port D served as an auxiliary slot and accommodated an anti-negative pressure drainage tube. Post-redocking, surgery continued with ports other than port B, and the incision at port B was sutured to maintain pneumoperitoneum integrity (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003ed). A caudal resection of the nonfunctioning ureter was performed within 1 cm of the bladder (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003ef). To evaluate the integrity of the collecting system and differentiate the normal ureter, methylene blue was retrogradely administered into the ureteral catheter that had already been placed. The abnormal ureter was resected (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003eg), and the resected ureteral stump was sealed (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003eh). After careful examination of the excised kidney wounds showed no active bleeding, the incision was extended approximately 4 cm to the right from port C. After being extracted from the incision, all excised specimens (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003ee) were sent for a standard pathological analysis. An anti-negative pressure drainage tube was set at port D for abdominal drainage. Finally, intra-abdominal gas was evacuated, trocars were taken out, and layers of closure were applied to the wounds. On the second postoperative day, the drainage tube and Foley catheter were withdrawn, and the ureteral catheter was taken out right away.\u003c/p\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003eStatistical analysis\u003c/h2\u003e \u003cp\u003eAll quantitative values are presented as the mean\u0026thinsp;\u0026plusmn;\u0026thinsp;standard deviation (SD). Continuous variables were compared via the Student's t-test. For categorical variables, comparison was carried out using the Chi-square test or Fisher's test, as deemed appropriate. All statistical tests were two-tailed, and the significance level was set at p\u0026thinsp;\u0026lt;\u0026thinsp;0.05 for all tests. The analysis was conducted using SPSS software, version 26.0.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003e23 patients (13 males and 10 females) underwent duplex kidney resection from March 2020 to December 2023. There was no intraoperative conversion to open surgery. 10 patients underwent robot-assisted laparoscopic nephroureterectomy in a single position (single-position group), while 13 patients had traditional robot-assisted laparoscopic nephroureterectomy (non-single-position group). The indications for surgery included hydronephrosis, hydroureter, and a history of lumbago. No remarkable differences were detected in the baseline clinical characteristics. In comparison to the non-single-position group, the single-position group demonstrated a shorter operation time (166.20\u0026thinsp;\u0026plusmn;\u0026thinsp;21.29 min vs. 208.31\u0026thinsp;\u0026plusmn;\u0026thinsp;23.30 min, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001) and a shorter drainage tube indwelling time (3.50\u0026thinsp;\u0026plusmn;\u0026thinsp;0.53 days vs. 4.15\u0026thinsp;\u0026plusmn;\u0026thinsp;0.69 days, p\u0026thinsp;\u0026lt;\u0026thinsp;0.05). Additionally, a statistically significant disparity in estimated blood loss (EBL) was noted between the two groups (136.00\u0026thinsp;\u0026plusmn;\u0026thinsp;18.14 ml vs. 165.77\u0026thinsp;\u0026plusmn;\u0026thinsp;40.72 ml, p\u0026thinsp;\u0026lt;\u0026thinsp;0.05). No differences were observed in post-operative hospital stays, pre-operative estimated glomerular filtration rate (eGFR), and post-operative eGFR (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eCharacteristics of patients in single-position and non-single-position groups.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCharacteristics\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003esingle-position group\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003enon-single-position group\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003ep-value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge (years)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e46.70\u0026thinsp;\u0026plusmn;\u0026thinsp;8.51\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e45.62\u0026thinsp;\u0026plusmn;\u0026thinsp;6.27\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.739\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBMI (body mass index, kg/m2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e23.25\u0026thinsp;\u0026plusmn;\u0026thinsp;3.48\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e22.58\u0026thinsp;\u0026plusmn;\u0026thinsp;2.52\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.613\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFemale (n, %)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4 (40.00)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6 (46.15)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.768\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEBL (ml)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e136.00\u0026thinsp;\u0026plusmn;\u0026thinsp;18.14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e165.77\u0026thinsp;\u0026plusmn;\u0026thinsp;40.72\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.031\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOperation time (min)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e166.20\u0026thinsp;\u0026plusmn;\u0026thinsp;21.29\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e208.31\u0026thinsp;\u0026plusmn;\u0026thinsp;23.30\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDrainage tube indwelling time (days)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3.50\u0026thinsp;\u0026plusmn;\u0026thinsp;0.53\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4.15\u0026thinsp;\u0026plusmn;\u0026thinsp;0.69\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.017\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePost-op hospital stays (days)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4.40\u0026thinsp;\u0026plusmn;\u0026thinsp;0.70\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4.92\u0026thinsp;\u0026plusmn;\u0026thinsp;0.86\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.123\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePre-operative eGFR (mL/min/1.73 m\u0026sup2;)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e114.40\u0026thinsp;\u0026plusmn;\u0026thinsp;7.03\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e110.62\u0026thinsp;\u0026plusmn;\u0026thinsp;7.37\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.224\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePost-operative eGFR (mL/min/1.73 m\u0026sup2;)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e98.00\u0026thinsp;\u0026plusmn;\u0026thinsp;13.51\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e95.77\u0026thinsp;\u0026plusmn;\u0026thinsp;7.42\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.646\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOverall complication\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRecurrence\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eOne patient in the non-single-position group received blood transfusions (7.69%, Clavien-Dindo grade II) on the first and second postoperative days and developed an infection (7.69%, Clavien-Dindo grade I) during the same period, which was managed with ceftizoxime. All patients underwent excision of the affected kidney and ureter, yielding a subjective surgical success rate of 100% (23/23). In the single-position group, 10 patients were followed up for 3\u0026ndash;9 months. In the non-single-position group, 13 patients were followed up for 4\u0026ndash;9 months. No recurring hydronephrosis was discovered since all patients were monitored.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eOne typical anomaly in the urinary system is duplicated renal collecting systems [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. These anomalies are frequently unnoticed until adulthood, though obstructions related to the upper polar nephron typically manifest in children. Approximately 60% of affected individuals exhibit no apparent or characteristic clinical symptoms [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. But for those experiencing notable symptoms such as hydronephrosis, dysuria, lumbo-abdominal pain, recurrent urinary tract infections, and persistent vaginal or rectal leakage, the conventional upper-pole nephrectomy is still frequently used, to treat symptomatic duplex systems with inadequately performing superior segments [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eDuplicated renal collecting systems represent a frequent urological anomaly. In 1993, Jordan GH and Winslow BH et al. [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e] pioneered the application of laparoscopic techniques for addressing kidney and ureter duplication, highlighting the benefits of laparoendoscopy and establishing the viability of laparoendoscopic upper pole partial nephrectomy for such anomalies. By 2007, Abouassaly R et al. [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e] provided a detailed description of their laparoscopic upper pole partial nephrectomy technique in a cohort of adult patients. They believed that this approach is both safe and effective for treating symptomatic duplicated systems in adults, offering reduced morbidity, swift recovery, and a high success rate. Further advancements were made in 2010 when Patel MN et al. [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e] demonstrated the viability and effectiveness of handling inherited renal abnormalities using robot assistance. In 2012, Mason MD et al. [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e] recognized robot-assisted laparoscopy as ideally suited for upper pole heminephrectomy. This technique boosted the surgeon's movements and ergonomics while simultaneously enhancing vision during the removal of the ureter and upper pole collecting system as it passed through the lower pole vasculature.\u003c/p\u003e \u003cp\u003eIn individuals who have duplicated renal collecting systems, the presence of an excessively long ureter stump is a significant concern that urologists should acknowledge. Retained long ureteral stumps have been documented to function similarly to diverticula, leading to infections caused by urinary stasis [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. This complication, known as distal stump syndrome (DSS), manifests through symptoms including empyema of the stump, recurrent urinary tract infections, and/or urethritis. Approximately 20% of patients experience DSS several months to years following heminephrectomy [\u003cspan additionalcitationids=\"CR16\" citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. Managing DSS often requires a secondary and complex distal ureterectomy, challenged by severe inflammation and adhesions [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. Despite the potential risks of damaging the normal ureter, the complete resection of the duplicated ureter remains a contentious topic. Some literature indicates that under laparoscopic procedures, duplicated ureters were excised at various points along the iliac vessel or pelvic border [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan additionalcitationids=\"CR20\" citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. In robot-assisted laparoscopy, studies have reported resections were within 1 cm of the bladder or at the bladder hiatus [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. In our procedures, nonfunctioning ureters were carefully dissected to within 1 cm of the bladder to minimize complications and avoid subsequent operations.\u003c/p\u003e \u003cp\u003eAdditionally, the need to reposition and perform secondary disinfection during traditional surgeries prolongs both operation and anesthesia duration, potentially worsening patient outcomes and elevating the risk of postoperative infections. The use of a single position in robot-assisted nephroureterectomy eliminates the need for repositioning and resterilization, offering several advantages over conventional procedures: (1) the transperitoneal technique offers enough of surgical space and distinct anatomical features; (2) optimal trocar angles and distances enhance the field of view, unhindered by robotic arms; (3) the procedure comfortably accommodates removal of duplicated kidneys and ureters, allowing precise suturing of the renal incisal edge and ureteral stump; (4) the robotic system ensures greater precision, particularly in dissecting fine blood vessels; (5) vascular complications are better managed due to instrument flexibility; (6) procedural time is reduced by approximately 40 minutes by eliminating repositioning and disinfection; (7) muscle injury was reduced by the larger camera port at the outside of the rectus abdominis, aiding recovery [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]; (8) complete ureter removal is achieved by modifying the robot and robotic arms position; (9) the accuracy of blood vessel dissection is boosted by utilizing the three-dimensional reconstruction, better preserving renal function by not clamping the renal arteries during all surgical procedures; (10) certain trocars can be reused by adjusting the robot's position, which saves surgery costs and consumables.\u003c/p\u003e \u003cp\u003eThis report details our single-position robot-assisted nephroureterectomy for managing abnormalities in duplicated renal collecting systems. While single-position surgery is not novel, and lateral recumbency is common nationwide, this study explores maximizing surgical precision and efficiency through robotic assistance. Our findings demonstrate the feasibility and safety of performing duplex kidney resections without altering patient position, with a high success rate.\u003c/p\u003e \u003cp\u003eUnavoidably, there are several restrictions on this research. The strength of our findings may be limited by the relatively tiny cohort and short follow-up time, which will be consummated in the future. The short- and long-term effects of maintaining a single position also warrant further investigation. Finally, because this study is retrospective and single-center, it will take longer follow-up and larger sample sizes to validate our findings.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eSingle-position robot-assisted nephroureterectomy is both a reliable and secure surgical treatment for duplicated renal collecting systems. Removing the duplicated kidneys and ureters obviates the need for intraoperative repositioning of the patients, and it has the advantages of short operative time, acceptable minor complications, less estimated blood loss, and a high surgical success rate. Large-sample and multi-center studies are still required in the long run.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eEBL\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eestimated blood loss\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eeGFR\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eestimated glomerular filtration rate\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eIVP\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eintravenous pyelography\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eCT\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003ecomputerized tomography\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eMRI\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003emagnetic resonance imaging\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eSD\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003estandard deviation\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eDSS\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003edistal stump syndrome\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eBMI\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003ebody mass index.\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll procedures used in research involving human subjects were compliant with the 1964 Declaration of Helsinki and its subsequent amendments, as well as the ethical requirements of the national and/or institutional research committees. The Yuhuangding Hospital Ethics Committee gave permission to the project. The informed consent was signed by each participant.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe data that support the findings of this study are available from the corresponding author by email: [email protected].\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was supported by grants from the National Natural Science Foundation of China (No. 81972376), Taishan Scholars Program of Shandong Province (No. tsqn202211379), and Major Science and\u0026nbsp;Technology\u0026nbsp;Project of Shandong Antibody Drug Innovation and Entrepreneurship Community in 2023.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026rsquo; contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWCS, FZ, and JNS drafted the manuscript. HWZ operated on the patients. XYW, GLT, XC, CYL, and JDZ collected the materials. All authors read and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgments\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003ePatel S, Abimbola O, Roy OP (2020) Tortuous Duplicated Collecting System Complicated by Ureterovesical Junction Compression. Curr Urol 14(1):50\u0026ndash;53. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1159/000499260\u003c/span\u003e\u003cspan address=\"10.1159/000499260\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDidier RA, Chow JS, Kwatra NS, Retik AB, Lebowitz RL (2017) The duplicated collecting system of the urinary tract: embryology, imaging appearances and clinical considerations. 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World J Surg Oncol 18(1). \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1186/s12957-020-01872-1\u003c/span\u003e\u003cspan address=\"10.1186/s12957-020-01872-1\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Robotic surgery, Nephroureterectomy, Duplicated system, Single position, Technique","lastPublishedDoi":"10.21203/rs.3.rs-5867796/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-5867796/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003ePurpose\u003c/h2\u003e \u003cp\u003eRobot-assisted laparoscopic nephroureterectomy has reached a high level of maturity. However, operating on patients with duplex kidneys presents added challenges, primarily due to the large-scale resection and the need for re-positioning. This study aims to elaborate on the technique and outcomes of single-position robot-assisted nephroureterectomy for duplicated kidneys and ureters.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eIn our department, 23 patients diagnosed with duplicated renal collecting systems were selected. 10 patients underwent single-position robot-assisted laparoscopic nephroureterectomy (single-position group), and 13 had traditional robot-assisted laparoscopic nephroureterectomy (non-single-position group). We systematically collected their demographic data, surgical indications, and perioperative variables, and meticulously evaluated the surgical outcomes.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eAll 23 patients underwent successful surgeries without conversion to open procedures. No remarkable differences were detected in the baseline clinical characteristics. The single-position group had a shorter operation time (166.20\u0026thinsp;\u0026plusmn;\u0026thinsp;21.29 min vs. 208.31\u0026thinsp;\u0026plusmn;\u0026thinsp;23.30 min, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001) and drainage tube indwelling time (3.50\u0026thinsp;\u0026plusmn;\u0026thinsp;0.53 days vs. 4.15\u0026thinsp;\u0026plusmn;\u0026thinsp;0.69 days, p\u0026thinsp;\u0026lt;\u0026thinsp;0.05). Additionally, a statistically significant disparity in estimated blood loss (EBL) was noted between the two groups (136.00\u0026thinsp;\u0026plusmn;\u0026thinsp;18.14 ml vs. 165.77\u0026thinsp;\u0026plusmn;\u0026thinsp;40.72 ml, p\u0026thinsp;\u0026lt;\u0026thinsp;0.05). There were no differences in post-operative hospital stays and pre-and post-operative estimated glomerular filtration rate (eGFR), and no recurrence was observed.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eSingle-position robot-assisted nephroureterectomy is both a reliable and secure surgical treatment for duplicated renal collecting systems, offering benefits such as reduced operative time, minimal minor complications, less estimated b\u003cb\u003el\u003c/b\u003eood loss, and a high rate of surgical success.\u003c/p\u003e","manuscriptTitle":"Single-Position Robot-Assisted Laparoscopic Nephroureterectomy for Duplicated Kidneys and Ureters: Technique and Outcomes","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-01-24 15:41:25","doi":"10.21203/rs.3.rs-5867796/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"55866b6c-f8be-44df-b7a9-8940388e0343","owner":[],"postedDate":"January 24th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2025-03-30T20:38:16+00:00","versionOfRecord":[],"versionCreatedAt":"2025-01-24 15:41:25","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-5867796","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-5867796","identity":"rs-5867796","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}