Endoscopic removal of lower ureter in nephroureterectomy

ENDOSCOPIC REMOVAL OF LOWER URETER IN NEPHROURETERECTOMY CESAR J. J. ERCOLE.

M.D.

From the Department of Urologic Surgery University of Minnesota Hospital Clinics, Minneapolis, and the Foley Urologic Department. St. Paul-Ramse) Medical Center. St. Paul, Minnesota

&

ABSTRACT-Endoscopic removal of the lower ureteral stump by transurethral re,yection of the mrcosal czifj and intussusception of the ureter is safe. effective. and relatively easy. Although the technique has been used primarily for malignant disease, the ca,w described herein illustrate that it also is useful for benign disease.

The treatment of choice for cancer of the upper ureter and renal pelvis is nephroureterectomy with removal of a bladder mucosa cuff. Two methods are in general use. In the more popular technique, one incision is made in the flank for the nephrectomy, and another incision is created in the suprapubic area for removal of the lower ureteral stump. The disadvantages of this method include the increased morbidit! of the second incision and the need for repositioning and redraping of the patient. The other method is a single, long incision from the costovertebral angle to the inguinal ring. In both methods it is difficult to expose the lower ureter. especiall>. in an obese patient with a deep pelvis. Several techniques have been described in an attempt to solve this problem; the most positive arc those that promote intussusception of the ureter into the bladder without extravesical dissection. A pioneer of this approach was McDonald,’ who in 1953 introduced a method for removing the lower ureteral stump endoscopically without the need for a second incision. The ureter is intussuscepted into the bladder, and the ureterovesical junction is resected transurethrally. Although this method does not reduce the anesthesia time, it avoids the morbid it)- from a second incision and the difficult extravesical dissection of the ureter with possible damage of the bladder neck mechanism or the \-as defer-ens. However. there vvere concerns that patients who undervvent this procedure would have an increased rate of bladder cancer recurrence or extravesical dissemination from spillage of urine at the time of surgery. Although there is considerable evidence that

such concerns are not warranted, a search of the published literature suggests that this technique has not been widely used, even in patients with benign disease. Based on our experience, w:e would like to review. the pitfalls of this technique and to give suggestions to improve its acceptance during a nephroureterectomy for upper ureteral or renal pelvic cancer. This technique also could be useful when performing nephroureterectomies for benign disease in adults and older children vvhose urethras are large enough to allow the safe passage of a resectoscope and the intussuscepted ureter. Material

and Methods

Six patients were treated with nephroureterectomy with endoscopic removal of the lower ureter from 1988 to 1992. Three women and one man were treated for renal pelvic cancer, and 2 patients were treated for renal atrophy and vesicoureteral reflux. All the patients who had cancer were followed up with cystoscopic examinations every three months. The patient is placed in the lithotomy position with the pelvis horizontal and 45” elevation of the chest on the side of the proposed nephroureterectom)-. If confirmatoq. ureteroscopy is necessary the chest is elevated after this examination is completed unless a flexible nephroscope is used. The ureter on the affected side is catheterized with a SF open-end catheter, the tip of vv,hich is left in the renal pelvis and the other end of which exits through the urethral meatus.

Resectoscope with Collings knife

Tent

ureteral

ular intact

surface

FIGURE1.

Transurethral

freed

incision of bladder

The bladder mucosa is endoscopically cut with the Collings knife 1 cm from the ureteral meatus without cutting the intramural ureter or the muscular layer of the bladder wall (Fig. 1). During this procedure, the ureteral catheter is kept in a position that tents the ureteral orifice to facilitate incision of the mucosa (Fig. 1A). Once the mucosa has been completely incised (Fig. lB), the bleeders are fulgurated, the endoscope is removed, and an 18F Foley catheter is inserted for bladder drainage. The ureteral catheter is then connected to a drainage bag. Once this first stage of the procedure is completed, the nephrectomy and lymphadenectomy are accomplished through a subcostal or flank incision that starts from the costovertebral angle in the eleventh intercostal space and follows the direction of the nerves obliquely into the flank toward the suprapubic region. This incision should be done as low as possible to allow exposure and resection of the ureter at the level of the iliac vessels. It also permits inspection for bleeders after the ureter is removed. The area around the ureter is covered with sponges moistened in water to prevent seeding, and the ureter is double-ligated and severed together with the ureteral catheter at the iliac vessel crossover. The edges are fulgurated. The upper ureter and the contents of Gerota’s fascia, including the kidneys, are then removed en bloc. The lymphadenectomy is done following the standard technique. The ureteral catheter in the distal stump is sutured to the ureter with a transfixion stitch of 2-O nylon.

50

.

SUPPLEMENT

_

mucosa

around

ureteral

orifice.

With continuous and gentle traction on the ureteral catheter end at the urethral meatus, the ureter intussuscepts into the bladder (Fig. 2). In the majority of patients, the ureter can be removed in one block without any additional endoscopic manipulation. When the ureteral meatus or the bladder

FIGURE 2. (A and B) Excision, stitching of ureter to catheter, and beginning of intussusception. (C and D) Completed intussusception.

TO UROLOGY

/ JANUARY

199.3 / VOI,UME

41, NUMBER

1

hiatus

is too small

cepted

ureter.

lated

to permit

the

to facilitate

\vith pelvih

this stage

for bleeders.

bleeding.

The

should

bladder

is completed.

In general.

before

is

11o

is irrigated drain usual

is performed

extra\,asation

the

there

retroperitoneurn

examination

for urinar\,

deep

is drained

the

is left in manner.

pelvis.

invasive

is rc’-

difficult

ciall!-

dissection

in patients

pronlpted deal

the

properly

lvith

dure

a deep

development with

For

and Sturdevant”

to detach

ureter

then

being the

scopic

remo\.al

susception

from

has to

stump

during

McDonald.

Up-

together

incision.

of the low.er ureter

kvith the

Lvith the kid-

Trarwesical

ureteral

and

proce-

the bladder.

\++thdrawm flank

of the

pelvis.

techniques

ureteral

example,

espe-

used a transurethral

the ureter

nc\’ through

ureter,

or obese

of other

the lovw

nephroureterectomy. church.

of the lower

stump

endob>, intus-

transurethral

resection

of the mucosal cuff has proved to be a safe. effective, rapid method that eliminates the additional

and

morbidit!-

of a second

b
having by t\vo

surgeon

suprapubic

Lvith the to redrape. surgeons

the other surgeon groups ha\re no\v twhniclrle

designed

This

Lvorking

does the initial

incision

patient

and

in one

can

position could

operation simultaneously:

endoscopic

be

one

procedure.

Lvhile

starts the nephrectomy. Several described their experience \vith

and

its \aariations,”

an intuss~weption

I’ and

catheter

Kayca”’ has

to facilitate

the

olv2ration. Contrary to early concerns. this operation has not an increase in the frequency of tumor recur-

caused

rence nor has it been associated with extravesical seeding of tumor.‘“’ In part. this good result ma!. be attributable drlrin,g trrovesical

to preservation

urcteral \,alve

excision. and

of the Lvhich

prevents

detrusor

preserves

gross

muscle the

ure-

extravasation.

As Ao\vn b!. the 2 cases described here. this method is also useful for patients \vith benign disease arlcl 111ay t)e particularly desirable in male children. l)ro\ided the urethra is large enough to allon. passage of the resectoscope

or the intussuscepted

ureter.

find

ment

of severe

renal

common

indication

This method cal dissection

resection.

is an!. disease come

ability

that

once

the proposed

tenting

were

a

o\wsewing

may

cxtravcsi-

of the ureteroves-

it awids

of thr> ~II-

the extensiw

damage

fixed.

ureter

technique process

that

and

lcss-

in the manage-

lvhich

and

‘I since

ma!.

the

es-

bladder

can be injured

is contraindicated in the

have

pelvis

caused

of the

more

reports

safety

it should

one-incision appear

previous

ureter

has increased

be more

\\idely

to

its

procc-

the desir-

nephronrrtcrectorn!..

attesting

to be-

in the presence

in the distal ureter.” on minimally invasive

cost containment

inadif there

or any the

It also is contraindicated

of malignant disease The present focus dures

of tllthis

mechanism. During tenting and tractrigonal mucosa through the ureteral

This

treatment

a place

than

the contralateral

\.ertentl!:

the in the

for nephroureterectomy.

is better

dissection

continues,

infections.

of the ureter.

cosa extravesicall\,.

hiatus.

States

may

fairly

of damaging of the ureter

use in the incidence

United

operation

neck closure tion of the

CoIIlIneIlt

the chances

the dissection

If its present in the

travesical

The

decrease during

ical junction,

to e\,aluate catheter

,11&d.

this

it lvould

vas deferens bcrculosis

profuscl! \vith Lvater, and a Penrose place. Thcb incision is closed in the C!3to~rapliic

be di-

days.

of the procedure

is checked

profuxc

The

for seven

since

of the intussrls-

ureter

passage.

a E‘ole!, catheter

Once

passage

intramural

success

As and

adopted.

The Foley Urologic L)epartment St. Paill-Han~sc~y Medical (Zentcr A40 Jackson Street 35101 St. PallI. hlinnesota References