Nephroureterectomy is the standard surgical treatment for upper tract urothelial carcinoma (UTUC). The adoption of the robotic-assisted platform, particularly the da Vinci surgical system, offers enhanced dexterity and precision. This report aims to present a step-by-step technique for performing total intracorporeal nephroureterectomy, including nephrectomy, ureterolysis, and bladder cuff excision, entirely through an extraperitoneal approach.

Between July 2024 and February 2025, we performed 12 consecutive robotic retroperitoneal nephroureterectomies using the total intracorporeal technique at a single tertiary medical center, conducted by a single experienced surgeon. Trocar placement was optimized for retroperitoneal access, including a detailed port configuration for nephrectomy and a four-arm setup for distal ureterolysis and bladder cuff excision. Key procedural steps and technical tips are shared.

Compared to five cases performed using the traditional open method, the total intracorporeal group demonstrated comparable median console time (160 vs. 162 minutes) and shorter bladder cuff operation time (61.5 vs. 69.4 minutes). Notably, no remnant ureteral orifice was identified under cystoscopic follow-up in the intracorporeal group, whereas three cases of remnant orifice were detected in the open group.

The extraperitoneal approach, combined with a four-arm robotic configuration, allows precise and ergonomic performance of bladder cuff excision without entering the peritoneal cavity. Our findings suggest that total intracorporeal robotic nephroureterectomy provides favorable surgical outcomes and oncological safety, and may serve as a reproducible technique for appropriately selected UTUC patients.