Modified transurethral technique for the management of distal ureter during laparoscopic assisted nephroureterectomy

INTRODUCTION: Laparoscopic assisted nephroureterectomy is a well established technique for managing the upper urinary tract urothelial cancer. However, management of the distal ureter remains a controversial issue. We describe a modified method of cystoscopic loop ligation and detachment of the distal ureter. TECHNICAL CONSIDERATION: We performed transperitoneal laparoscopic assisted nephroureterectomy in 13 patients. The lower end of the ureter was managed perurethrally using our modified technique. We circumscribed the ureteric orifice with a bladder cuff using a Collins knife. We ligated the ureteric stump via cystoscope to avoid urine spillage from the upper tract. We achieved the complete excision of the distal ureter with a bladder cuff in all cases with our modified technique. CONCLUSIONS: Our modified technique appears to be a simple, less invasive, and oncologically safe method to manage the distal ureter perurethrally.     

Laparoscopic radical nephroureterectomy: dilemma of the distal ureter

PURPOSE OF REVIEW: Laparoscopic nephroureterectomy has recently emerged as a safe, minimally invasive approach to upper tract urothelial cancers. The most controversial and challenging feature of laparoscopic nephroureterectomy is the management of the distal ureter. We review the most common methods of managing the distal ureter, with emphasis on contemporary oncologic outcomes, indications, advantages, and disadvantages. RECENT FINDINGS: There are currently in excess of five different approaches to the lower ureter. These techniques often combine features of endoscopic, laparoscopic, or open management. They include open excision, a transvesical laparoscopic detachment and ligation technique, laparoscopic stapling of the distal ureter and bladder cuff, the "pluck" technique, and ureteral intussusception. Each technique has distinct advantages and disadvantages, differing not only in technical approach, but oncological principles as well. While the existing published data do not overwhelmingly support one approach over the others, the open approach remains one of the most reliable and oncologically sound procedures. SUMMARY: The principles of surgical oncology dictate that a complete, en-bloc resection, with avoidance of tumor seeding, remains the preferred treatment of all urothelial cancers. The classical open technique of securing the distal ureter and bladder cuff achieves this principle and has withstood the test of time. Transvesical laparoscopic detachment and ligation is an oncologically valid approach in patients without bladder tumors, but is limited by technical considerations. The laparoscopic stapling technique maintains a closed system but risks leaving behind ureteral and bladder cuff segments. Both transurethral resection of the ureteral orifice (pluck) and intussusception techniques should be approached with caution, as the potential for tumor seeding exists. Additional long-term comparative outcomes are needed to solve the dilemma of the distal ureter.     

腹直肌直线套管法单机位机器人辅助腹腔镜肾输尿管切除术的疗效分析

单机位机器人辅助腹腔镜肾输尿管切除术处理输尿管远端和膀胱时难度较大。我院对32例输尿管癌患者行腹直肌直线套管法单机位机器人辅助腹腔镜下肾输尿管切除术,手术难度低,手术时间短,出血量少,手术损伤小。该手术方式是治疗输尿管癌的一种安全有效的微创手术方法。     

Pure laparoscopic complete excision of distal ureter with a bladder cuff for upper tract urothelial carcinoma

PURPOSE: In laparoscopic nephroureterectomy for upper tract urothelial carcinoma techniques for removing the lower ureter with a bladder cuff have been a matter of debate. We have developed a pure laparoscopic technique for the complete resection of the lower ureter with a bladder cuff. MATERIALS AND METHODS: Laparoscopic nephroureterectomy was performed in ten patients with upper tract urothelial carcinoma using this technique. After a working space was made retroperitoneally, the ureter was ligated at the distal site of the tumor. Retracting the ureter cranially, a stay suture was placed at an anterior point on the bladder and the bladder opened. With the patient placed in a lateral position, there was no urine leakage from the opened bladder. The ureteral orifice was confirmed laparoscopically. Incising around the ureteral orifice, the distal ureter was detached with the bladder cuff. The opened bladder wall was closed with running stitches. RESULTS: This method was technically successful in these ten cases with minimal bleeding and average operative time of 87 min. The margins of the bladder cuff were all negative and the average follow-up period of 19 months revealed only one (10%) bladder tumor recurrence. CONCLUSIONS: The ligation of the distal part of the ureter and the complete excision of the ipsilateral orifice and a bladder cuff under laparoscopic vision could reduce bladder tumor recurrence. Although this is a limited study with a small sample, the observation of low rates of bladder tumor recurrence after 19 months warrants further study.     

Laparoscopic nephroureterectomy with bladder-cuff resection: techniques and outcomes

Advancements in minimally invasive instrumentation and technique have provided the impetus to performing urologic procedures with reduced perioperative morbidity, shorter hospital stays, and, most importantly, efficacious oncologic results. At multiple centers of excellence, laparoscopic nephroureterectomy (LNU) has evolved into a new standard for the management of upper-tract transitional-cell carcinoma (TCC) that is not amenable to endoscopic resection. An LNU may be performed via a transperitoneal or retroperitoneal approach together with excision of the distal ureter and a bladder cuff. Analysis of present-day studies comparing LNU with open techniques demonstrates equivalent oncologic outcomes. In addition, those patients undergoing LNU fare better than their counterparts having open surgery with respect to hospital stay, analgesic requirements, and convalescence. With multiple options for excision of a cuff of bladder, a consensus has not been established. However, LNU has emerged as the new standard of care for the treatment of upper- tract TCC. Review of the techniques and outcomes of LNU from the minimally invasive urology community are described.     

Robot-assisted laparoscopic nephroureterectomy for upper tract urothelial carcinoma (UT-UC)

Upper tract urothelial carcinoma (UT-UC), including tumors evolving from the renal pelvis and ureter, accounts for around 5% of all UCs and 10% of all renal tumor cases. In Taiwan, the incidence of UT-UC is higher than the western countries especially in the female and patients at renal replacement therapy. The standard care of UT-UC is nephroureterectomy with bladder cuff excision. In the past decades, minimally invasive surgery is proved to achieve comparable oncological results as conventional open procedure. Though laparoscopic nephroureterectomy with bladder cuff excision including pure laparoscopic or hand-assisted technique have been very common practice in Taiwan, several institutes have the early experience of robot-assisted nephroureterectomy which is believed to provide 3-D visualization with magnification, better surgical exposure, and safer watertight suture of the cystostomy. In this review, we review the published reports of robot-assisted nephroureterectomy with bladder cuff excision.     

Pneumovesicum method in en-Bloc laparoscopic nephroureterectomy with bladder cuff resection for upper-tract urothelial cancer

BACKGROUND AND PURPOSE: A novel technique for managing the distal ureter and bladder cuff during laparoscopic nephroureterectomy is introduced. TECHNIQUE: The procedure consists of three steps: (1) cystoscopy and PediPort (Tyco) insertion; (2) establishment of pneumovesicum and intramural ureter mobilization; and (3) laparoscopic nephroureterectomy. The use of PediPorts, a 5-mm lens, and Ski needles greatly facilitates the pneumovesicum. The ureteral orifice is closed, and the intramural ureter is dissected out with the patient in the lithotomy position. Laparoscopic nephroureterectomy is then accomplished with the patient in the lateral position. RESULTS: The postoperative course was uneventful, and the pathology examination showed clear margins. CONCLUSION: Pneumovesicum is a minimally invasive approach that provides an excellent endoscopic view. It is an oncologically sound method, as the ureteral orifice is closed early, and the chance of cancer-cell spillage is minimized by the use of gas instead of liquid in the bladder. Moreover, the procedure is not technically demanding.     

A novel technique for distal ureterectomy and bladder cuff excision

IntroductionWe describe a novel endoscopic approach and provide a literature review for the “en bloc” dissection of the distal ureter and bladder cuff during laparoscopic radical nephroureterectomy using a transvesical single port approach under pneumovesicum.Materials and methodsThe procedure was performed in an 80-year old male with a history of gross hematuria due to left renal pelvic TCC and no history of prior bladder TCC. Laparoscopic radical nephroureterectomy was performed and the ureter was dissected down to the bladder and clipped. A single-port device was inserted transvesically and pneumovesicum established. A full thickness incision of the bladder around the ureter was performed with progressive intravesical mobilization of the distal ureter. Subsequently, a water-tight closure of the bladder defect was achieved. The distal ureter, together with the bladder cuff, was then delivered en bloc laparoscopically with the specimen.ResultsThe operating time (LESS radical nephroureterectomy, RPLND, and bladder cuff excision) was 6 hours and 15 minutes. The bladder cuff time was 45 minutes. There were no intra or postoperative complications and the catheter was removed after 6 days. Histopathological analysis showed kidney-invasive papillary urothelial cancer, pT3 pN0 (0/7) G3.ConclusionThe distal ureter and bladder cuff techniques have not yet been standardized. Management of the bladder cuff with a single port is feasible. Additional studies are needed to identify the best approach for management of the distal ureter at the time of laparoscopic nephroureterectomy.     

腹腔镜肾输尿管全长切除术及膀胱袖状切除术治疗上尿路移行细胞癌

目的:评价腹腔镜经腹腔径路行肾输尿管全长切除术及膀胱袖状切除术治疗上尿路移行细胞癌的有效性及安全性。方法:对6例上尿路移行细胞癌患者行腹腔镜经腹腔径路肾切除术,经同侧下腹斜切口、袖状切除输尿管并完整取出标本。结果:6例手术均获成功,无中转开放手术,手术时间200～320min,平均250min,术中出血100～300ml,均未输血,住院8～12d,平均9d,术后常规膀胱灌注丝裂霉素,随访2～14个月,均无复发或转移。结论:腹腔镜肾输尿管全长切除术是治疗上尿路移行细胞癌安全有效的微创手术,具有痛苦小、康复快等优点。     

Initial experience with robot-assisted minimally-invasive nephroureterectomy

PURPOSE: Various techniques have been described for laparoscopic nephroureterectomy. We reviewed our initial experience of laparoscopic nephroureterectomy with robot-assisted extravesical excision of the distal ureter and bladder cuff. MATERIALS AND METHODS: Nine consecutive patients aged 43 to 83 years underwent laparoscopic nephroureterectomy for transitional cell carcinoma (TCC) between August 2005 and March 2007. The first five patients were repositioned after laparoscopic nephrectomy from flank to lithotomy position to dock the robot for excision of the distal ureter and bladder cuff by a single surgeon. In contrast, the last four patients remained in flank position throughout the entire procedure, with the robot docked in flank position following laparoscopic nephrectomy. A two-layer closure re-approximated the cystotomy and a urethral catheter was left in place for a mean of 5 days. RESULTS: Eight men and one woman with a mean age of 64.2 years and mean body mass index (BMI) of 28.4 kg/m(2) underwent flexible cystoscopy and laparoscopic nephroureterectomy for five right-sided and four left-sided tumors. Mean operative time was 303 minutes (range 210-430 minutes), estimated blood loss was 211 mL (range 50-700 mL), and mean length of hospital stay was 2.3 days. Pathologic staging revealed T(3) for five (55.6%), T(a) for two (22.2%), carcinoma in situ (CIS) for two (22.2%) patients, and high-grade disease for seven (77.8%) patients. With a mean follow-up of 16.2 months (range 4.3-24.3 months), three patients with a history of bladder cancer have experienced recurrence in the bladder, and one of the three has also developed metastatic disease. CONCLUSIONS: Laparoscopic nephroureterectomy with robot-assisted extravesical excision of the distal ureter and bladder cuff appears to be a feasible alternative for patients with TCC of the upper urinary tract.     

A sealed laparoscopic nephroureterectomy: a new technique

OBJECTIVES: To describe a purely laparoscopic nephroureterectomy approach that avoids the disadvantages of transurethral bladder cuff excision and open/laparoscopic distal ureterectomy using the EndoGIA. METHODS: A standard transperitoneal laparoscopic nephrectomy is carried out through three or four ports in the flank. The ureter is dissected caudally into the pelvis. Two additional (5- and 10-mm) trocars are placed in the ipsilateral lower abdomen. Caudal ureteral dissection continues until the detrusor muscle fibers at the ureterovesical junction are identified. A 1-cm area of bladder adventitia around the ureterovesical junction is cleared. The ureter is retracted upward and laterally, tenting up the bladder wall. The bladder cuff is excised using a 10-mm LigaSure Atlas and detached from the bladder. A 6-cm lower-quadrant incision is used to remove the specimen in an Endocatch bag. An indwelling 16F Foley catheter is then placed. RESULTS: Thirteen adult patients with suspected upper-tract transitional cell carcinoma underwent this surgical technique (operative time: 170-270 min): none had local recurrence, and two had recurrence remote from the bladder cuff scar (follow-up: 1-23 months). CONCLUSIONS: The described procedure adheres strictly to oncologic principles (removal of the affected renal unit without opening the urinary tract), and circumvents the need for transurethral/intraureteral instrumentation and patient repositioning.     

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.     

Management of patients with upper urinary tract transitional cell carcinoma

Multiple therapeutic options are available for the management of patients with upper urinary tract transitional cell carcinoma (TCC). Radical nephroureterectomy with an ipsilateral bladder cuff is the gold-standard therapy for upper-tract cancers. However, less invasive alternatives have a role in the treatment of this disease. Endoscopic management of upper-tract TCC is a reasonable strategy for patients with anatomic or functional solitary kidneys, bilateral upper-tract TCC, baseline renal insufficiency, and significant comorbid diseases. Select patients with a normal contralateral kidney who have small, low-grade lesions might also be candidates for endoscopic ablation. Distal ureterectomy is an option for patients with high-grade, invasive, or bulky tumors of the distal ureter not amenable to endoscopic management. In appropriately selected patients, outcomes following distal ureterectomy are similar to that of radical nephroureterectomy. Bladder cancer is a common occurrence following the management of upper-tract TCC. Currently, there are no variables that consistently predict which patients will develop intravesical recurrences. As such, surveillance with cystoscopy and cytology following surgical management of upper-tract TCC is essential. Extrapolating from data on bladder TCC, both regional lymphadenectomy and neoadjuvant chemotherapy regimens are likely to be beneficial for patients with upper-tract TCC, particularly in the setting of bulky disease.     

Does the surgical technique for management of the distal ureter influence the outcome after nephroureterectomy?

Study Type – Therapy (case series)
Level of Evidence 4 What’s known on the subject? and What does the study add? The resection of the distal ureter and its orifice is an oncological principle during radical nephroureterectomy which is based on the fact that it represents a part of the urinary tract exposed to a considerable risk of recurrence. After removal of the proximal part it is hardly possible to image or approach it by endoscopy during follow‐up. Recent publications on survival after nephroureterectomy do not allow the conclusion that removal of distal ureter and bladder cuff are useless. Several techniques of distal ureter removal have been described but they are not equivalent in term of oncological safety. ? The standard treatment of upper urinary tract urothelial carcinomas (UUT‐UCs) must obey oncological principles, which consist of a complete en bloc resection of the kidney and the ureter, as well as excision of a bladder cuff to avoid tumour seeding. ? The open technique is the ‘gold standard’ of treatment to which all other techniques developed are necessarily compared, and various surgical procedures have been described. ? The laparoscopic stapling technique maintains a closed system but risks leaving behind the ureteric and bladder cuff segments. ? Transvesical laparoscopic detachment and ligation is a valid approach from an oncological stance but is technically difficult. The major inconvenience of the transurethral resection of the ureteric orifice and intussusception techniques is the potential for tumour seeding. ? Management of the distal ureter via the robot‐assisted laparoscopic method is technically feasible, but outcomes from these procedures are still preliminary. ? Therefore, prospective comparative studies with more thorough explorations of these techniques are needed to solve the dilemma of the management of the distal ureter during nephroureterectomy. However, bladder cuff excision should remain the standard of care irrespective of the stage of the disease.     

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

Hand-assisted laparoscopic nephroureterectomy with laparoscopic, cystoscopic, or open management of the distal ureter and bladder cuff allow anyone from the novice to the advanced laparoscopic surgeon to perform en-bloc resection of the kidney, ureter, and bladder cuff without compromising oncologic principles. Patients receive significant benefits in the form of less pain, shorter hospital stay, and rapid convalescence. As more urologic surgeons develop skills with this procedure, a more critical analysis of early and long-term results will be possible. As operative times decrease, hand-assisted laparoscopic nephroureterectomy may become the procedure of choice for upper-tract transitional-cell carcinoma. The techniques and early results are described.     

Hand-assisted laparoscopic nephroureterectomy with open cystotomy for removal of the distal ureter and bladder cuff

BACKGROUND AND PURPOSE: While performing laparoscopic nephroureterectomy, different techniques are used for removal of the distal ureter and bladder cuff. We present a series of patients with urothelial carcinoma of the renal pelvis or ureter who underwent hand-assisted laparoscopic nephroureterectomy (HALNU) with open cystotomy for removal of the distal ureter and bladder cuff. PATIENTS AND METHODS: From January 2000 to August 2004, 34 patients underwent HALNU. The hand-port device was placed in a lower-midline infraumbilical incision in all cases. After laparoscopic removal of the kidney and ureter down to the bladder, the hand port incision was extended caudally to allow open cystotomy. Intravesical dissection was performed at the ureteral orifice, and the bladder cuff and distal ureter were removed in a traditional open fashion. RESULTS: The mean operative time was 317 +/- 150 (SD) minutes, but the median operative time was 247 minutes. The mean estimated blood loss was 252 +/- 146 mL. The mean length of stay was 7.6 +/- 6.0 days, but the median stay was 5 days postoperatively (range 3-25). The mean morphine equivalent required postoperatively was 33 +/- 22 mg. The time of Foley catheter removal ranged from 3 to 15 days (mean 6.1 +/- 3.8 days), with no cases of extravasation by cystography at removal. Within a mean follow-up of 13.9 months, no recurrence of urothelial carcinoma was seen at the site of the excised ureteral orifice. CONCLUSION: A HALNU utilizing an open cystotomy for removal of the entire distal ureter with a bladder cuff provides excellent oncologic control while not adding significantly to the operative time or the morbidity of the procedure.     

Case report: percutaneous management of transitional-cell carcinoma of the upper urinary tract using the bipolar resectoscope

BACKGROUND: The traditional management of upper-tract urothelial tumors is radical nephroureterectomy. However, in recent years, minimally invasive nephron-sparing endoscopic approaches have been utilized. We present our initial experience using the bipolar resectoscope with saline irrigation in the management of renal transitional-cell carcinoma (TCC). CASE REPORT: A 74-year-old woman presented with a 3.5-cm filling defect in the collecting system on CT. Cystoscopy and retrograde ureterography demonstrated normal bladder mucosa and a normal contralateral ureter. Ureteroscopy revealed a papillary TCC in the renal pelvis. Ureteroscopic treatment was declined because of the lesion's size. We elected to proceed with percutaneous resection. Using the bipolar resectoscope, the lesion was removed completely. The procedure was accomplished in 90 minutes. The estimated blood loss was 50 mL. The hospital stay was 23 hours. Pathology examination revealed a low-grade TCC. Follow-up for 9 months has shown no recurrence. CONCLUSION: In our initial experience, percutaneous treatment of upper-tract urothelial tumors may be accomplished using the bipolar resectoscope with favorable results.     

Port-site metastasis after retroperitoneoscopy-assisted nephroureterectomy and cystectomy for bladder cancer invading the ureter: a case report

We report a case of port-site metastasis of bladder cancer after left retroperitoneoscopy-assisted nephroureterectomy and cystectomy. The patient was a 73-year-old man with a chief complaint of gross hematuria. The diagnosis was invasive bladder cancer with bone metastasis. He received two courses of chemotherapy (methotrexate, vinblastine, adriamycin, cisplatin), and this resulted in resolution of the bone metastases. Two months later, abdominal and pelvic computed tomography showed a bladder tumor invading the left lower ureter with hydronephrosis. Left retroperitoneoscopy-assisted nephroureterectomy and cystectomy were performed. The patient was unable to undergo systemic chemotherapy because of renal dysfunction. Four months later, a lateral abdominal wall tumor was found at a port-site, and needle biopsy confirmed this to be metastatic urothelial carcinoma. Clinicians need to be aware of port-site metastasis, particularly in patients with UC, and take steps to prevent it during laparoscopic procedures.     

Tumor recurrence incidence following hand-assisted laparoscopic nephroureterectomy.

BACKGROUND AND OBJECTIVES: We evaluated the incidence of tumor recurrence following hand-assisted laparoscopic nephroureterectomy (HALNU) for the treatment of upper tract urothelial carcinoma. METHODS: The medical records of consecutive patients who underwent HALNU by a single surgeon (CW) between October 2001 and May 2005 were reviewed. The ureter was clipped before kidney dissection to prevent distal migration of tumor. Following liberation of the kidney, the bladder cuff and intramural ureter were excised by using a Collings knife under cystoscopic guidance. RESULTS: Ten patients were identified. The primary location of disease was confined to the intrarenal collecting system. Eight high-grade (HG) and 2 low-grade (LG) tumors were removed, with pT3 (6), pT2 (1), pT1 (1), and pTa (2) disease. The patient having a LG pTa urothelial carcinoma developed pulmonary metastasis 20 months following surgery and survived an additional 26 months. Two patients, each having a HG pT3 tumor, developed a urothelial carcinoma in the bladder contralateral to the site of ureteral excision. At a mean follow-up of 41 months, there has been no evidence of tumor recurrence in the pelvis. CONCLUSION: Our technique of HALNU does not appear to harbor an increased risk for urothelial carcinoma recurrence.     

Transitional-cell carcinoma recurrence rate after nephroureterectomy in patients who undergo open excision of bladder cuff v transurethral incision of the ureteral orifice

BACKGROUND AND PURPOSE: The gold standard treatment for upper-tract transitional-cell carcinoma is radical nephroureterectomy, but management of the distal ureter is not standardized. Two treatment options to detach the distal ureter are open cystotomy (OC) and excision of a bladder cuff or transurethral incision of the ureteral orifice (TUIUO). We compared the clinico-pathologic outcomes of these two techniques. PATIENTS AND METHODS: Hospital records were reviewed on all 51 patients who had undergone open or laparoscopic nephroureterectomy at our institution between 1 January 1990 and 30 June 2005. Patient demographics, intraoperative parameters, and pathology data were collected. The mean follow-up was 23.2 months (range 4.5-75 months) and 22.1 months (range 1-50 months) for the OC and TUIUO groups, respectively. There were no significant differences in sex, age at operation, American Society Anesthesiologists risk score, previous transitional-cell tumors, pathologic tumor grade and stage, or metastatic disease status in the two groups. RESULTS: Five patients had an unplanned incomplete ureterectomy. The bladder recurrence rates were similar in the OC group (22.2%; 6/27) and the TUIUO group (26.3%; 5/19). There were no pelvic recurrences in either group. Four of the five patients who had an incomplete ureterectomy had tumor recurrences, three in the form of metastatic disease. CONCLUSION: Management of the distal ureter by TUIUO in appropriate patients offers the same rate of bladder recurrence as OC. Incomplete ureterectomy results in a significantly higher rate of recurrence, often associated with the development of metastatic disease.