经腹腔路径完全腹腔镜下移植肾同侧原肾输尿管全长切除术2例报告（附视频）

目的探讨经腹腔路径完全腹腔镜下移植肾同侧原肾输尿管全长切除术治疗肾移植受者上尿路移行细胞癌的技术要点及临床效果。方法 2例肾移植术后移植肾同侧上尿路移行细胞癌患者,采用经腹腔路径完全腹腔镜下操作方法切除移植肾同侧原肾及输尿管全长。通过腹腔镜切除的原肾及输尿管最终从下腹正中小切口完整取出。结果两例手术时间分别为180,120 min,术中出血量分别为80,20 mL;无术中、术后并发症,术后血红蛋白及血清肌酐无明显变化。术后随访6个月均未出现肿瘤复发及转移。结论经腹腔路径完全腹腔镜下肾输尿管全长切除术治疗肾移植后移植肾同侧上尿路移行细胞癌具有手术损伤小、患者痛苦少、术后恢复快等优点,是一种安全有效的微创治疗方法。     

Hand-assisted laparoscopic nephroureterectomy with cystoscopic en-bloc excision of the distal ureter and bladder cuff and isthmusectomy in a horseshoe kidney for invasive urothelial carcinoma of the renal pelvis

Upper tract invasive urothelial carcinoma and horseshoe kidneys are familiar to the practicing urologist but relatively rare individual entities. The complication of managing them when they coexist in the same patient can be challenging. Herein, we present the first reported case in which an upper tract invasive urothelial carcinoma in a horseshoe kidney was successfully managed with a combined hand-assisted laparoscopic nephroureterectomy and isthmusectomy with cystoscopic en-bloc excision of the distal ureter and bladder cuff. This highlights the fact that complex anatomy can be managed in a completely minimally invasive fashion, and sound oncologic principles can still be maintained.     

Laparoscopic nephroureterectomy for upper tract transitional cell carcinoma: comparison of laparoscopic and open surgery

OBJECTIVES: We made a comparative study of laparoscopic nephroureterectomy (LNU) and standard open surgery (ONU) for upper urinary tract transitional cell carcinoma. METHODS AND METHODS: From July 2000 to February 2005, 49 patients underwent total nephroureterectomy for upper tract transitional cell carcinoma at Osaka University Medical Hospital. Of the 49 patients, twenty-five were treated with LNU, and twenty-four with ONU. Each group of cases was reviewed with respect to operative time, complications and postoperative convalescence. RESULTS: The average operative time of the LNU and ONU group was 305.9 min (range 190-480) and 271.2 min (range 135-480) respectively, and the average blood loss was 321.5 ml (80-1370) and 557.7 ml (range 100-1730), respectively. The average time until ambulation after LNU and ONU was 2.2 days (range 1-3) and 4.0 days (range 3-5), respectively. No major postoperative complications were observed in either group. CONCLUSION: ONU still represents the gold standard for the management of upper tract transitional cell carcinoma; however, for low stage cases, LNU offers the advantages of minimally invasive surgery.     

非气腹手助腹腔镜肾盂癌根治术(附4例报告)

目的　探索非气腹手助腹腔镜肾、输尿管、部分膀胱切除术治疗肾盂癌的方法。　方法　自 2 0 0 1年 7月至 2 0 0 1年 11月使用自制非气腹装置实施非气腹手助腹腔镜治疗肾盂癌 4例。　结果　手术时间平均 170分钟 ,失血量 195ml。术后未使用镇痛剂 ,平均恢复进食时间 2 8天。术后随访 1～ 4个月 ,未见肿瘤复发。　结论　手助非气腹腹腔镜肾输尿管膀胱部分切除术治疗肾盂癌具有手术时间短、对病人心肺功能损害小、出血少、病人术后恢复快、操作简单易学等优点     

Oncological outcomes after laparoscopic and open radical nephroureterectomy: results from an international cohort

Study Type – Therapy (case series) Level of Evidence 4 What’s known on the subject? and What does the study add? Despite widespread adoption of laparoscopic nephroureterectomy (LNU) for upper tract urothelial cancer (UTUC), few studies have confirmed that it shares equivalent oncological outcomes with conventional open nephroureterectomy. This second large multicentre study confirms oncological equivalence for ONU and LNU in cohorts of both low and high risk patients.

OBJECTIVE

? To compare oncological outcomes in patients undergoing open radical nephroureterectomy (ONU) with those in patients undergoing laparoscopic radical nephroureterectomy (LNU).

PATIENTS AND METHODS

? A total of 773 patients underwent radical nephroureterectomy at nine centres worldwide; 703 patients underwent ONU and 70 underwent LNU. ? Demographic, perioperative and oncological outcome data were collected retrospectively. ? Statistical analysis of data was performed using chi‐squared, Mann–Whitney U‐ and log‐rank tests, and Cox regression analyses. ? The median (interquartile range) follow‐up for the cohort was 34 (15–65) months.

RESULTS

? The two groups were well matched for tumour stage, presence of lymphovascular invasion (LVI) and concomitant carcinoma in situ (CIS). ? There were more high‐grade tumours (77.1% vs. 56.3%; P < 0.001) but fewer lymph node positive patients (2.9% vs. 6.8%; P= 0.041) in the LNU group. ? Estimated 5‐year recurrence‐free survival (RFS) was 73.7% and 63.4% for the ONU and LNU groups, respectively (P= 0.124) and estimated 5‐year cancer‐specific survival (CSS) was 75.4% and 75.2% for the ONU and LNU groups, respectively (P= 0.897). ? On multivariable analyses, which included age, gender, race, previous endoscopic treatment for bladder cancer, technique for distal ureter management, tumour location, pathological stage, grade, lymph node status, LVI and concomitant CIS, the procedure type (LNU vs. ONU) was not predictive of RFS (Hazard ratio [HR] 0.80; P= 0.534) or CSS (HR 0.96; P= 0.907).

CONCLUSION

? The present study is the second large, independent, multicentre cohort to show oncological equivalence between ONU and LNU for well selected patients with upper urinary tract urothelial cancer, and the first to suggest parity for the techniques in patients with unfavourable disease.     

The oncological results of laparoscopic nephroureterectomy for upper urinary tract transitional cell cancer are equal to those of open nephroureterectomy

OBJECTIVE

To compare the overall, tumour‐specific, recurrence‐free, and progression‐ free survival of patients with upper urinary tract transitional cell carcinoma (UUT‐TCC) treated with laparoscopic nephroureterectomy (LNU) or standard open NU (ONU).

PATIENTS AND METHODS

Clinical, pathological and follow‐up data were analysed for 43 LNUs and 59 ONUs performed at our institution from 1999 to 2006. In LNU the kidney was removed laparoscopically as in radical nephrectomy, but without transecting the ureter. The specimen was then removed intact with the entire ureter and a bladder cuff through a nonmuscle‐splitting supra‐inguinal incision. ONU was performed through separate intercostal and supra‐inguinal incisions with the entire specimen being removed intact with a bladder cuff through the latter.

RESULTS

The mean (sd ) follow‐up was 41 (20) months for LNU and 41 (29) for ONU. Pathological staging was: pTa 26% vs 20%, pT1 21% vs 27%, pT2 12% vs 17%, pT3 42% vs 34% for LNU and ONU, respectively. In all, seven vs six patients had positive nodes on final histology. Recurrent tumours in the bladder were detected in 26% of patients after LNU and in 27% after ONU after the mean follow‐up. There were no local recurrences after LNU but there was local recurrence in six patients after ONU. There were no port‐site metastases during the follow‐up. Five LNU patients and seven ONU patients developed distant or lymph node metastasis. The actuarial 5‐year tumour free‐survival rate was 79% in the LNU group vs 76% in the ONU group (P = 0.82). The actuarial disease‐specific survival at 5‐years was 85% for LNU and 80% for ONU patients (P = 0.62). The surgical approach did not influence recurrence or survival.

CONCLUSION

Oncological results of LNU and ONU are comparable. The lower morbidity of LNU offers advantages for the patient.     

手助腹腔镜根治性肾输尿管全切术治疗上尿路移行细胞癌疗效观察

目的：评价手助腹腔镜根治性肾输尿管全切术治疗上尿路移行细胞癌的安全性和有效性。方法：对4例上尿路移行细胞癌患者在行手助腹腔镜根治性肾输尿管全切术后，原切口向下延长2cm，行常规开放性膀胱袖套状切除术；对另1例行手助腹腔镜根治性肾输尿管全切术后，原切口向上下各延长2～3cm，再行开放根治性全膀胱切除术并盆腔淋巴结清扫术并左侧输尿管皮肤造口术。结果：5例均手术成功，前4例手术时间180～240min，术中出血50～180ml；后1例手术时间540min，术中出血l000ml。术后8～28天出院，均无严重并发症发生。结论：采用手助腹腔镜根治性肾输尿管全切术治疗上尿路移行细胞癌是安全有效的，具有痛苦小、并发症少、术后恢复快等优点。     

Propensity-score-matched comparison of perioperative outcomes between open and laparoscopic nephroureterectomy: a national series

Background

Nephroureterectomy (NU) represents the primary management for patients with nonmetastatic upper tract urothelial carcinoma (UTUC). Either an open NU (ONU) or a laparoscopic NU (LNU) may be considered. Despite the presence of several reports comparing perioperative and cancer-control outcomes between the two approaches, no reports relied on a population-based cohort.

Objectives

Examine intraoperative and postoperative morbidity of ONU and LNU in a population-based cohort.

Design, setting, and participants

We relied on the US Nationwide Inpatient Sample (NIS) to identify patients with nonmetastatic UTUC treated with ONU or LNU between 1998 and 2009. Overall, 7401 (90.8%) and 754 (9.2%) patients underwent ONU and LNU, respectively. To adjust for potential baseline differences between the two groups, propensity-score-based matching was performed. This resulted in 3016 (80%) ONU patients matched to 754 (20%) LNU patients.

Intervention

All patients underwent NU.

Measurements

The rates of intra- and postoperative complications, blood transfusions, prolonged length of stay (pLOS), and in-hospital mortality were assessed for both procedures. Multivariable logistic regression analyses were performed within the cohort after propensity-score matching.

Results and limitations

For ONU versus LNU respectively, the following rates were recorded: blood transfusions, 15% versus 10% (p < 0.001); intraoperative complications, 4.7% versus 2.1% (p = 0.002); postoperative complications, 17% versus 15% (p = 0.24); pLOS (≥5 d), 47% versus 28% (p < 0.001); in-hospital mortality, 1.3% versus 0.7% (p = 0.12). In multivariable logistic regression analyses, LNU patients were less likely to receive a blood transfusion (odds ratio [OR]: 0.6; p < 0.001), to experience any intraoperative complications (OR: 0.4; p = 0.002), and to have a pLOS (OR: 0.4; p < 0.001). Overall, postoperative complications were equivalent. However, LNU patients had fewer respiratory complications (OR: 0.4; p = 0.007). This study is limited by its retrospective nature.

Conclusions

After adjustment for potential selection biases, LNU is associated with fewer adverse intra- and perioperative outcomes than ONU.     

后腹腔镜下行上尿路上皮癌根治术2种输尿管末端处理方式的疗效比较

目的探讨经后腹腔途径借助完全腹腔镜下肾输尿管切除及膀胱袖状切除术的安全性、有效性及可行性。方法回顾性收集2016年10月至2018年10月于山西医科大学第一医院泌尿外科确诊为上尿路尿路上皮癌(UUT-UC)的60例患者的资料,根据治疗术式的不同分为完全后腹腔镜组、联合下腹小切口组,其中完全后腹腔镜组29例患者行完全后腹腔镜下肾输尿管切除及膀胱袖状切除术,联合下腹小切口组31例患者行后腹腔下肾输尿管切除联合下腹部小切口膀胱袖状切除术。记录两组的手术时间、术中出血量及术后恢复情况。结果完全后腹腔镜组平均手术时间(143±12)min,联合下腹小切口组平均手术时间(206±19)min,两组平均手术时间差异有统计学意义(P<0.05);两组的术中出血、排气时间、VAS评分、住院时间和肿瘤复发转移差异无统计学意义(P>0.05)。结论在处理输尿管末端时,完全后腹腔镜下肾输尿管切除及膀胱袖状切除术的手术时间短,手术过程安全、疗效确切,值得在临床上进一步推广。     

Hand-assisted laparoscopic nephroureterectomy for upper urinary tract transitional cell carcinoma.

OBJECTIVE: We report our experience with hand-assisted laparoscopic nephroureterectomy (HALN) for upper urinary tract transitional cell carcinoma and compare our results with a contemporary series of open nephroureterectomy (ON) performed at our institution. METHODS: Between August 1996 and May 2003, 90 patients underwent nephroureterectomy for upper-tract transitional cell carcinoma (TCC). Thirty-eight patients underwent HALN, while 52 had an ON. End-points of comparison included operative time, estimated blood loss (EBL), intraoperative and postoperative complications, length of hospital stay, pathologic grade and stage of tumor, and tumor recurrence. RESULTS: The mean patient age was 72.3 and 70.6 years in the ON and HALN groups, respectively. Mean operative duration was 243 minutes (ON) and 244 minutes (HALN), with an EBL of 478mL in the open group versus 191 mL in the hand-assisted group (P<0.001). No intraoperative complications occurred, but postoperative complications occurred in 4% and 11% of the ON and HALN groups, respectively (P=0.21). The mean hospital duration was 7.1 days (ON) versus 4.6 days (HALN) (P<0.01). No difference existed in the pathologic grade or stage distribution of urothelial tumors between the 2 groups. The mean follow-up was 51.0 months in the ON group and 31.7 months in the HALN group. Recurrence of urothelial carcinoma occurred in 50% of patients who underwent ON and 40% treated by HALN (P=0.38) at a median interval of 9.1 and 7.7 months, respectively, after surgery. CONCLUSION: Hand-assisted laparoscopic nephroureterectomy is an effective modality for the treatment of upper urinary tract urothelial carcinoma. Patients benefited from less intraoperative blood loss and a shorter hospitalization with an equivalent intermediate-term oncologic outcome compared with that of the open approach.     

Risk factors for intravesical recurrence after radical nephroureterectomy for upper tract urothelial carcinoma: A meta-analysis

PurposeAfter radical nephroureterectomy (RNU), approximately 22% to 47% of patients with upper tract urothelial carcinoma (UTUC) develop a subsequent intravesical recurrence (IVR). Considering this high incidence of occurrence, several risk factors were reported as predictive of IVR after RNU. Until recently, most of the risk factors were still under debate. The aim of study was to conduct a meta-analysis based on the recent literature to explore the risk factors for IVR after RNU for UTUC.Patients and methodsAn electronic search of the Medline, Embase, Cochrane Library, CancerLit, and ClinicalTrials.gov databases was performed to identify relevant studies published before May 2013. The studies were included if they reported risk factors related to bladder or IVR after RNU for UTUC.ResultsOverall, 40 studies, with 12,010 patients, were included in our meta-analysis. Our study indicated that a statistically significant difference in IVR after RNU was found in the male vs. female patients (odds ratio [OR] = 0.72, 95% CI: 0.59–0.85), ureteral vs. renal pelvis (OR = 1.18, 95% CI: 1.00–1.36), T2–4 vs. Tis, Ta, and T1 (OR = 0.53, 95% CI: 0.40–0.66), larger vs. smaller tumor size (OR = 1.02, 95% CI: 1.01–1.03), and previous/synchronous bladder cancer vs. the absence of bladder cancer (OR = 1.59, 95% CI: 1.26–1.9). No significant differences in IVR after RNU were found in the younger vs. older age groups, multifocal tumors vs. single tumor, G3 vs. G1 and G2, high vs. low grade, N0 vs. N+, concomitant carcinoma in situ vs. the absence of carcinoma in situ, positive vs. negative lymphovascular invasion, open vs. laparoscopic nephroureterectomy, and endoscopic vs. transvesical technique.ConclusionsOur study showed that female patient; ureteral tumor; larger tumor; Tis, Ta, and T1; and the history of bladder cancer were significant risk factors related to IVR after RNU.     

Variant histology as a significant predictor of survival after radical nephroureterectomy in patients with upper urinary tract urothelial carcinoma

Objectives

To investigate the effect of variant histology (VH) on survival after radical nephroureterectomy in patients with upper urinary tract urothelial carcinoma (UTUC) and the effect of adjuvant chemotherapy on the survival of patients with UTUC with VH.

Mayo Clinic Scottsdale Experience with laparoscopic nephroureterectomy.

OBJECTIVES: To evaluate the efficacy of laparoscopic nephroureterectomy for patients with transitional cell carcinoma of the upper urinary tract. METHODS: Eighteen patients underwent attempted transperitoneal laparoscopic nephroureterectomy between June 2000 and October 2002. Mean patient age was 67.5 years. The specimen was removed intact through a 7- to 9-cm extraction incision in the lower midline. In the majority of patients, the distal ureter was dissected through the extraction incision. RESULTS: Sixteen cases were completed laparoscopically. Two cases required conversion to an open procedure. In these cases, dense fibrosis was present around the renal hilum preventing further dissection. The mean operative time was 180 minutes, and the mean estimated blood loss was 160 mL. The mean length of stay was 3.3 days. Complications included the 2 conversions, and 1 patient with a postoperative Mallory Weiss tear. No port-site or distant metastasis occurred; however, 1 patient developed a retroperitoneal recurrence. CONCLUSION: Laparoscopic nephroureterectomy is an alternative to open nephroureterectomy. Cases with high-stage and grade may cause the laparoscopic dissection to be difficult. The extraction incision allows for easy dissection of the distal ureter.     

Health-related quality of life after hand-assisted laparoscopic and open radical nephrectomies of renal cell carcinoma

Aim  To compare the health-related quality of life (HRQOL) in contemporaneous groups of patients undergoing hand-assisted laparoscopic radical nephrectomy (HALRN) or open radical nephrectomy (ORN) for renal cell carcinoma (RCC). Patients and methods  The clinical data of 20 cases receiving hand-assisted laparoscopic radical nephrectomy (the HALRN group) and 51 cases receiving open radical nephrectomy (the ORN group) were analyzed retrospectively and health questionnaires were mailed to these patients at 1 year postoperatively. The two groups were compared in terms of general surgery-related information, tumor characteristics, days to return to work or routine daily activities, and health-related quality-of-life scales. Results  Patients in the HALRN group had significantly less mean incision length (6.25 versus 17.8 cm), faster return to work or routine daily activities (5.3 versus 8.6 weeks), and earlier out-of-bed activity (4.76 versus 6.59 days) compared with those in the ORN group (P < 0.05). There were no significant differences in HRQOL scales at 1 year between the both groups (P > 0.05). Conclusion  The results showed that hand-assisted laparoscopic surgery is a minimally invasive surgical technique for RCC offering earlier recovery and similar long-term HRQOL compared with open surgery.     

Comparative analysis of comorbidity and performance indices for prediction of oncological outcomes in patients with upper tract urothelial carcinoma who were treated with radical nephroureterectomy

ObjectiveComorbidity and performance indices (CPIs) are useful tools to evaluate patient?s risk of comorbidities and thus may guide clinical decision making regarding surgery or multimodal therapy approaches. Hence, the aim of the current study was to assess the predictive capacity of CPIs comprising the American Society of Anaesthesiologists (ASA)-score, the Charlson comorbidity index (CCI), the age-adjusted CCI (ACCI), and the Eastern Cooperative Oncology Group performance status (ECOG-PS) in patients with upper tract urothelial carcinoma (UTUC) who were treated with radical nephroureterectomy (RNU).Methods and materialsA total of 242 patients with UTUC underwent RNU without neoadjuvant chemotherapy between 1992 and 2012 at 3 German academic centers. Patients were stratified according to the pre-RNU CPIs dichotomized as ASA 1/2 vs.≥3, CCI 0 to 2 vs.>2, ACCI 0 to 5 vs. >5, and ECOG-PS 0 to 1 vs. >1. We assessed the associations of CPIs with clinicopathologic features, as well as the prognostic effect on recurrence-free survival, cancer-specific survival (CSS), overall survival, and cancer-independent mortality (CIM), using univariable and multivariable Cox regression analyses.ResultsSixty-two patients (25.6%) had an ASA-score≥3, 71 patients (29.3%) a CCI>2, 50 patients (20.7%) an ACCI>5, and 122 (50.4%) patients an ECOG-PS>1. The ASA-score (P = 0.001), CCI (P = 0.029), and the ECOG-PS (P<0.001) were significantly associated with age. In addition, the ECOG-PS was associated with pelvicalyceal tumors (P = 0.012), and the CCI with preoperative hydronephrosis (P = 0.026). The median follow-up was 30 months. In Kaplan-Meier analyses, ACCI>5 (P≤0.025) and ECOG-PS>1 (P≤0.042) were associated with recurrence-free survival, CSS, and overall survival, and ASA-score≥3 (P = 0.011) and ACCI>5 (P = 0.006) with CIM. In multivariable analysis that adjusted for standard clinicopathologic parameters, an ECOG-PS>1 was an independent predictor for CSS (hazard ratio = 1.89, P = 0.019), and an ASA-score≥3 (hazard ratio = 1.86, P = 0.026) was a predictor for CIM.ConclusionCPIs are easy assessable predictors for outcome in patients with UTUC who were treated with RNU. CPIs have carefully to be taken into account in patient counseling regarding operative decision making and multimodal treatment.     

Laparoscopic nephroureterectomy for upper urinary tract transitional cell carcinoma: results of a Belgian retrospective multicentre survey

OBJECTIVES: To evaluate the technical and oncologic feasibility of laparoscopic nephroureterectomy for upper urinary tract transitional cell carcinoma. METHODS: A retrospective survey of 100 patients, treated with laparoscopic nephroureterectomy in 10 Belgian centres, was performed. Most procedures were performed transperitoneally. The distal ureter was managed by open surgery in 55 patients and laparoscopically in 45 patients. The mean follow-up was 20 mo. RESULTS: Mean operation time was 192 min and mean blood loss 234 ml. The conversion rate was 7%. Important postoperative complications were seen in 9%. Pathologic staging was pTa in 31 patients, pT1 in 23, pT2 in 12, pT3 in 33, and pT4 in 1, concomittant pTis in 3. Pathologic grade was G1 in 24 patients, G2 in 28, and G3 in 48. Negative surgical margins were obtained in all but one patient. Twenty-five patients developed progressive disease (24%) at a mean postoperative time of 9 mo (local recurrence in 8%, metastases in 11%, both in 5%). Progression was 0% for pTa, 17% for pT1, 17% for pT2, 51% for pT3, and 100% for pT4. Cancer-specific survival was 100% for pTa, 86% for pT1, 100% for pT2, 77% for pT3, and 0% for pT4. CONCLUSION: Laparoscopic nephroureterectomy appears to be a technically and oncologically feasible operation. To prevent tumour seeding, one should avoid opening the urinary tract and should extract the specimen with an intact organ bag. The high local recurrence rate in this study probably reflects the high percentage of high-grade and high-stage tumours in this study.     

Grasping and dissecting instrument for hand-assisted laparoscopic surgery

Background: The operative potential of hand-assisted laparoscopic surgery (HALS) could be enhanced by the introduction of a new generation of assisting instruments. These tools will have to meet specific requirements of shape, function, and safety of use. Methods: Problems related to the working environment of HALS and deriving projectual restrictions of HALS instruments were analyzed in order to develop and manufacture a working prototype with grasping and dissecting properties to assist during HALS procedures. The resulting instrument was mechanically and clinically tested in 22 HALS procedures. Results: The additional benefit of the new device was particularly appreciated during dissection and isolation of vascular pedicles (nephrectomies and splenectomies). It was shown to be safe and effective in providing the additional assistance it was designed for. Conclusion: The described grasping and dissecting instrument for HALS is of great value in assisting the surgeon during fine dissection, as required in selected procedures. New generation of HALS instruments should comply with the functional and safety issues analyzed in this report.