Left ventricular assist devices (LVADs) have revolutionized management options for patients with advanced heart failure. It is not uncommon for patients treated with these devices to present with noncardiac surgical conditions including urologic problems. Maintaining perioperative hemodynamic and hematologic stability is a special challenge. The minimally invasive surgery provides well-documented advantages over the open approach including a less operative blood loss and faster convalescence. In carefully selected patients, robotic-assisted surgery can be utilized in the management of patients with complex urologic diseases in a dire need for these benefits. We present the first case of robotic-assisted laparoscopic nephroureterectomy (RANU) with retroperitoneal lymph node dissection for upper tract transitional cell carcinoma (TCC) in a patient treated with LVAD. 1. Introduction Nephroureterectomy with bladder cuff excision is the standard of care for high-grade and invasive TCC [1]. The procedure can be performed via an open or minimally invasive laparoscopic approach with similar oncologic outcomes [2]. However, management of the distal ureter and bladder cuff remains the biggest challenge of laparoscopic technique [3, 4]. Several authors have reported an easier excision of the distal ureter and bladder cuff, in addition to a less blood loss and faster recovery when the robotic approach was used [5–8]. Since approval by the Food and Drug Administration (FDA) as a bridge to heart transplant in 2008 and as destination therapy in 2010, the HeartMate II LVAD continues to provide an effective mode of treatment for the growing population of advanced heart failure patients [9]. With this in mind, increasing number of LVAD-treated patients has been presented with surgical conditions [10, 11]. Due to the risk of device thrombosis, these patients need to stay on anticoagulation during and after surgery [12], which carriers the risk of increased operative blood loss. Pneumoperitoneum and location of the LVAD may lead to unique intraoperative challenges. We present the first case of RANU for upper tract TCC in LVAD-treated patient focusing on intraoperative management and short-term outcomes. 2. The Case 2.1. Patient Presentation A 71-year-old Caucasian male presented with the New York Heart Association (NYHA) class III heart failure managed with HeartMate II LVAD as destination therapy and implantable cardioverter defibrillator (ICD). Following right renal colic, the patient underwent intravenous pyelogram at an outside institution which demonstrated right
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