Laparoscopic Nephroureterectomy with Bladder-Cuff Resection: Techniques and Outcomes

Complete transperitoneal laparoscopic nephroureterectomy in a single position for upper urinary tract urothelial carcinoma and comparative outcomes

BACKGROUND

To describe the techniques and outcomes of complete transperitoneal laparoscopic nephroureterectomy (CTLNU) for upper urinary tract urothelial carcinoma (UTUC) in a single position.

MATERIALS AND METHODS

Those patients with localized UTUC were included, among which 50 cases had CTLNU while 48 cases had laparoscopic nephroureterectomy with open bladder cuff excision (LNOBE). The clinical data were collected and analyzed retrospectively.

RESULTS

All 98 patients underwent successful procedures of radical nephroureterectomy without transferring into open surgery. No significant difference was found among baseline clinical characteristics. Compared with the LNOBE group, the CTLNU group had a shorter operative time (98.5±40.3 min vs. 132.4±60.2 min), less blood loss (60.4±20.3 ml vs. 150.6±50.2 ml), shorter length of hospital stay (5.3±2.2 days vs. 8.1±2.3 days), and shorter incision (6.3±1.2 cm vs. 11.5±3.2 cm). The disease-related outcomes such as pathological stage, tumor grade, and recurrence rate were similar between the two groups.

CONCLUSIONS

The CTLNU in a single position had advantages of shorter operation time, less blood loss, and shorter incision length. This surgical technique is a more minimally invasive, simplified, and effective way to perform the radical nephroureterectomy.

Complete retroperitoneal laparoscopic nephroureterectomy with bladder cuff excision for upper tract urothelial carcinoma without patient repositioning: a single-center experience

Objective

This study was performed to evaluate the outcome of complete retroperitoneal laparoscopic nephroureterectomy with bladder cuff excision (RLNU-BCE), which is performed to treat urothelial carcinomas in the renal pelvis or in the ureter higher than the crossing of the common iliac artery without patient repositioning.

Methods

We retrospectively analyzed the clinical data of 48 patients with upper tract urothelial carcinoma who underwent complete RLNU-BCE in our institution from May 2017 to September 2019.

Results

RLNU-BCE was successfully performed in all 48 patients. The median operation time was 110 minutes [interquartile range (IQR), 100–130 minutes], and the median postoperative anesthesia recovery time was 10 minutes (IQR, 7–15 minutes). The median postoperative hospitalization period was 5 days (IQR, 4–6 days). Pathologic examination revealed that the margin of all resected specimens was negative. After a median follow-up of 13 months (IQR, 7–20 months), no local recurrence or distant metastasis was found. No complications occurred during follow-up.

Conclusion

Based on our experience with this technique, RLNU-BCE deserves application and promotion in clinical practice. Long-term comparative studies are required to confirm its superiority over other techniques.

Techniques to resect the distal ureter in robotic/laparoscopic nephroureterectomy

Treatment of clinically-organ confined high grade urothelial carcinoma of the upper tract has historically comprised open nephroureterectomy, with the distal ureter and bladder cuff mobilized through a separate open pelvic incision. To decrease morbidity, urologists have increasingly adopted laparoscopy and robotics in performing nephroureterectomy. In many published series of laparoscopic nephroureterectomy, the distal ureter and bladder cuff are detached from the bladder endoscopically by a variation of the “pluck” technique, with the resulting bladder defect left to heal by prolonged indwelling urethral catheter drainage. While the distal ureter and bladder cuff can be excised laparoscopically, it does require advanced laparoscopic skills. With the wrist articulation and stereoscopic vision in robotic surgery, robotic nephroureterectomy (RNU) and bladder cuff excision can be performed in antegrade fashion to mimic the open technique together with the ability to intracorporeally close the bladder defect in a watertight, mucosa to mucosa fashion after excising the bladder cuff. In this review, we discuss the published minimally invasive techniques in resecting the distal ureter and bladder cuff during laparoscopic and RNU.

Distal ureterectomy techniques in laparoscopic and robot-assisted nephroureterectomy: Updated review

Controversies exist about the best method for managing the distal ureter during the laparoscopic (LNU) and robot-assisted nephroureterectomy (RANU). Therefore, PubMed, Scopus and Web of Science databases were searched in order to identify articles describing the management of distal ureter during LNU or RANU in patients suffering from upper urinary tract urothelial cell carcinoma. Forty seven articles were selected for their relevance to the subject of this review. The approaches that are usually performed regarding the distal ureter management are open excision, transurethral resection of ureteral orifice (Pluck Technique), ureteric intussusception and pure LNU or pure RANU. Pure LNU and RANU with complete laparoscopic dissection and suture reconstruction of ureter and bladder cuff seems to be better tolerated than open nephroureterectomy providing equal efficacy, without deteriorating the oncological outcome, however evidence is poor. Transurethral resection of the ureteric orifice and the bladder cuff after occlusion of the ureter with a balloon catheter seems to be an attractive alternative option for low stage, low grade tumors of the renal pelvis and the proximal ureter, while stapling technique is correlated with the increased risk of positive surgical margins. The open resection of the distal ureter in continuity with the bladder cuff is considered the most reliable approach, preferred in our practice as well, however the existing data are based on retrospective and non-randomized studies.

Transvesical Laparoendoscopic Single-Site Management of Distal Ureter During Laparoscopic Radical Nephroureterectomy

Objective: To describe the management of the distal ureter during radical nephroureterectomy with the transvesical laparoendoscopic single-site surgery (T-LESS) approach. Methods: Between January 2010 and October 2013, five patients underwent laparoscopic radical nephroureterectomy for upper urinary tract carcinoma (UTUC) with the T-LESS approach. Patients were placed in the supine position. A 2.5-cm skin incision was made in the line between the pubis and the umbilicus. The bladder was identified and a multiport was inserted into the bladder. The patients were repositioned to a lateral decubitus position; pneumovesicum was established and the ureteral openings were identified. We marked the bladder cuff with electrocautery all the way through to the extravesical fat. The bladder defect was sealed with sutures. After checking for any leak or bleeding, the multiport was removed and the bladder was closed. At this point, we continued with nephrectomy by standard laparoscopy or LESS. A 18F Foley catheter was placed into the bladder. Results: The mean age was 70 years (range 58-81 years), the mean operative time was 198 minutes (range 115-390 minutes), the mean time for the management of the distal ureter was 35 minutes (range 27-45 minutes), the mean estimated blood loss was 234 mL (range 60-850 mL), and the mean hospital stay was 3.8 days (range 2-8 days). In all patients the bladder cuff was free of disease. Conclusion: The transvesical laparoendoscopic single-site approach to the distal ureter for UTUC appears safe and reproducible, with faster closure of the bladder defect and improved cosmesis.

Delayed ureterectomy after incomplete nephroureterectomy for upper tract urothelial carcinoma: pathologic findings and outcomes

OBJECTIVES

To evaluate the pathologic findings and outcomes after distal ureterectomy for a retained ureteral segment following incomplete nephroureterectomy for urothelial carcinoma of the renal pelvis or ureter.

MATERIALS AND METHODS

After IRB approval, an institutional database identified patients who underwent distal ureterectomy for a retained ureteral segment after assumed complete nephroureterectomy for urothelial carcinoma of the upper ureter or renal pelvis. Clinical and pathologic variables were analyzed.

RESULTS

From January 1993 to July 2007, 12 patients were identified with median age at the time of ureterectomy of 60.5 years (41-85 years). Initial approach to surgery was open in 9 patients and laparoscopic in 3 patients. The median time from nephroureterectomy to distal ureterectomy was 23.5 months (range 2-66). At the time of initial surgery, pathologic stage was Ta, T1, T2, and T3 in 3,4,1, and 4 patients respectively. Initial pathology was urothelial carcinoma; grade 2 in 6 patients and grade 3 in six patients. Pathology from the subsequent surgery demonstrated urothelial carcinoma in the retained ureteral segment in 8 patients, dysplasia or atypia in 3 patients, and 1 patient with chronic inflammation. Local recurrence in 2 patients was present in a segment of ureter discontinuous with the bladder after laparoscopic nephroureterectomy. Three patients (25%), all with initial grade 3 renal pelvis lesions, developed metastatic disease.

CONCLUSIONS

Tumor recurrence in a retained ureteral segment after incomplete nephroureterectomy is a significant problem and may contribute to intravesical recurrence or metastatic disease. Complete, en bloc resection is imperative to minimize these risks.

Total retroperitoneal laparoscopic nephroureterectomy with bladder-cuff resection for upper urinary tract transitional cell carcinoma

BACKGROUND

Open nephroureterectomy (ONU) and bladder cuff resection (ONU-BCR) has been the gold standard of surgical treatment for upper urinary tract transitional cell carcinoma (UUT-TCC). The aim of this study is to introduce a modified total retroperitoneal laparoscopic nephroureterectomy (LNU) with bladder-cuff resection (LNU-BCR) method for treating UUT-TCC and compare its clinical efficacy with ONU-BCR.

METHODS

Sixty-five patients with UUT-TCC, who underwent ONU-BCR (n = 36) or LNU-BCR (n = 29) between January 2008 and June 2012, were analyzed in this retrospective study. Perioperative data as well as incidence of disease recurrence at the primary site or distant metastasis was compared in patients with at least 6 months follow-up.

RESULTS

As compared with patients with ONU-BCR, the patients with LNU-BCR had significantly shorter operative time, lower estimated blood loss, shorter time to oral intake, lower analgesic dose, shorter duration of analgesic use, shorter duration of incision drainage tube, shorter time to ambulation out of bed and reduced postoperative hospital stay (all, p < .05). No significant difference in postoperative complications or incidence of bladder carcinoma recurrence and distant metastasis during the follow-up period was observed.

CONCLUSIONS

The modified LNU-BCR represents an effective and safe alternative technique to ONU-BCR with the advantages of reduced invasiveness, bleeding and hospitalization.

Robotic-assisted laparoscopic nephroureterectomy and bladder cuff excision

BACKGROUND AND OBJECTIVES

Our aim was to show that bladder cuff excision and distal ureterectomy can be safely performed by using the LigaSure device during robotic-assisted laparoscopic nephroureterectomy.

METHODS

A 60-year-old man presented with gross hematuria. He was diagnosed with upper urinary tract transitional cell carcinoma (TCC) on the left side and was scheduled for robot-assisted laparoscopic surgery. Without changing the patient's position, sealing with the LigaSure atlas for bladder cuff excision and distal ureterectomy was performed.

RESULTS

The operating time was 140 minutes from the initial incision to skin closure of all incisions. The estimated blood loss during the surgery was 120 mL. There were no intraoperative or postoperative complications. The Foley drain was removed on day 3 after normal cystographic findings, and the patient was discharged from the hospital on the fourth postoperative day.

CONCLUSION

Robot-assisted nephroureterectomy with distal ureterectomy in the same position using a LigaSure device is a safe alternative for upper tract transitional cell carcinoma.

[A novel technique for distal ureterectomy and bladder cuff excision]

INTRODUCTION

We 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 METHODS

The 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.

RESULTS

The operating time (LESS radical nephroureterectomy, RPLND, and bladder cuff excision) was 6hours and 15minutes. The bladder cuff time was 45minutes. 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.

CONCLUSION

The 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.

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.

A novel bulldog clamp technique for management of a distal ureter and bladder cuff during laparoscopic nephroureterectomy

A novel technique for achieving complete laparoscopic excision of the intramural ureter with a bladder cuff is presented using the bulldog clamp without opening the urinary tract.

Laparoscopic nephroureterectomy: the distal ureteral dilemma

Transitional cell carcinoma affecting the upper urinary tract, though uncommon, constitutes a serious urologic disease. Radical nephroureterectomy remains the treatment of choice but has undergone numerous modifications over the years. Although the standard technique has not been defined, the laparoscopic approach has gained in popularity in the last two decades. The most appropriate oncological management of the distal ureteral and bladder cuff has been a subject of much debate. The aim of the nephroureterectomy procedure is to remove the entire ipsilateral upper tract in continuity while avoiding extravesical transfer of tumor-containing urine during bladder surgery. A myriad of technical modifications have been described. In this article, we review the literature and present an overview of the options for dealing with the lower ureter during radical nephroureterectomy.

Perceptions of surgical specialists in general surgery, orthopaedic surgery, urology and gynaecology on teaching endoscopic surgery in The Netherlands

BACKGROUND

Specific training in endoscopic skills and procedures has become a necessity for profession with embedded endoscopic techniques in their surgical palette. Previous research indicates endoscopic skills training to be inadequate, both from subjective (resident interviews) and objective (skills measurement) viewpoint. Surprisingly, possible shortcomings in endoscopic resident education have never been measured from the perspective of those individuals responsible for resident training, e.g. the program directors. Therefore, a nation-wide survey was conducted to inventory current endoscopic training initiatives and its possible shortcomings among all program directors of the surgical specialties in the Netherlands.

METHODS

Program directors for general surgery, orthopaedic surgery, gynaecology and urology were surveyed using a validated 25-item questionnaire.

RESULTS

A total of 113 program directors responded (79%). The respective response percentages were 73.6% for general surgeons, 75% for orthopaedic surgeon, 90.9% for urologists and 68.2% for gynaecologists. According to the findings, 35% of general surgeons were concerned about whether residents are properly skilled endoscopically upon completion of training. Among the respondents, 34.6% were unaware of endoscopic training initiatives. The general and orthopaedic surgeons who were aware of these initiatives estimated the number of training hours to be satisfactory, whereas the urologists and gynaecologists estimated training time to be unsatisfactory. Type and duration of endoscopic skill training appears to be heterogeneous, both within and between the specialties. Program directors all perceive virtual reality simulation to be a highly effective training method, and a multimodality training approach to be key. Respondents agree that endoscopic skills education should ideally be coordinated according to national consensus and guidelines.

CONCLUSIONS

A delicate balance exists between training hours and clinical working hours during residency. Primarily, a re-allocation of available training hours, aimed at core-endoscopic basic and advanced procedures, tailored to the needs of the resident and his or her phase of training is in place. The professions need to define which basic and advanced endoscopic procedures are to be trained, by whom, and by what outcome standards. According to the majority of program directors, virtual reality (VR) training needs to be integrated in procedural endoscopic training courses.

Oncologic Control After Open or Laparoscopic Nephroureterectomy for Upper Urinary Tract Transitional Cell Carcinoma: A Single Center Experience

OBJECTIVES

To determine the surgical and oncologic outcomes in patients who underwent either open nephroureterectomy (ONU) or laparoscopic nephroureterectomy (LNU) for upper urinary tract transitional cell carcinoma.

METHODS

We performed a retrospective review of data for patients who underwent ONU or LNU for upper urinary tract transitional cell carcinoma from 1994 to 2004 at one institution. The recorded data included sex, age, mode of diagnosis, smoking, history of bladder cancer, type of surgery, complications, tumor site, tumor size, tumor stage, tumor grade, length of hospital stay, recurrence, and progression. We also determined the recurrence and survival rates.

RESULTS

We reviewed the data for 46 patients. The median age was 70 years. Seven patients had a history of bladder cancer. Overall, 26 patients underwent ONU and 20 LNU. No differences in the complication rate (15% versus 15%) were observed. The median hospital stay was 4 days (range 3 to 6) after LNU and 9 (range 7 to 12) after ONU (P <0.001). The tumor stage and grade were independent prognostic factors for survival on multivariate analysis (P <0.05). The 5-year disease-specific survival rate was 89.4% for low-grade tumors and 63.1% for high-grade tumors (P = 0.04). ONU was associated with high-grade (P = 0.02) or invasive (P = 0.001) tumors. The 5-year tumor-free survival rate after ONU and LNU was 51.2% and 71.6%, respectively (P = 0.59).

CONCLUSIONS

LNU does not affect the mid-term oncologic control and enables a shorter hospital stay. It can be recommended as an alternative to ONU in the management of low-risk upper urinary tract transitional cell carcinoma (Stage T1-T2 and/or low-grade disease). However, long-term follow-up is necessary to recommend it for highly invasive tumors (Stage T3-T4 or N+).

[Results of laparoscopic nephroureterectomy for transitional cell carcinoma]

OBJECTIVE

To report our experience of laparoscopic nephroureterectomy and to compare our results to those published in the literature.

PATIENTS AND METHOD

Between 1997 and 2005, 15 laparoscopic nephroureterectomies were performed by 2 surgeons, in 12 men and 3 women for upper urinary tract transitional cell carcinoma. The mean age of the patients was 66 years. Three to five trocars were used depending on intraoperative findings in order to meet oncological imperatives: primary control of the renal pedicle before any contact with the tumour dissection in the plane of the radical nephrectomy. The operative specimen was extracted in a sealed bag via an infraumbilical mini-laparotomy that allowed pelvic ureterectomy and resection of the bladder cuff.

RESULTS

The mean operating time was 210 min. The procedure was converted to open lumbar laparotomy in 3 patients. The mean hospital stay was 13 days. The final histological stage showed 8 invasive tumours (pT2-pT3), 4 superficial tumours (pTa-pT1), 2 CIS and a benign tumour. Two patients died from local progression of the disease. The mean follow-up was 41 months (range: 12-96 months).

CONCLUSION

Laparoscopic nephroureterectomy for upper urinary tract transitional cell carcinoma, still under evaluation, is indicated in selected cases. Apart from patient selection, which remains difficult preoperatively, the cancer control results depend on compliance with the principles of this surgery.

Robot-assisted laparoscopic nephroureterectomy

BACKGROUND

Laparoscopic nephroureterectomy for upper-tract urothelial tumors is a minimally invasive approach that parallels the open technique in oncologic efficacy. Multiple approaches to manage the distal ureter have been described. We developed a new technique using the daVinci robot system to perform a transvesical excision of the distal ureter and bladder cuff.

PATIENTS AND METHODS

Ten consecutive patients with upper-tract urothelial cancer underwent a laparoscopic nephroureterectomy. The daVinci robot was docked through the umbilical, ipsilateral lateral rectus, and an additional contralateral lateral rectus port. The bladder was clam-shelled in a coronal orientation at the dome and the distal ureterectomy performed.

RESULTS

Our technique was successful in all ten patients. The mean operative time for the entire case was 4.4 hours. The average hospital stay was 3 days.

CONCLUSIONS

Robot-assisted laparoscopic nephroureterectomy is a safe, minimally invasive approach to upper- tract urothelial cancer that reduces the technical challenge of excision of the distal ureter.