Modified approach of hand-assisted laparoscopic nephroureterectomy for transitional cell carcinoma of the upper urinary tract

Laparoscopic radical nephroureterectomy with only three trocars: Results of a prospective single centre study

INTRODUCTION

Radical nephroureterectomy (RNU) with full bladder cuff excision is the gold standard for treatment of non-metastatic upper tract urothelial cancer (UTUC). We describe our technique of laparoscopic nephroureterectomy (LNU) with bladder cuff excision technique with modified port placement, reporting our long-term follow-up outcomes.

METHODS

Patients affected by UTUC were prospectively enrolled and undergone to LNU. Perioperative outcomes, oncological data at 6, 12, 24 and 36 months after surgery, and all the surgical complications according to Clavien-Dindo classification were evaluated in all subjects.

RESULTS

A total of 50 patients with UTUC underwent LNU, using this new technique without patient and port repositioning. The mean operative time was 168 minutes, estimated blood loss was 75 mL, mean length of hospital stay was 3 days. There were no intraoperative complications while four late complications occurred (two grade IIIb and two grade II according to Clavien-Dindo classification, incisional hernias and fever, respectively). Postoperative pathology was T1 in 12 patients, T2 in 17 patients, and T3 in 21 patients. Tumor grade was low in 12 patients and high in 38 patients.

CONCLUSIONS

In our study the described LNU technique was related to a significant reduction in terms of operative time and length of hospital stay, with a faster patients' recovery and no peri and postoperative complications. The long-term oncological outcomes were similar to data reported in literature.

Single-docking robotic-assisted nephroureterectomy and extravesical bladder cuff excision without intraoperative repositioning: The technique and oncological outcomes

BACKGROUND

/Objective: Currently there are few report of oncologic outcomes following robotic-assisted radical nephroureterectomy (RRNU) based on long-term follow-up. To evaluate the therapeutic effect of RRNU for upper tract urothelial carcinoma (UTUC), a technique of single-docking RRNU was described and its oncological outcomes was evaluated.

PATIENTS AND METHODS

The data of 29 patients underwent RRNU for UTUC of Ta-T3 from July 2013 to June 2016 was analyzed. The data of 131 patients of UTUC underwent laparoscopic radical nephroureterectomy (LRNU) over the same period was analyzed as control. Kaplan-Meier analysis and Cox regression were used for prognosis evaluation.

RESULTS

The median follow-up time was 40.5 and 40.4 months in RRNU cohort and LRNU cohort. No difference in 5-year intravesical recurrence-free survival (IVRFS) (88.0% vs. 85.5%, p = 0.611) or distant metastasis-free survival (93.1% vs.96.7%, p = 0.323) between RRNU cohort and LRNU cohort. The 5-year retroperitoneal recurrence-free survival and cancer-specific survival (CS) were lower in RRNU cohort than in LRNU cohort (77.3% vs. 87.7%, and 71.2% v.s. 84.7%, respectively).

CONCLUSION

The single-docking RRNU is an effective treatment for UTUC, avoiding the re-docking of patient-side cart or the intraoperative reposition of patient, and bringing equivalent 5-year IVRFS compared to LRNU. However, the lower 5-year retroperitoneal recurrence-free survival and CS in RRNU cohort warned the concern of higher chance of local tumor spillage during RRNU. The noninferiority of RRNU to LRNU still needed the confirmation of large sample sized, prospective randomized controlled study.

Comparison of Single-docking Robotic-assisted and Traditional Laparoscopy for Retroperitoneal Lymph Node Dissection During Nephroureterectomy With Bladder Cuff Excision for Upper-tract Urothelial Carcinoma

OBJECTIVE

To compare the results of traditional laparoscopy and a simple, single-docking robotic approach for retroperitoneal lymph node dissection (RPLND), nephroureterectomy, and bladder cuff excision.

MATERIALS AND METHODS

We evaluated 63 and 37 consecutive patients who underwent laparoscopic and robotic nephrouretectomy with RPLND, respectively, for upper-tract urothelial carcinoma (UTUC).

RESULTS

Our robotic approach was associated with improved lymph node procurement (21.0 nodes [interquartile range 16.0-30.0]) when compared with laparoscopy (11.0 nodes [interquartile range 5.5-21.0]) (P < .0001). Major blood loss as defined by requiring a blood transfusion was less for the robotic group than for the laparoscopic cohort (8% vs 30%) (P = .012). In contrast, the robotic group had longer operative times (5.1 vs 3.9 hours) (P = .0001) and longer hospital stays (5.0 vs 4.0 days) (P = .0002).

CONCLUSION

Our single-docking robotic technique for concomitant RPLND during nephrouretectomy is associated with improved lymph node yield.

Hand-assisted retroperitoneoscopic nephroureterectomy with bladder cuffing after preperitoneal and retroperitoneal perivesical ballooning

Purpose

We aimed to describe the surgical technique of hand-assisted retroperitoneoscopic nephroureterectomy (HARNU) with bladder cuffing after preperitoneal and retroperitoneal perivesical ballooning.

Materials and Methods

From March 2008 to September 2012, we performed HARNU and open bladder cuffing in 28 consecutive series of patients with upper urinary tract urothelial carcinoma. We performed HARNU according to the following procedure: (1) a camera port incision was made on the posterior axillary line; (2) multiple, repeated, preperitoneal and retroperitoneal ballooning was performed on both the posterior axillary line and in the umbilicus; (3) a 7.0 cm skin incision was made from the suprapubic to the lower inguinal with the balloon present in the extraperitoneal area; (4) hand-assisted laparoscopic retroperitoneal nephroureterectomy; (5) cessation of gas insufflation; and (6) extravesical cuffing as an open surgical procedure.

Results

The mean estimated blood loss was 250 mL. The mean operation time was 240 minutes. The mean time to oral intake and ambulation was 1.0 day and two days, respectively. As for postoperative complications due to the hand-assisted device, one patient developed febrile urinary tract infection within three weeks postoperatively and was hospitalized again to receive parenteral antibiotics.

Conclusions

We made a low Gibson incision for a route for the hand-assisted procedure as well as a window for open surgery in dissecting the distal ureter and extracting the surgical specimens. Thus, our results indicate that the HARNU might be a feasible surgical modality.

Long-term outcome of hand-assisted laparoscopic nephroureterectomy for pathologic T3 upper urinary tract urothelial carcinoma

PURPOSE

To determine the feasibility and long-term outcomes of hand-assisted laparoscopic nephroureterectomy (HALNU) compared with open nephroureterectomy (ONU) in the management of pT(3)N0 upper urinary tract urothelial carcinoma (UUT-UC).

PATIENTS AND METHODS

Between January 1994 and December 2005, 21 patients who underwent HALNU for stage pT(3)N0 UTT-UC were matched and compared with 31 patients who underwent ONU. The oncologic out-comes, including bladder recurrence, recurrence-free survival, cancer-specific survival, and overall survival, were statistically analyzed.

RESULTS

The median follow-up period in the HALNU group was 72 months (range 33-111 months) and 115 months in the ONU group (range 24-161 months). Patient age, sex, body mass index, tumor size, specimen weight, and American Society of Anesthesiologists classification showed no significant difference between the two groups. The HALNU group had statistically less blood loss than the ONU group (113 mL versus 487 mL; P = 0.02). The average hospital stay and doses of narcotic analgesics were significantly less in the HALNU group than the ONU group. The complication and bladder recurrence rates were similar between the two groups. The 5-year recurrence-free survival, cancer-specific survival, and overall survival were also comparable in both groups.

CONCLUSIONS

HALNU is a safe and efficacious procedure with comparable long-term oncologic outcomes in comparison with ONU in treating patients with locally advanced pT(3)N0UUT-UC.

Intermediate follow-up of hand-assisted retroperitoneoscopic nephroureterectomy for management of upper urinary tract urothelial carcinoma: comparison with open nephroureterectomy

OBJECTIVES

To evaluate the oncologic outcomes of hand-assisted retroperitoneoscopic nephroureterectomy (HARNU) for upper urinary tract urothelial carcinoma and compare them with the data from conventional open surgery.

METHODS

We collected the data from 25 patients who underwent HARNU at our institution from January 1999 to December 2003 for upper urinary tract urothelial carcinoma. The clinical data were collected retrospectively by reviewing the medical records. The convalescence results and oncologic outcomes were analyzed and compared with the corresponding data from 41 contemporary conventional open nephroureterectomy (ONU) procedures.

RESULTS

The median follow-up period in the HARNU group was 32 months (range 21 to 43) and was 62 months (range 8 to 88) in the ONU group. Patient age, sex, body mass index, tumor size, specimen weight, and American Society of Anesthesiologists classification showed no significant differences between the two groups. The HARNU group required a longer operation time (252 versus 212 minutes; P = 0.02). Significantly less blood loss (212 versus 408 mL; P = 0.03) was noted in the HARNU group. The complication rates between the HARNU group and ONU group were similar (12% and 7.3%, respectively, P = 0.67). No open conversion was required in the HARNU group. The average hospital stay, days to oral intake, days to ambulation, and dose of parenteral narcotic analgesics were significantly less in the HARNU group. No significant differences were found in the 3-year bladder recurrence-free survival rate, cancer-specific survival rate, or overall survival rate between the two groups.

CONCLUSIONS

The results of our study have shown that HARNU, with an open method for the removal of the distal ureter and bladder cuff, is a less-invasive technique and provides comparable oncologic outcomes as ONU for upper urinary tract urothelial carcinoma.

Long-Term Outcome of Hand-Assisted Laparoscopic Radical Nephroureterectomy for Upper-Tract Urothelial Carcinoma: Comparison with Open Surgery

PURPOSE

To evaluate the efficacy and long-term outcome of hand-assisted laparoscopic radical nephroureterectomy (HALNU) in treating upper urinary-tract transitional-cell carcinoma (UT-TCC).

PATIENTS AND METHODS

We analyzed the data from 39 patients who underwent HALNU in our institution between January 1999 and December 2002 for urothelial carcinoma of the ureter or kidney. Preoperative and perioperative data were collected retrospectively by reviewing medical records. The oncologic outcomes, including bladder recurrence-free survival, cancer-specific survival, and overall survival, were compared with those of 36 contemporary patients undergoing conventional open radical nephroureterectomy (ONU). The median follow-up was 48 months (range 6 2 months) in the HALNU group and 59.5 months in the ONU group (range 8 8 months). Patients ages, sex, body mass index, pathologic parameters, and American Society of Anesthesiologists (ASA) classification showed no significant difference between the groups.

RESULTS

The HALNU group had statistically less blood loss (183 mL v 422 mL; P = 0.02). The average hospital stay and dose of narcotic analgesics were significantly less in the HALNU group. The complication rates were similar (12.8% for HALNU and 8.3% for ONU; P = 0.53). The 5-year bladder recurrence-free survival, cancer-specific survival, and overall survival were similar in the two groups.

CONCLUSIONS

The HALNU is a less-invasive technique with 5-year bladder recurrence-free survival, cancer-specific survival, and overall survival rates similar to those of ONU for patients with UT-TCC.

A modified supine position to speed hand assisted retroperitoneoscopic nephroureterectomy: the Johnnie Walker position

PURPOSE

To minimize the operative time of hand assisted retroperitoneoscopic nephroureterectomy by avoiding position change we report an especially designed surgical position.

MATERIALS AND METHODS

A total of 41 patients with upper tract transitional cell carcinoma who underwent hand assisted retroperitoneoscopic nephroureterectomy and bladder cuff resection were enrolled. Patients lay supine, and the flank and hip on the lesion side were elevated 30 degrees. The legs were extended and abducted in the Johnnie Walker position, allowing the operator to stand between them. Operation was completed via a 7 to 8 cm Gibson incision and 2 additional laparoscopic ports.

RESULTS

All procedures were successful except 1 open conversion due to bleeding, in which there was no need to reposition the patient. Average patient age was 65.2 years (range 34 to 85), mean operative time was 207.6 minutes (range 130 to 345) and mean estimated blood loss was 166 ml (range 50 to 900). Simultaneous transurethral endoscopic procedures were performed in 11 patients in the same position. Time to oral intake and ambulation was 2.1 and 2.0 days, respectively. Two patients had postoperative complications, including pneumonia and wound hematoma in 1 each. No complication was related to the position.

CONCLUSIONS

The Johnnie Walker position minimizes operative time by eliminating the delay caused by patient positioning and draping changes, allowing better coordination for the surgeon and assistant, and permitting more efficient use of the nondominant hand. The retroperitoneal approach prevents bowel interference in the visual field, making laparoscopic surgery in this modified supine position possible. Nephroureterectomy, bladder cuff resection and endoscopic procedures can be done with ease with the patient in this position.

Hand-assisted laparoscopic nephroureterectomy: Analysis of distal ureterectomy technique, margin status, and surgical outcomes

OBJECTIVES

To review our experience with various techniques used to manage the distal ureter during hand-assisted laparoscopic nephroureterectomy and to evaluate the surgical outcomes, including pathologic margin status and the incidence of disease recurrence.

METHODS

We retrospectively analyzed 55 hand-assisted laparoscopic nephroureterectomies performed to treat transitional cell carcinoma (TCC), with the distal ureter managed as follows: cystoscopic disarticulation in 16 patients, stapled division in 7, open distal ureterectomy in 3, and hand-assisted laparoscopic extravesical en bloc distal ureterectomy with bladder cuff in 29. The cystotomy was not closed in 7 patients.

RESULTS

The coexistence of renal pelvic and ureteral tumors was common but in 27% of cases was not recognized preoperatively. One outer and four distal ureteral margins were positive for tumor (n = 2) or carcinoma in situ (n = 3). Two (29%) of the seven cystotomies that were not closed and only 1 (2%) of the 42 that were closed demonstrated extravasation. The operative time was 60 to 90 minutes longer and the estimated blood loss, open conversion rate, and indwelling catheterization time were two to three times greater for the cystoscopic ureteral disarticulation cohort. The stapled division cohort had a greater positive margin rate (29%) than the other cohorts (10% or less). With a mean follow-up of 24 months, 19 patients had developed bladder cancer, 1 prostate cancer, 1 an extravesical malignancy with synchronous liver metastasis, and 4 distant recurrence (lung in 2 and the retroperitoneum and spine in 1 each).

CONCLUSIONS

The results of our study have shown that distal ureteral tumors have the greatest likelihood for a positive margin. Cystoscopic ureteral disarticulation increased the operative time and estimated blood loss. Cystotomy closure reduced the extravasation rate. We favor hand-assisted laparoscopic en bloc distal ureterectomy followed by cystotomy closure to minimize the risk of distal ureteral or extravesical recurrence.

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.

Outcomes of hand-assisted laparoscopic nephroureterectomy for managing upper urinary tract transitional cell carcinoma—China Medical University Hospital experience

OBJECTIVES

To report our experience with hand-assisted laparoscopic nephroureterectomy (HALNU) to treat upper urinary tract transitional cell carcinoma (TCC). In addition, we report the treatment of 4 patients with upper urinary tract TCC and synchronous superficial urinary bladder TCC by HALNU and simultaneous transurethral resection of bladder tumor (TURBT).

METHODS

We retrospectively reviewed 33 patients who had undergone HALNU. Recovery was evaluated according to the Eastern Cooperative Oncology Group performance status. Four patients had concomitant superficial urinary bladder cancer and underwent simultaneous TURBT at the beginning of surgery. We compared our data with those of our open surgery group and previously published data.

RESULTS

Partial recovery had occurred by 1 week and complete recovery by 4 weeks postoperatively. Conversion to open surgery was required in 2 (6%) of the 33 patients. The complication rate was 24% (8 of 33) without any mortality. The recurrence rate of urinary bladder TCC was 6% (2 of 33). Both patients with recurrent tumor were treated successfully by TURBT and bacille Calmette-Guérin instillation. All 4 patients with synchronous superficial urinary bladder TCC had undergone simultaneous transurethral resection of bladder tumor, and all 4 were disease free at the last follow-up visit.

CONCLUSIONS

Hand-assisted procedures are appropriate for surgeons with limited experience with laparoscopic surgery. In our study, the convalescence of patients was excellent, and the postoperative results were compatible with those of previous studies. To treat upper urinary tract TCC with synchronous urinary bladder TCC, HALNU and TURBT together seems to be a safe and efficient technique.

Laparoscopic nephroureterectomy for upper urinary tract transitional cell carcinoma: is it better than open surgery?

OBJECTIVE

In 1991, laparoscopic nephroureterectomy has been introduced as a treatment option for upper tract transitional cell carcinoma. Based on the review of the current literature and personal experience we want to analyze the actual results of this technique in comparison to open surgery.

MATERIALS AND METHODS

We performed a MEDLINE/PubMed search and reviewed the literature on laparoscopic and open nephroureterectomy between 1991 and 2004 (n = 1365 patients) including the results of 45 patients who underwent either laparoscopic (n = 23) or open nephroureterectomy (n = 21) during the same period of time at the Klinikum Heilbronn. Demographic, perioperative and follow-up data were compared.

RESULTS

The analysis revealed a slightly longer OR-time (276.6 vs. 220.1 min), and significantly lower blood loss (240.9 vs. 462.9 ml) in the laparoscopic series. No differences of minor (12.9 vs. 14.1%) or major complication rate (5.6 vs. 8.3%) were observed. All nine comparative studies revealed a significant dose reduction of the morphine-equivalents after laparoscopy. In all ten comparative series the hospital stay was shorter after laparoscopy, but only in 6 series the difference was statistically significant. The frequency of bladder recurrence (24.0 vs. 24.7%), local recurrence (4.4 vs. 6.3%), and distant metastases (15.5% vs. 15.2) did not differ significantly in both groups. The actual disease-free two-year survival rates (75.2 vs. 76.2%) were similar. The five-year survival rates averaged 81.2% in the three laparoscopic (n = 113 pat.) and 61% in the ten open series (n = 681 pat.) Six port site metastases were reported in 377 (1.6%) analyzed patients occurring 3 to 12 months following laparoscopy.

CONCLUSION

Open radical nephroureterectomy still represents the golden standard for the management of upper tract transitional cell carcinoma, however, laparoscopic radical nephroureterectomy offers the advantages of minimally invasive surgery without deteriorating the oncological outcome. In case of advanced tumors (pT3,N+) open surgery is still recommended.

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 urological laparoscopy

Hand-assisted laparoscopy has been successfully applied to various applications within the field of urology. Many authors have proved the safety and efficacy of this technique, as well as demonstrating improved patient recovery for such procedures as radical nephrectomy, radical nephroureterectomy and donor nephrectomy. The recent literature regarding this topic is reviewed and evaluated here.