Laparoscopic nephroureterectomy for upper tract transitional cell carcinoma: a critical appraisal

[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.

[Endosopic organ-sparing treatment of urothelial tumors of the upper urinary tract: indications and results]

In addition to radical nephrourterectomy with removal of the bladder cuff, which is still the gold standard in the therapy of urothelial tumors of the upper urinary tract, various percutaneous and transurethral endoscopic methods are now well established for organ-sparing therapies due to technical improvements in endoscopy. Although these were originally only used with selective indications, if radical nephrourterectomy were not coupled with an unreasonable postoperative morbidity (e.g. dialysis-dependence after removal of a tumor-carrying single kidney), organ-sparing therapy attempts are increasingly more recommended, even by extended indications. Analysis of the current literature shows that organ-sparing is strived for, especially with small (<1.5 cm) solitary urothelial tumors with low grade malignancy and without muscle invading growth. Although tumor-specific survival with 69-100% is comparable to nephrourterectomy, organ-sparing treatment appears more inclined to tumor recurrence (relapse rate 23-90%). These data must, however, be interpreted with caution because they originate from retrospective single center studies with low patient numbers, very different patient collectives and mostly relatively short follow-up time periods. Prospective randomized multicenter studies with large patient collectives and long follow-up times are not yet available. After organ-sparing therapy of urothelial tumors of the upper urinary tract, it is important to have life-long follow-up with imaging and endoscopy, in order to initiate an early second therapy in the case of a relapse.

Comparing lymphadenectomy during radical nephroureterectomy: open versus laparoscopic

OBJECTIVES

Laparoscopic nephroureterectomy (LNU) is an accepted treatment for tumors of the ureter and renal pelvis, although the ability to perform a regional lymphadenectomy has been criticized. We compared the quality of lymphadenectomy with LNU with that involving open nephroureterectomy (ONU) to determine whether oncologic principles are maintained.

METHODS

We searched our institutional database for patients who had undergone ONU from 1990 to 2005. These were compared with a series of patients from January 2003 to April 2007 who underwent LNU. From each patient's medical records, we assessed the number of lymph nodes removed, the number of positive nodes removed, and the density of positive nodes. The differences between groups were analyzed using the Wilcoxon rank sum statistical test.

RESULTS

We identified 106 patients who underwent ONU with lymphadenectomy and 28 who underwent LNU with lymphadenectomy. The median number of nodes removed, median number of positive nodes, and median density of positive nodes were, respectively, 3, 0, and 0 for the ONU group; and 6, 0, and 0, for the LNU group. There was a statistically significant difference between groups with respect to the number of nodes removed (P = 0.01) but not with respect to the number of positive nodes removed (P = 0.61) or the lymph node density (P = 0.42).

CONCLUSIONS

Offsetting the benefits of laparoscopy could be a flawed oncologic technique. We have demonstrated that lymphadenectomy, which is a potentially important component of nephroureterectomy, can be performed as well during LNU as it is with ONU when a dedicated effort is made.

Urothelial carcinoma of the upper urinary tract: surgical approach and prognostic factors

OBJECTIVES

Open radical nephroureterectomy (O-RNU) has been the gold standard for the treatment of upper urinary tract urothelial carcinoma (UUT-UC) for decades. With the advances in laparoscopic techniques and endourologic procedures, this concept has been increasingly challenged. Oncologic outcome prediction is mainly based on stage and grade. With progress in medical treatment, adjuvant therapies may gain importance in the future. This review assesses the values of the variety of available treatments as well as prognostic factors that may become relevant regarding patient selection for future adjuvant treatment trials.

METHODS

We performed a systematic literature research using MEDLINE with emphasis on open surgical, laparoscopic, and endourologic (ureteroscopic or percutaneous) techniques and prognostic contents.

RESULTS

Overall, no evidence level 1 information from prospective randomised trials is available for treatment of UUT-UC. Laparoscopic radical nephroureterectomy (L-RNU) is increasingly challenging open surgery. Currently, L-RNU should be reserved for low-stage, low-grade tumours. Ureteroscopy and percutaneous nephron-sparing techniques show favourable survival data but high local recurrence rates. Regarding prognosis, estimation of outcome still relies mainly on stage and grade because no additional parameters have been introduced in a routine clinical setting.

CONCLUSIONS

O-RNU still represents the gold standard for the treatment of UUT-UC. The laparoscopic approach is not yet standard of care and should be reserved for low-stage, low-grade tumours. Endourologic nephron-sparing treatments are still experimental in elective indications due to high local recurrence rates. For prognosis, no parameters in addition to stage and grade have been standardised.

Incidence of local recurrence and port site metastasis after laparoscopic radical nephroureterectomy

OBJECTIVES

To address the incidence of local recurrence and port site metastasis in patients who underwent laparoscopic radical nephroureterectomy (RNU) for upper tract transitional cell carcinoma (TCC).

METHODS

Between August 1993 and February 2006 116 laparoscopic RNU were performed in 115 patients at our institution. A traditional open excision, a laparoscopic stapler resection or a different approach was used for the management of the distal ureter in 76, 27, and 11 cases, respectively. Clinical follow-up as well as perioperative and pathologic data were retrospectively collected.

RESULTS

Perioperative and pathologic data were available in all 116 cases. Clinical outcomes were available in 107 patients with a mean follow-up of 30.5 months (range 1 to 148). Six patients (5.6%) had a local recurrence develop, including 1 patient with port site metastasis (0.9%) at an average of 5.7 months. In 2 of these patients, violation of the ipsilateral urinary tract was noted perioperatively.

CONCLUSIONS

We report, in this large single-center series of laparoscopic RNU, a low incidence of local recurrence. Our results confirm that a laparoscopic approach to upper tract TCC does not result in a clinically significant increased risk of tumor spillage provided that principles of oncologic surgery are followed.

The atypical urothelial cancer patient: management of bladder cancers of non-transitional cell histology and cancers of the ureters and renal pelvis

Non-transitional cell neoplasms of the bladder and upper tract transitional cell carcinomas (ureter and renal pelvis) represent only a small fraction of urothelial carcinomas. Clinicians faced with the rare case are always confronted with management dilemmas complicated by the scarcity of published experience to guide decisions. The current review brings together the best of the limited published data in an attempt to provide some reasonable context to help in the management of these difficult neoplasms.

Risk Factors for Intravesical Recurrence Following Urothelial Carcinoma of the Upper Urinary Tract: No Relationship to the Mode of Surgery

OBJECTIVE

The aim of this study was to clarify whether intravesical recurrence of upper urinary tract cancer after treatment is related to the mode of surgery or other oncological factors.

METHODS

We evaluated 106 patients (mean age 70.4 years; mean follow-up 24.0 months) who underwent surgery for the upper urinary tract cancer at Hiroshima University and its affiliated hospitals between January 1995 and August 2005. Seventy-nine of the patients underwent retroperitoneoscopy-assisted radical nephroureterectomy (RN) and 27 underwent nephroureterectomy by open surgery (OS). Fifty-two patients had renal pelvic tumors, 48 had ureteral tumors, and six had both renal pelvic and ureteral tumors. Twenty-eight (26%) of the 106 patients had a pre-operative history of bladder cancer. We identified the risk factors predicting intravesical recurrence of upper urinary tract cancer according to the type of previous surgery using the Kaplan-Meier method, log-rank test, and univariate and multivariate analysis using the Cox proportional hazards model.

RESULTS

Thirty-one (29%) of the 106 patients developed bladder tumors post-operatively. The 2-year intravesical recurrence-free rate was 55% in the RN group and 60% in the OS group. There was no significant difference (P = 0.51, log-rank test) in the rate of intravesical recurrence between the two groups. Multivariate analysis identified only a history of pre-operative bladder tumor (HR = 3.25, P = 0.003) as a predictor of post-operative intravesical recurrence.

CONCLUSIONS

Intravesical recurrence after surgery for upper urinary tract cancer is not related to the mode of surgery (i.e. laparoscopy-assisted or open surgery) employed. The only risk factor for intravesical recurrence is a history of bladder cancer.

Oncological outcome of retroperitoneoscopic nephroureterectomy for upper urinary tract transitional cell carcinoma

OBJECTIVE

To report the oncological outcome of retroperitoneoscopic nephroureterectomy (RNU) with bladder cuff excision for upper urinary tract transitional cell carcinoma (TCC), and to compare the outcome with that of the traditional open nephroureterectomy (ONU).

PATIENTS AND METHODS

From January 2001, 48 patients with upper urinary tract TCC were enrolled in the study; 25 had RNU and 23 had ONU. Oncological parameters (disease-free survival and disease-specific survival) were calculated from the time of surgery to the date of last follow up and were analysed by the Kaplan-Meier method.

RESULTS

Mean follow up was 24.3 months in the RNU group, significantly shorter than in the ONU group. Bladder recurrence was identified in two patients with grade 3 pathological stage pT3, one patient with grade 3 stage pT2 disease and two patients with grade 2 stage pT2 disease. Multiple organ metastases in the lung, liver and lymph nodes were associated with bladder recurrence in two cases (grade 2 stage pT3, and grade 3 stage pT3). The recurrence rate was 20% (5 of 25 cases) and mean time to recurrence was 9.5 months. In the ONU group, bladder recurrence and metastases developed in four and three patients, respectively. The recurrence rate was 17% (4 of 23 cases) and mean time to recurrence was 23.4 months. No significant difference was detected in the disease-free survival rate and cancer-specific survival rate between the two groups (P=0.759 and P=0.866, respectively).

CONCLUSION

The oncological outcome of RNU appears to be equivalent to that of ONU. Moreover, long-term follow up is necessary to evaluate the oncological outcome in comparison to ONU.

Novel technique for management of distal ureter and en block resection of bladder cuff during hand-assisted laparoscopic nephroureterectomy

OBJECTIVES

To report our experience with a novel flexible cystoscopic approach to excise the en block bladder cuff and juxtavesical ureter during hand-assisted laparoscopic nephroureterectomy. The optimal technique for excising the distal ureter and bladder cuff during nephroureterectomy continues to evolve.

METHODS

Hand-assisted laparoscopic nephroureterectomy was performed in 6 patients. A hand-assist device and two 5 to 12-mm ports were placed in the mid and upper abdomen. Two 10-mm clips were placed on the proximal ureter to occlude it, and the kidney was resected in the usual fashion. An additional 5 to 12-mm port was placed in the midline between the umbilicus and symphysis pubis. The ureter was dissected down into the pelvis to the level of the bladder. Without repositioning the patient, a flexible cystoscope was inserted into the bladder and a 2-cm bladder cuff excised using a 5F electrode on cutting current, with coagulating current used as needed. The specimen was removed intact through the hand port.

RESULTS

The mean time to resect the distal bladder cuff was 30 minutes (range 22 to 35). The mean estimated blood loss was 254 mL. The mean operating room time was 264 minutes, mean hospital stay 6.3 days, and mean time to a general diet 2.6 days. All patients underwent cystography at 7 to 10 days postoperatively, with no extravasation or diverticula. Cystoscopic and computed tomography follow-up demonstrated no evidence of recurrence.

CONCLUSIONS

This technique allows for complete resection of the kidney, distal ureter, and a cuff of bladder, avoiding repositioning.