Purse-string technique for laparoscopic excision of a bladder mucosal cuff in patients with transitional cell carcinoma of the upper urinary tract: initial report with intermediate follow-up

Effects of different combinations of radical nephroureterectomy and bladder cuff excision procedures for upper tract urothelial carcinoma on bladder recurrence

PURPOSE

To compare the effects of different combinations of radical nephroureterectomy (RNU) and bladder cuff excision (BCE) surgical procedures on intravesical recurrence (IVR) in patients with upper tract urothelial carcinoma (UTUC).

MATERIALS AND METHODS

This retrospective observational study included 452 patients who underwent RNU with BCE for UTUC between January 2010 and December 2020. The patients were classified into three groups based on different combinations of RNU and BCE surgical procedures: open RNU with open BCE (group 1, n=104), minimally invasive (MIS) RNU with open BCE (group 2, n=196), and MIS RNU with intracorporeal BCE (group 3, n=152). Data on demographics, body mass index, history, preoperative renal function, perioperative status, tumor characteristics, histopathology, and recurrence conditions were collected. Multivariate Cox regression analyses were performed to determine the impact of the surgical procedures on IVR. P-values < 0.05 were considered statistically significant.

RESULTS

After a median follow-up of 29.5 months, the IVR rate was 29.6% and the IVR-free survival rate was the lowest in group 2 (group 1 vs. group 2 vs. group 3: 69.0% vs. 55.1% vs. 67.5%; log-rank P=0.048). The overall survival rate was comparable among the three groups. Multivariate analysis revealed that group 2 had a significantly higher risk of IVR than group 1 (hazard ratio=1.949, 95% confidence interval=1.082-3.511, P=0.026), while groups 1 and 3 had similar risks.

CONCLUSIONS

For patients with UTUC, MIS RNU with open BCE is associated with a higher risk of IVR than open RNU with open BCE and MIS RNU with intracorporeal BCE.

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.

Supine extraperitoneal laparoscopic nephroureterectomy without patient repositioning

OBJECTIVE

To describe a novel technique allowing laparoscopic nephroureterectomy with bladder cuff excision and lymphadenectomy, in a complete supine position, without patient repositioning.

METHODS

Between January 2016 and October 2018, 20 consecutive patients with upper urinary tract urothelial carcinoma underwent supine extraperitoneal laparoscopic nephroureterectomy. The patients were placed in the complete supine position. A 4-cm pararectal skin incision was made and the extraperitoneal space was developed. We used a unique port placement that permits complete access for nephroureterectomy, bladder cuff excision and concomitant lymphadenectomy. Operative parameters and pathological data were analyzed.

RESULTS

The median age was 70 years (range 49-88 years), the mean operative time was 234 min (range 175-293 min) and the mean estimated blood loss was 67 mL (range 50-200 mL). There were no intraoperative complications, and no patients required transfusion or open conversion. The median number of removed lymph nodes was 10; only one patient had node metastasis. The total operative time and time for nephroureterectomy were significantly longer in the first 10 patients (first group) than in the second 10 patients (second group). Times required for bladder cuff excision and lymphadenectomy did not differ between the two groups.

CONCLUSIONS

Our novel technique, which enables completion of the entire procedure of nephrouretectomy with bladder cuff excision and lymphadenectomy in the supine position without patient repositioning, is safe and minimizes operative time while maintaining oncological efficacy. We believe this approach might become a standard option for patients with upper urinary tract urothelial carcinoma.

Initial experience of complete laparoscopic radical nephroureterectomy combined with transvesical laparoscopic excision of distal ureter in patients with upper urinary tract cancer

Background

Selecting the treatment procedure for cancer patients is a challenging task. We report our initial experience of complete laparoscopic radical nephroureterectomy (RNU) for patients with upper urinary tract urothelial cancer (UTUC).

Methods

A total of four patients with UTUC underwent complete laparoscopic RNU combined with transvesical laparoscopic excision of the distal ureter using three 5-mm ports. Transvaginal specimen extraction was applied in female patients to reduce incisional pain and improve cosmesis. Peri-operative complications were evaluated using the Clavien-Dindo classification system. Postoperative pain was evaluated during hospitalization using a numeric pain rating scale (scales of 1 to 10). Patients who underwent retroperitoneal laparoscopic surgery combined with open excision of the distal ureter during the same period were included as a control group (conventional RNU, consisting of laparoscopic nephrectomy combined with open bladder cuff excision) for pain scale evaluation.

Results

The novel surgery was successfully completed for all four patients (two males and two females). The mean pneumoperitoneum time for retroperitoneoscopic nephroureterectomy and specimen extraction was 174 min, while the mean pneumovesicum time for the ureteral orifice excision was 88 min. One male patient had bladder leakage at the suture site of the bladder wall, which lasted for 2 weeks. No patient experienced recurrent disease during the follow-up period (median, 10 months). Mild to moderate pain lasted for 5 or 6 days after RNU. A couple of days after surgery, the numeric pain rating scale of complete laparoscopic RNU and conventional RNU group reached its peak level at 3.0 ± 1.8 and 5.3 ± 2.8, respectively. There was no statistical difference in the degree of postoperative pain (P = 0.31).

Conclusions

We described our initial experience and outcome of complete laparoscopic RNU for UTUC. Further experience and research are required to determine whether this advanced laparoscopic technique yields better outcomes and has true clinical value.

Pure retroperitoneoscopic extravesical standardized seeable (PRESS) excision of distal ureter and bladder cuff in radical nephroureterectomy: step-by-step technique

BACKGROUND

Concerns have been raised regarding the management of bladder cuff with these minimally invasive approaches. The aim of this study was to describe a modified radical nephroureterectomy (RNU) with pure retroperitoneoscopic extravesical standardized seeable (PRESS) bladder cuff excision (BCE) and to assess its outcomes based on a novel concept of intraoperative "trifecta."

METHODS

Twenty-four patients with upper urinary tract urothelial carcinoma underwent retroperitoneoscopic RNU from August 2017 to August 2019. A modified RNU with PRESS BCE and lymph node dissection (LND) was performed. Descriptive analysis of patients' characteristics, surgical technique, perioperative outcomes, and follow-up data was performed. BCE trifecta was defined as en-bloc excision, mucosa-to-mucosa reliable closure and no urine spillage.

RESULTS

In 23 out of 24 cases (95.8%) the procedure was successfully completed. One patient was converted to open distal ureterectomy with a Gibson incision due to peritoneum rupture during dissection of the distal ureter. BCE trifecta was achieved in 95.7% (22/23) cases of all patients finished with PRESS technique. Median OT was 260 min (IQR: 220-305) with median EBL of 100 mL (IQR: 100-250). Median OT for distal ureterectomy was 52 min (IQR: 40-69). No positive surgical margin occurred. Median postoperative hospital stay was 6 d (IQR: 5-7). Median follow-up time was 7 mo (IQR: 5-17). One patient (4.3%) experienced bladder recurrence and no patient developed distant metastasis or died of the disease.

CONCLUSIONS

Herein, we demonstrate a standardized retroperitoneoscopic RNU technique that is safe and reproducible, enabling the visual confirmation of complete BCE and facilitating LND. BCE trifecta should be a routine goal in minimally invasive RNU. Prospective comparison with the standard open surgical technique is warranted.

Distal Ureter Management During Nephroureterectomy: Evidence from a Systematic Review and Cumulative Analysis

INTRODUCTION AND OBJECTIVES

Standard of care in upper tract urothelial cancer is nephroureterectomy with bladder cuff excision (BCE). However, alternative techniques such as transurethral incision/resection have been used to simplify distal ureterectomy. The optimum strategy is unclear, and current guidelines do not specify a gold standard technique. The objective of this study was to perform a systematic review of the literature, to compare BCE and transurethral distal ureter methods.

MATERIALS AND METHODS

A Cochrane and PRISMA-guided systematic literature search was conducted on English language articles from January 2000 to present, reporting on centers' experience with either BCE or transurethral distal ureterectomy. A cumulative meta-analysis comparison between the two procedures was performed. Primary outcome was intravesical recurrence. Secondary outcomes were local/distant recurrence, surgical margins, and disease-specific mortality (DSM). Groups were compared using chi-square analysis.

RESULTS

In total, 66 studies were included after excluding 1795. BCE and transurethral groups contained 6130 and 1183 patients, respectively. Mean/median age ranged from 57.5 to 75.2 years, and follow-up from 6.1 to 78 months. Level of evidence was low, with high risk of bias and small sample size (<100 patients) in 41 (62%) and 52 (79%) studies, respectively. Baseline cancer demographic analysis identified significantly higher rates of high grade, advanced stage, node-positive and carcinoma in situ disease in the BCE group. However, intravesical recurrence (23.6% vs 28.7%, p = 0.0002) and local/distant recurrence (17.9% vs 21.6%, p = 0.02) were significantly lower than the transurethral group. No difference was seen regarding surgical margins (3.1% vs 2.4%, p = 0.27) or DSM (16.8% vs 14.3%, p = 0.06).

CONCLUSIONS

No prospective, randomized comparisons exist for distal ureterectomy at nephroureterectomy. In this analysis, patients undergoing BCE had more advanced disease burden compared with the transurethral group. Despite this, the BCE group had statistically lower intravesical and local/distant recurrence. Further prospective research should be encouraged to identify gold standard ureter management.

Laparascopic nephrectomy: different techniques and approaches

Nephrectomy is, perhaps, one of the techniques in which laparoscopic approach has been widely used. It has quickly evolved since Clayman introduced it in 1990 with a renal tumor. Since then, its goodness has been extrapolated to most entities that require surgical removal of the kidney. We review the current most discussed aspects referred to the main laparoscopic nephrectomy techniques (simple nephrectomy, nephroureterectomy, radical, and nephron-sparing nephrectomy) and particularities of this approach.

Complete laparoscopic nephroureterectomy with intravesical lockable clip

Introduction

We present a cohort of patients with low-stage pelviureteric neoplastic disease who underwent complete laparoscopic nephroureterectomy (CLNUE) with intravesical lockable clip (IVLC). Due to the absence of a standard technique of NUE, the study was not randomized.

Materials

From 1/2010 to 1/2012, 21 patients were subjected to CLNUE-IVLC. The first step was transurethral excision of the ureterovesical junction with Collin's knife deep into the paravesical adipose tissue. The ureter was grasped with biopsy forceps and the distal end of the ureter was occluded with lockable clip. The applicator was introduced through a 5 mm port inserted as an epicystostomy. The patients were rotated to flank position and CLNUE followed. The endoscopically introduced clip on the distal ureter is proof of completion of the total ureterectomy.

Results

The mean operation time was 161 (115-200) min. In four (19.0%), the application of the clip failed and CLNUE was completed with non-occluded ureter. In three cases, subsequent laparoscopic nephrectomy was converted to open surgery. In two cases, the distal ureterectomy was completed with pluck technique through a lower abdominal incision that was also used for extraction of the specimen. There were four complications (Clavien II 2x, IIIb, V). Follow-up was available for all – mean 10.6 (range: 0-25) months. One died of disease generalization within 11 months.

Conclusion

CLNUE-IVLC is fast and safe. If needed, the endoscopic phase can be switched to open NUE. Disadvantages include: the need to change the position of the patient, the risk of inability to apply the clip on the distal ureter, and the risk of an unclosed defect of the urinary bladder.

Laparoendoscopic Single-Site (LESS) Nephroureterectomy and En Bloc Resection of Bladder Cuff With a Novel Extravesical Endoloop Technique

Objective: To present the initial experience of laparoendoscopic single-site (LESS) nephroureterectomy via the transperitoneal approach using the Alexis wound retractor and bladder cuff resection by endoloop. Methods: Two patients received LESS nephroureterectomies and bladder cuffs resection with homemade single ports, which were created by using an Alexis wound retractor as an access platform through a 4-cm incision. Distal ureters were resected through the same incision with endoloop. No additional ports were used and both procedures were completed successfully. Results: Both LESS procedures were completed successfully without traditional laparoscopic conversion or complication. LESS nephreoureterectomy with bladder cuff excision was performed in 165 and 325 minutes with estimated blood loss of 30 and 65 mL, respectively. Patients were discharged on postoperative days 3 and 7, respectively. Conclusions: The initial results demonstrated that LESS technique of nephroureterectomy and bladder cuff resection with endoloop is a safe and feasible procedure for urothelial carcinoma of upper urinary tract.

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.