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Laparoscopic nephroureterectomy for upper tract urothelial carcinoma - Update. Asian J Urol 2016; 3:115-119. [PMID: 29264177 PMCID: PMC5730822 DOI: 10.1016/j.ajur.2016.05.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2016] [Revised: 05/08/2016] [Accepted: 05/12/2016] [Indexed: 12/13/2022] Open
Abstract
Upper urinary tract urothelial carcinomas (UTUCs) are uncommon and account for only 5%-10% of urothelial carcinomas. Pyelocaliceal tumors are about twice as common as ureteral tumors. Sixty percent of UTUCs are invasive at diagnosis. Radical nephroureterectomy, including the excision of the distal ureter and bladder cuff is standard of care for treatment of localized UTUCs, because of the high potential for recurrence, multifocality, and progression. Since first laparoscopic nephroureterectomy (LNU) was introduced by Clayman et al. in 1991 and improvement of laparoscopic technique and equipment, LNU has been reported to be equivalent to conventional open method. We reviewed the current literature of patients with UTUCs treated by LNU focusing on technical aspects, peri-operative and oncological outcomes. Laparoscopic radical nephroureterectomy offers the advantages of minimally invasive surgery without deteriorating the oncological outcome for treatment of UTUCs. Indications tend to increase as operator skills increase. Indications for laparoscopic or open nephroureterectomy are in principle the same. The basic requirement for laparoscopic surgery in UTUCs is to achieve benefits of minimal invasive surgery and maintain oncologic principles.
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Liu P, Fang D, Xiong G, Yang K, Zhang L, Yao L, Zhang C, Li X, He Z, Zhou L. A Novel and Simple Modification for Management of Distal Ureter During Laparoscopic Nephroureterectomy Without Patient Repositioning: A Bulldog Clamp Technique and Description of Modified Port Placement. J Endourol 2016; 30:195-200. [PMID: 26414919 DOI: 10.1089/end.2015.0603] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
Affiliation(s)
- Pei Liu
- Department of Urology, Peking University First Hospital, Beijing, China
- Institute of Urology, Peking University, Beijing, China
- National Urological Cancer Center, Beijing, China
| | - Dong Fang
- Department of Urology, Peking University First Hospital, Beijing, China
- Institute of Urology, Peking University, Beijing, China
- National Urological Cancer Center, Beijing, China
| | - Gengyan Xiong
- Department of Urology, Peking University First Hospital, Beijing, China
- Institute of Urology, Peking University, Beijing, China
- National Urological Cancer Center, Beijing, China
| | - Kaiwei Yang
- Department of Urology, Peking University First Hospital, Beijing, China
- Institute of Urology, Peking University, Beijing, China
- National Urological Cancer Center, Beijing, China
| | - Lei Zhang
- Department of Urology, Peking University First Hospital, Beijing, China
- Institute of Urology, Peking University, Beijing, China
- National Urological Cancer Center, Beijing, China
| | - Lin Yao
- Department of Urology, Peking University First Hospital, Beijing, China
- Institute of Urology, Peking University, Beijing, China
- National Urological Cancer Center, Beijing, China
| | - Cuijian Zhang
- Department of Urology, Peking University First Hospital, Beijing, China
- Institute of Urology, Peking University, Beijing, China
- National Urological Cancer Center, Beijing, China
| | - Xuesong Li
- Department of Urology, Peking University First Hospital, Beijing, China
- Institute of Urology, Peking University, Beijing, China
- National Urological Cancer Center, Beijing, China
| | - Zhisong He
- Department of Urology, Peking University First Hospital, Beijing, China
- Institute of Urology, Peking University, Beijing, China
- National Urological Cancer Center, Beijing, China
| | - Liqun Zhou
- Department of Urology, Peking University First Hospital, Beijing, China
- Institute of Urology, Peking University, Beijing, China
- National Urological Cancer Center, Beijing, China
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Stravodimos KG, Komninos C, Kural AR, Constantinides C. Distal ureterectomy techniques in laparoscopic and robot-assisted nephroureterectomy: Updated review. Urol Ann 2015; 7:8-16. [PMID: 25657536 PMCID: PMC4310125 DOI: 10.4103/0974-7796.148575] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2014] [Accepted: 09/15/2014] [Indexed: 01/24/2023] Open
Abstract
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.
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Affiliation(s)
| | - Christos Komninos
- Department of Urology, Athens University Medical School, Laiko Hospital, Athens, Greece
| | - Ali Riza Kural
- Department of Robotic Surgery and Urology, Acibadem University, Maslak Hospital, Istanbul, Turkey
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Abel EJ, Fisher MB, Matin SF, Kamat AM, Dinney CP, Grossman HB. Delayed ureterectomy after incomplete nephroureterectomy for upper tract urothelial carcinoma: pathologic findings and outcomes. Int Braz J Urol 2014; 39:817-22. [PMID: 24456786 DOI: 10.1590/s1677-5538.ibju.2013.06.07] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2013] [Accepted: 09/17/2013] [Indexed: 11/22/2022] Open
Abstract
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.
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Affiliation(s)
- E Jason Abel
- Department of Urology, Anderson Cancer Center, University of Texas, TX, USA
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Ozdemir AT, Altinova S, Asil E, Balbay MD. Robotic-assisted laparoscopic nephroureterectomy and bladder cuff excision. JSLS 2013; 16:320-4. [PMID: 23477188 PMCID: PMC3481236 DOI: 10.4293/108680812x13427982376662] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
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.
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Affiliation(s)
- A T Ozdemir
- Ataturk Teaching and Research Hospital, 1st Urology Clinic, Ankara, Turkey
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Lee Z, Cadillo-Chavez R, Lee DI, Llukani E, Eun D. The technique of single stage pure robotic nephroureterectomy. J Endourol 2012; 27:189-95. [PMID: 22876964 DOI: 10.1089/end.2012.0394] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Abstract
PURPOSE To describe a novel technique for a single setup approach for robotic radical nephroureterectomy (RANU) that does not require patient repositioning, port reassignment, or redocking of the robotic arms. MATERIALS AND METHODS Twenty consecutive patients underwent RANU at a single institution between January 2009 and January 2012. We implemented a unique port placement strategy based on a modified paramedian line (MPL), which allowed sufficient access to both the upper abdomen and the deep pelvis for radical NU with bladder cuff excision and concomitant lymphadenectomy. RESULTS The mean operative time was 161.3 minutes (range 91-330 minutes), mean estimated blood loss was 98.8 (range 50-200), and the mean hospital stay was 3 days (median 2 days, range 1-16 days). None of the procedures were converted to open or required blood transfusions. Lymphadenectomy was performed on 16 out of 20 patients, and the mean number of lymph nodes removed per patient when lymphadenectomy was performed was 14.1 (range 2-35). Three patients had positive lymph nodes. One patient had prolonged postoperative ileus, and one had a hospital course that was complicated by pneumonia. Mean patient follow-up was 13.5 months (range 1-24 months); one patient was found to have a recurrence at 3 month follow-up. CONCLUSION The use of our MPL line for novel port placement allows for an effective, efficient, and reproducible method for RANU without the need for repositioning of the patient or the robot.
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Affiliation(s)
- Ziho Lee
- Thomas Jefferson University, Philadelphia, Pennsylvania, USA
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Delibegović S, Iljazović E, Katica M, Koluh A. Tissue reaction to absorbable endoloop, nonabsorbable titanium staples, and polymer Hem-o-lok clip after laparoscopic appendectomy. JSLS 2011; 15:70-6. [PMID: 21902947 PMCID: PMC3134701 DOI: 10.4293/108680811x13022985131336] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND AND OBJECTIVES The standard technique for securing the base of the appendix during laparoscopic appendectomy is by absorbable endoloop ligature, although clinical reports favor the use of the stapler. Nonabsorbable Hem-o-lok clips have been shown to be an alternative technique to this. However, it is currently not clear whether nonabsorbable clips have any effects on the intestine or promote infection in the surgical area. MATERIALS AND METHODS Sixty Wistar albino rats were randomized into 3 treatment groups: group I (n=20) the base of the appendix was secured by endoloop 2-0 ligature; group II (n=20) dissection of the appendix was performed by a 45-mm thick stapler; and group III (n=20) the base of the appendix was secured by a Hem-o-lok plastic clip. The animals were sacrificed on the 14th and 28th days after surgery. The secured stump was used for histopathological examination. RESULTS There were no significant differences in histopathological changes observed on the 14th postoperative day between the groups. On the 28th postoperative day, it was proved that mild and moderate inflammation is more frequent in the endoloop and Hem-o-lok groups than in the stapler group. Reaction to a foreign body is more frequent in the endoloop than in stapler and Hem-o-lok groups. CONCLUSION The mildest postoperative inflammatory changes were seen in the stapler group, followed by the Hem-o-lok group. However, because of the price of the plastic clip and the simplicity of its application, its use is still favored during laparoscopic appendectomy.
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Affiliation(s)
- Samir Delibegović
- Department of Surgery, University Clinic Center Tuzla, Bosnia and Herzegovina.
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Ritch CR, Kearns JT, Mues AC, Hruby GW, Benson MC, McKiernan JM, Landman J. Comparison of Distal Ureteral Management Strategies During Laparoscopic Nephroureterectomy. J Endourol 2011; 25:1149-54. [DOI: 10.1089/end.2010.0542] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Chad R. Ritch
- Department of Urology, Columbia University Medical Center, New York, New York
| | - Jamie T. Kearns
- Department of Urology, Columbia University Medical Center, New York, New York
| | - Adam C. Mues
- Department of Urology, Columbia University Medical Center, New York, New York
| | - Gregory W. Hruby
- Department of Urology, Columbia University Medical Center, New York, New York
| | - Mitchell C. Benson
- Department of Urology, Columbia University Medical Center, New York, New York
| | - James M. McKiernan
- Department of Urology, Columbia University Medical Center, New York, New York
| | - Jaime Landman
- Department of Urology, Columbia University Medical Center, New York, New York
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Lambert EH, Schachter LR, Altamar HO, Tikhonenkov S, Moeckel G, Miller NL, Herrell SD. A sealed bladder cuff technique during laparoscopic nephroureterectomy utilizing the LigaSure electrosurgical device: laboratory and clinical experience. J Endourol 2010; 24:327-32. [PMID: 20078234 DOI: 10.1089/end.2009.0187] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
INTRODUCTION Laparoscopic nephroureterectomy (LNU) is a safe, minimally invasive approach for management of upper tract urothelial tumors. Controversy exists over the optimal technique for the distal ureter and bladder cuff (DUBC) excision. We examined the novel technique of using the LigaSure bipolar electrosurgical device in laboratory investigations and during clinical LNU to manage the DUBC. PATIENTS AND METHODS Initial investigations were undertaken in the porcine model. Areas of both normal porcine ureters and bladders, and ex vivo human ureters from radical nephrectomy specimens were sealed with the LigaSure and stained with nicotinamide adenine dinucleotide (NADH) and hematoxylin and eosin to examine the length of treatment effect and the viability of the ablated tissue. Clinically, we performed 22 LNU for proximal urothelial tumors using the LigaSure for the management of the DUBC. Intraoperative cystoscopy assessed cuff resection and bladder leakage. On postoperative day 10, a cystogram was performed. RESULTS In the porcine model, the technique sealed the bladder effectively with a mean burst pressure of 14 mm Hg. Cellular staining revealed no viable urothelial tissue in the seal area and an additional 2 mm outside this area. Eighteen patients had a successful seal/ablation intraoperatively. Cystoscopy revealed cautery artifact and blanching over the former position of the ureteral orifice. CONCLUSION The LigaSure device ablates and seals urothelial tissue with no viable cells in the clamped and adjacent blanched tissue. Our technique is technically feasible, removes an adequate bladder cuff, typically maintains a closed urinary system, and adheres to sound oncological principles. This procedure could be performed in both laparoscopic and open nephroureterectomy for proximal upper tract transitional cell tumors.
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Affiliation(s)
- Erica H Lambert
- Department of Urology, Vanderbilt University Medical Center, Nashville, Tennessee 37232, USA.
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Laparoscopic nephroureterectomy and management of the distal ureter: a review of current techniques and outcomes. Adv Urol 2009:721371. [PMID: 19148293 PMCID: PMC2615831 DOI: 10.1155/2009/721371] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2008] [Accepted: 11/03/2008] [Indexed: 12/31/2022] Open
Abstract
Laparoscopic nephroureterectomy (LNU) is becoming an increasingly common alternative treatment for transitional cell carcinoma (TCC) of the renal pelvis and ureter due to decreased perioperative morbidity, shorter hospitalization, and comparable oncologic control with open nephroureterectomy (ONU). Mobilization of the kidney and proximal ureter may be performed through a transperitoneal, retroperitoneal, or hand-assisted approach. Each technique is associated with its own benefits and limitations, and the optimal approach is often dictated by surgeon preference. Our analysis of the literature reflects equivalent cancer control between LPN and OPN at intermediate follow-up with significantly improved perioperative morbidity following LPN. Several methods for bladder cuff excision have been advocated, however, no individual technique for management of the distal ureter proved superior. Overall, complete en-bloc resection with minimal disruption of the urinary tract should be optimized to maintain oncologic outcomes. Longer follow-up and prospective studies are needed to fully evaluate these techniques.
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Srirangam SJ, van Cleynenbreugel B, van Poppel H. Laparoscopic nephroureterectomy: the distal ureteral dilemma. Adv Urol 2008; 2009:316807. [PMID: 19020654 PMCID: PMC2581726 DOI: 10.1155/2009/316807] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2008] [Accepted: 09/22/2008] [Indexed: 11/18/2022] Open
Abstract
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.
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Affiliation(s)
- Shalom J Srirangam
- Department of Urology, Royal Blackburn Hospital, Blackburn, BB2 3HH, UK. Shalom J. Srirangam,
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Landman J. Management of the distal ureter and bladder cuff during nephroureterectomy for transitional cell carcinoma. J Endourol 2008; 22:1959-60; discussion 1965. [PMID: 18811506 DOI: 10.1089/end.2008.9768] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Jaime Landman
- Department of Urology, Columbia University, New York, New York,
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Tsivian A, Benjamin S, Sidi AA. A Sealed Laparoscopic Nephroureterectomy: A New Technique. Eur Urol 2007; 52:1015-9. [PMID: 17084517 DOI: 10.1016/j.eururo.2006.10.036] [Citation(s) in RCA: 45] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2006] [Accepted: 10/17/2006] [Indexed: 11/26/2022]
Abstract
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.
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Affiliation(s)
- Alexander Tsivian
- Department of Urologic Surgery, Wolfson Medical Center, Holon, and the Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.
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