Robotic radical nephroureterectomy in a patient with situs inversus totalis.

Situs inversus totalis is a rare anatomical variant in which all major organs and blood vessels are mirrored from left to right. We present a case of upper tract urothelial carcinoma in a patient with situs inversus who underwent robotic-assisted laparoscopic nephroureterectomy. We utilized conventional surgical approaches and a successful oncologic outcome was achieved.

Introduction

We present a case in which successful minimally-invasive nephroureterectomy was performed on a patient with situs inversus totalis.

Case presentation

67-year old female presented with several months of right flank and gross hematuria. Imaging performed in the emergency department was notable for right renal mass suspicious for upper tract urothelial carcinoma, as well as an incidental finding of situs inversus totalis. Ureteroscopic biopsy was performed, consistent with high grade urothelial carcinoma. She underwent uneventful robotic-assisted laparoscopic right nephroureterectomy.

The steps to the procedure were equivalent to one performed in an anatomically normal patient via transperitoneal approach. The patient was prepped in the modified left lateral decubitus position. Veress needle was used to gain access to the abdomen. 3 Robotic ports were placed inferior to the right costal margin and 12mm assistant port was placed superior to the umbilicus. The robot was docked. We began by dissecting through the white line of Toldt to mobilize the right colon. The dissection was carried medially until the reversed great vessels were encountered. Kocherization of the duodenum was unnecessary due to the patient's SI. We dissected the renal hilar vessels which were stapled. The ureter was mobilized into the pelvis and clipped. The hilum was dissected and renal vessels were stapled. The ureter was identified and mobilized into the pelvis where it was resected along with bladder cuff, which was closed with 3–0 V-Loc suture in two layers. The specimen was removed en bloc. The bladder was irrigated to confirm watertight closure. A surgical drain was placed adjacent to the bladder. The procedure was concluded by undocking the robot, removing the ports, and closing skin. Intraoperative photographs displaying representative anatomy are featured in Fig. 1, Fig. 2.

Fig. 1

Anatomy of right renal hilum.

Fig. 2

Great vessel anatomy.

Recovery was uneventful and the patient was discharged on postoperative day 2 after receiving a single dose of intravesical gemcitabine. Final pathology was pT1N0 high grade urothelial carcinoma of the renal pelvis. At six months of followup, no intravesical or distant disease recurrence is noted.

Discussion

We present a patient with situs inversus totalis in whom successful robotic right nephroureterectomy was performed. Several anatomical features are noteworthy. The great vessels are mirrored in addition to sided organs. Anteroposterior anatomy is maintained; that is, the renal vein is the most anterior hilar structure and will be the first structure encountered when dissecting the renal hilum. The remainder of the dissection and surgical steps correspond to nephroureterectomy in an anatomically normal patient, as described above.

Multiple case reports exist describing safe and generally straightforward renal surgery involving patients with situs inversus in the setting of renal cell carcinoma, upper tract urothelial carcinoma, and elective donor nephrectomy. We present the third case report of successful minimally-invasive nephroureterectomy in this patient population, and the first to be performed robotically.,

Conclusion

When performing sided surgeries, conventional surgical principles can be applied to patients with situs inversus totalis with equivalent surgical and oncological outcomes.

Funding

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Declaration of competing interest

None.