Retroperitoneoscopy-assisted nephroureterectomy for the management of upper urinary urothelial cancer

Follow-up results of a pure retroperitoneoscopic/extraperitoneal nephroureterectomy for upper tract urothelial tumors

We present the results of a pure retroperitoneoscopic/ extraperitoneal nephroureterectomy (RENU) for upper urinary tract transitional cell cancer (UT-TCC). After establishment of RENU in benign indications (n=21 Patients), 14 patients (age range 51-92 years, mean 71.6) with UT-TCC have undergone the technique in our clinic from October 2005 to October 2008. This paper reports the operative procedure, clinical results and follow up. Total operative time was 110-240 minutes (median 154.5). Average blood loss was 132 mL. Tumor localization in oncology patients was renal pelvis (63.6%), ureter (18.2%) or both (18.2%). Postoperative tumor stages were Ta (n=2), Tis (n=2), T1 (n=3), T2 (n=3) and T3 (n=4) without lymph node involvement. No perioperative complications were observed. Urethral catheters were removed on Day 6-8 post surgery (median Day 7). Recovery to normal life activity ranged from 8 to 30 days (mean 17.8). During the 4-36 month (median 23) follow-up period, there was one mortality due to cancer progression. Four patients had developed superficial bladder cancer disease requiring regular cystoscopic resections. One patient had coincidental Bellini duct renal tumor and developed psoas metastasis after eight months. The 2-year tumor specific survival rate is 91%. The retroperitoneoscopic/ extraperitoneal nephroureterectomy is a lowrisk and minimally invasive procedure to be used whenever nephroureterectomy is indicated. It is an attractive alternative to both laparoscopic and open techniques and adheres to the oncological principles of radical nephroureterectomy. Short-term follow-up data showed no increased risk of tumor recurrence. However, long-term results are needed before this technique can be established as standard UT-TCC therapy.

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.

Is carbon dioxide insufflation safe for laparoscopic surgery? A model to assess the effects of carbon dioxide on transitional-cell carcinoma growth, apoptosis, and necrosis

PURPOSE

To study the effects of carbon dioxide insufflation pressure and concentration on the adhesion, growth, apoptosis, and necrosis of transitional-cell carcinoma (TCC).

MATERIALS AND METHODS

Adhesion and growth of the AY-27 rat TCC cell line was measured after CO2 insufflation in vitro at different pressures ranging from 0 to 15 mm Hg and after incubation in CO2-air mixtures at 5%, 10%, and 15% CO2 by volume.

RESULTS

Tumor adhesion decreased significantly after CO2 insufflation. For all insufflation pressures, there was an increase in cell growth, apoptosis, and necrosis for the first 24 hours followed by a steady decline. High concentrations of CO2 (>5%) inhibited cell growth for only the first 48 hours. The effects of CO2 pneumoperitoneum on tumor-cell adhesion, growth inhibition, apoptosis, and necrosis were more prominent at high CO2 pressure (> or =15 mm Hg) and concentration (>5% CO2). However, insufflation pressure had a greater inhibitory effect on tumor growth than did CO2 concentration. High insufflation pressures and CO2 concentrations significantly decreased extracellular pH.

CONCLUSION

The short-term effect of CO2 on TCC growth and apoptosis is complex. Overall, CO2 has a toxic effect on TCC and inhibits cell adhesion and growth. High CO2 concentrations (>5%) and high insufflation pressures (> or =15 mm Hg) are most effective in decreasing tumor-cell adhesion and growth.

Robotic assisted retroperitoneoscopic nephroureterectomy -- first experience and the hybrid port technique

Robot-assisted renal surgery is usually performed transperitoneally due to more available space for excursion of the robotic arms. To our knowledge, we report the first experience with robotic retroperitoneoscopic nephroureterectomy using the Da Vinci Surgical System (Intuitive Surgical, Sunnyvale, CA, USA) and a hybrid port technique. Robotic retroperitoneal nephroureterectomy was performed on two male patients. One 37-year-old patient had a painful non-functioning hydronephrotic left kidney and megaureter; the other aged 76 had a muscle invasive lower left ureteric tumour. Both the procedures were successfully completed with the robot without conversion. Mean operative time was 182.5 min and estimated blood loss 75 ml. Histological examination confirmed the preoperative diagnoses; margins were clear in the patient with tumour. Postoperative recovery was uneventful. We report the technical feasibility of robotic retroperitoneoscopic nephroureterectomy. However, as with all new technology, the benefits need to be further evaluated and proven before this technique can be widely accepted.

Hand-assisted retroperitoneoscopic nephroureterectomy without hand-assisted device

Various laparoscopic nephroureterectomy techniques for urothelial carcinoma of the upper urinary tract have been developed to minimize postoperative discomfort and the necessity for a lengthy convalescence. We performed hand-assisted retroperitoneoscopic nephroureterectomy without hand-assisted device in 3 male patients with urothelial carcinoma of the distal ureter. Average operative time and estimated blood loss were 251 min (range 235 to 280) and 250 mL (range 200 to 300), respectively. Complication did not occur and conversion to open surgery was not necessary in all cases. Postoperative analgesic requirements were moderate and the time to regular diet intake averaged 3 days (range 2 to 4). None of the patients had a positive margin on the final pathologic specimen. At the average follow-up of 8.1 months, no regional recurrence, port-site metastasis, bladder recurrence, or distant metastasis were noted in any patient. We described our initial experience with the described technique, which obviates the need for midprocedural patient repositioning.

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.

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.

A comparison of the clinical outcome between open and hand-assisted laparoscopic nephroureterectomy for upper urinary tract transitional cell carcinoma

OBJECTIVE

To report the surgical outcome of retroperitoneoscopic hand-assisted laparoscopic nephroureterectomy (LNU) with bladder cuff excision for upper urinary tract transitional cell carcinoma (TCC), and to compare the outcome with that of the open procedure (ONU).

PATIENTS AND METHODS

From January 1998 to January 2003, 145 patients with upper urinary tract TCC were enrolled in the study; 87 had ONU and 58 retroperitoneoscopic hand-assisted LNU. The specimens were reviewed by experienced pathologists to confirm the pathological stage. Operative duration, intraoperative blood loss, bowel recovery, analgesic use, hospital stay and time to convalescence were compared for both groups. The Mann-Whitney U-test and Fisher's exact test were used for statistical analysis. RESULTS The mean follow-up for ONU and LNU was 35.1 and 16.0 months, the mean operative duration 230.2 and 259.1 min (P = 0.006), the mean blood loss 747.3 and 408.9 mL (P < 0.001), the mean duration of Foley catheterization 6.8 and 5.1 days (P < 0.001), and the hospital stay 12.6 and 9.3 days (P < 0.001). The bladder recurrence rate 2 years after surgery was 9.1% for ONU and 8.6% for LNU (P = 0.23); the local recurrence rate during the follow-up was 3.4% and none, respectively (P = 0.35).

CONCLUSION

Although LNU took longer than ONU the intraoperative bleeding and hospital stay were better than for ONU. Both procedures have statistically comparable bladder recurrence and local recurrence rates.

Hand assisted retroperitoneoscopic nephroureterectomy: comparison with the open procedure

PURPOSE

We report our initial experience with hand assisted retroperitoneoscopic nephroureterectomy for upper urinary tract transitional cell carcinoma and compared our results to those of a contemporary series of open nephroureterectomy.

MATERIALS AND METHODS

Clinical data on 34 consecutive patients who underwent hand assisted retroperitoneoscopic nephroureterectomy were reviewed and compared with those on 34 who underwent open nephroureterectomy. All specimens were extracted intact.

RESULTS

Total operative time was similar in the 2 groups (233 versus 236 minutes). Estimated blood loss was significantly less in the hand assisted laparoscopy group (236 versus 427 ml.). During convalescence the frequency of parenteral analgesia postoperatively was significantly lower in the laparoscopy group than in the open surgery group. The former patients had a significantly shorter interval to oral intake and ambulation as well as a shorter hospital stay and convalescence compared with those who underwent open surgery. In each group the complication rate was 12% (4 of 34 cases). In the hand assisted laparoscopy group 1 conversion to an open procedure was due to bleeding. There was recurrence in 4 of the 34 patients (12%) in the laparoscopy group, including 2 with bladder recurrence and 2 with metastases, at an average followup of 13.1 months.

CONCLUSIONS

Hand assisted retroperitoneoscopic nephroureterectomy is an effective and safe alternative to open nephroureterectomy for upper urinary tract transitional cell carcinoma.

Retroperitoneoscopy-assisted total nephroureterectomy for upper urinary tract transitional cell carcinoma

OBJECTIVES

To apply retroperitoneoscopy-assisted nephroureterectomy (RTN) and examine its benefit compared with traditional open nephroureterectomy. The reference standard of treatment for upper urinary tract transitional cell carcinoma is standard total nephroureterectomy (STN) with excision of a bladder cuff.

METHODS

Retroperitoneoscopic radical nephrectomy was performed, followed by open distal ureterectomy with excision of a bladder cuff. The specimen was removed en bloc from the lower pararectal incision that was used during distal ureterectomy. From January 1999, 17 patients with upper urinary tract transitional cell carcinoma underwent this procedure at our institution. For comparison, the most recent 17 STNs were also reviewed.

RESULTS

The operative time was longer in the RTN group than in the STN group but not to a significant extent (239.5 versus 286.8 minutes; P = 0.2663). On the other hand, the estimated blood loss, duration to potential discharge, and recovery to normal activities were significantly reduced in the RTN group (151.1 versus 299.6 minutes, 2.7 versus 4.2 days, and 15.9 versus 19.3 days; P = 0.0262, 0.0479, and 0.0363, respectively). From an oncologic standpoint, local recurrence occurred in 1 patient of the RTN group and 4 patients of the STN group (median follow-up of 8.8 and 23.0 months, respectively). No significant difference was detected in the disease-free survival rate between the two groups (P = 0.6775).

CONCLUSIONS

RTN can make total nephroureterectomy less invasive. From an oncologic standpoint, although it revealed a disease-free survival rate comparable with the standard open procedure with limited follow-up, further follow-up of additional cases with simultaneous extended lymphadenectomy is necessary to evaluate the effectiveness of this procedure.

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

Objectives. To report a modified approach for hand-assisted laparoscopic nephroureterectomy (HALNU).Methods. Seven patients with localized transitional cell carcinoma of the upper urinary tract underwent unilateral HALNU. Patients were placed in a 60 degrees oblique position during the entire procedure. Via a 7-cm Gibson incision on the lesion side, the distal ureterectomy and bladder cuff excision were done by an open method without opening the bladder. Then, with the surgeon's hand inserted into the peritoneal cavity by way of the same wound, HALNU was performed with two to three additional laparoscopic ports. The perioperative parameters were compared with those of 15 cases of conventional open nephroureterectomy.Results. Patients in the HALNU group had significantly less mean blood loss (140 versus 455 mL) and earlier resumption of oral intake (33 versus 61 hours), required fewer narcotics (38 versus 70 mg of morphine sulfate equivalent), and were discharged earlier (7.33 versus 9.1 days), with a faster convalescence to normal activity (3.7 versus 5.6 weeks; all P < 0.05). The total mean surgical time was 3.7 hours for the HALNU group.Conclusions. Our approach used the same incision to both excise the distal ureter and apply the hand-assist device. It also preserved the benefits of the minimal invasiveness of laparoscopic surgery compared with its open counterpart.

Retroperitoneal laparoscopic nephroureterectomy and management options for the distal ureter

Radical nephroureterectomy, including en bloc excision of the ureter with a bladder cuff, is the standard treatment for upper tract transitional-cell carcinoma (TCC). This procedure requires either a flank and lower abdominal incision or an extended flank incision. Laparoscopic surgery for TCC has been used at several medical centers; the most challenging and controversial aspect is the oncologically correct management of the distal ureter. We believe that the Cleveland Clinic technique of securing the distal bladder cuff intravesically while simultaneously occluding the distal ureter prevents tumor spillage and allows accurate and complete resection of the targeted ureter in a manner mirroring the open procedure.

Gasless, hand-assisted retroperitoneoscopic nephroureterectomy for urothelial cancer of the upper urinary tract

We report our initial experiences with gasless, hand-assisted retroperitoneoscopic nephroureterectomy for the treatment of urothelial cancer of the upper urinary tract. One hand was inserted by way of the small incision made in the lower abdomen. This method provides easy maneuverability and an acceptable operative time without opening the upper urinary tract.