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Novel technique for management of distal ureter and en block resection of bladder cuff during hand-assisted laparoscopic nephroureterectomy
ADULT UROLOGY
NOVEL TECHNIQUE FOR MANAGEMENT OF DISTAL URETER AND EN BLOCK RESECTION OF BLADDER CUFF DURING HAND-ASSISTED LAPAROSCOPIC NEPHROURETERECTOMY ITAY Y. VARDI, JEFFREY A. STERN, CHRIS M. GONZALEZ, SIMON Y. KIMM, AND ROBERT B. NADLER
ABSTRACT 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. UROLOGY 67: 89–92, 2006. © 2006 Elsevier Inc.
M
anagement of the distal ureter during laparoscopic nephroureterectomy continues to be an area of indecision in urology.1 The nephrectomy portion of laparoscopic nephroureterectomy is well established,2 with dissection by way of a hand-assisted,3–5 transperitoneal,2 or retroperitoneal approach.6,7 Intact specimen extraction with the entire ureter and a cuff of bladder is also well established. However, the approach and management of the distal ureter continues to evolve, with each method having distinct benefits and shortFrom the Department of Urology, Northwestern University Feinberg School of Medicine, Chicago, Illinois Reprint requests: Robert B. Nadler, M.D., Department of Urology, Section of Endourology, Laparoscopy, and Stone Disease, Northwestern University Feinberg School of Medicine, 675 North St. Clair Street, Galter 20-150, Chicago, IL 60611. E-mail: [email protected] Submitted: February 15, 2005, accepted (with revisions): July 27, 2005 © 2006 ELSEVIER INC. ALL RIGHTS RESERVED
comings. Initial reports8 used a laparoscopic GIA stapling device transperitoneally, after cystoscopic transurethral incision of ureteral orifice and ureteral tunnel, followed by placement of a ureteral occlusion balloon. With time, several methods to incise the distal ureter and bladder cuff have been used, including transurethral Collins knife incision,9 transvesical laparoscopic detachment and ligation,1 laparoscopic stapling of the distal ureter and bladder cuff,8 the pluck technique,10 and an open approach.11 The principles of surgical oncology dictate that complete “en block” ureteral resection with avoidance of tumor seeding is the preferred method of treating all upper tract urothelial cancers.12,13 We report our experience with a novel flexible cystoscopic approach to excise the distal ureter and bladder cuff. Our technique to excise a cuff of bladder and the distal ureter uses the flexi0090-4295/06/$32.00 doi:10.1016/j.urology.2005.07.053 89
FIGURE 1. Patient placement for right-sided combined hand-assisted nephroureterectomy and bladder cuff resection.
ble cystoscope and is done at the end of the case without patient repositioning. We report our experience with this new technique in 6 patients. MATERIAL AND METHODS Since May 2001, after institutional review board approval and informed consent from the patients, 6 patients have undergone laparoscopic transperitoneal hand-assisted nephroureterectomy using this technique. Five patients had upper tract transitional cell carcinoma and one had long-standing hydroureteronephrosis with a nonfunctioning kidney. The average patient age was 61.3 years, and the male/female ratio was 1:1.
TECHNIQUE Imaging studies and office flexible cystoscopy were performed before the operation to rule out coexisting bladder and lower ureteral tumors. After the patient provided informed consent, a general anesthetic was given. The patient was placed in the lateral decubitus position with the hips at a 45° angle on a foam wedge and the legs supported by spreader bars (Fig. 1). A urethral catheter was inserted and connected to a drainage bag. The pressure points were padded. The ipsilateral arm was raised and suspended in an internally rotated position. A 6 to 8-cm midline periumbilical skin incision was made, and the peritoneum was entered. A hand port was placed and pneumoperitoneum obtained using carbon dioxide. Three 5 to 12-mm trocars were inserted under direct laparoscopic vision (Fig. 2): one lateral port at the right anterior axillary line at the level of the umbilicus, one in the midline between the umbilicus and the xiphoid process. All our cases were right sided, but patient positioning and port placement would be a mirror image for left-sided cases. Transperitoneal hand-assisted laparoscopic nephrectomy was performed.3,5,14 We prefer to place the nondominant hand through the hand port, but that is up to the operating surgeon. First, the line of Toldt was incised and the colon reflected medially, the ureter was identified over the psoas muscle, and two 10-mm clips were placed on the proximal ureter to avoid distal migration of tumor cells. The kidney was dissected free from its surrounding tissues, and the renal artery and vein were then identified, ligated, and divided using a 10-mm Weck clip or vascular Endo-GIA stapler. The kidney was then mobilized with blunt and sharp dissection. Next, the ureter was laparoscopically mobilized over the common iliac vessels toward its insertion in the bladder. A third 12-mm port in the inferior umbilical midline may be necessary to aid with this dissection. Once the kidney and ureter have been freed down to the bladder wall, a 15F flexible cystoscope was inserted into the bladder per urethra using sterile water for irrigation. A 5F electrode (ACMI, Norwalk, Conn) was used to incise a cir90
FIGURE 2. Right-sided nephroureterectomy: placement of umbilical hand port and trocars.
cumferential 2-cm cuff of bladder around the ureteral orifice using cutting and coagulating current. The surgeon’s hand allows excellent manipulation of the ureter and periureteral tissues and provides a means for blunt dissection. The surgeon’s finger also prevents extravasation of fluid from the bladder during cystoscopic ureteral dissection. The nephroureterectomy specimen was removed gently through the abdominal port and extracted intact. We did not use a ureteral stent in our procedure, because it could facilitate efflux of tumor cells and cause edema around the ureteral orifice, making ureteral dissection more difficult. A Jackson-Pratt drain was left adjacent to the bladder to drain the pelvis. We routinely did not close the bladder, and a 20F urethral catheter attached to a drainage bag was left for 1 week. At 7 to 10 days, all the patients underwent cystography, which confirmed no extravasation of urine or diverticula of the bladder wall before catheter removal. Cystoscopic examination every 3 months and upper tract and pelvic imaging with triphasic computed tomography every 6 months were done to rule out tumor recurrence.
RESULTS We have used this technique in 6 consecutive cases of hand-assisted laparoscopic nephroureterectomy. We used this technique for a pure laparoscopic transperitoneal approach for benign disease, but not a retroperitoneal case, although it should be possible. The mean time to resect the distal bladder cuff was 30 minutes (range 22 to 35). The mean surgical time for the complete procedure was 264 minutes (4.4 hours). The mean estimated blood loss during the operation was 254 mL. The mean time to a general diet was 2.6 days. The Jackson-Pratt drain was removed on postoperative day 2 or 3. The mean hospital stay was 6.3 days (range 3 to 10). The urethral catheter was left for 7 to 10 days, and cystography confirmed the absence of extravasation in all cases. The final pathologic examination showed the bladder cuff and ureteral margins UROLOGY 67 (1), 2006
to be negative for cancer in all cases. The mean follow-up time was 31 months (range 5 to 44) and consisted of bladder cystoscopy and computed tomography. One patient, a 70-year-old man, had deep vein thrombosis and pulmonary emboli on postoperative day 4. A second patient had two recurrences of transitional cell carcinoma of the bladder. The first recurrence was 1 year after the procedure (Stage Ta, grade 2) and the second recurrence 3 years after the procedure (Stage Ta, grade 3), both were on the left bladder wall, away from the resected (right) ureteral orifice. COMMENT Nephroureterectomy has become the reference standard treatment for upper urinary tract transitional cell carcinoma. The problem urologists have encountered has been in adhering to the basic oncologic principles of en bloc excision of the ureter with a distal cuff of bladder while maintaining a minimally invasive approach. The original description of laparoscopic nephroureterectomy by Clayman et al.8 used a laparoscopic GIA stapling device transperitoneally, after cystoscopic transurethral incision of ureteral orifice and ureteral tunnel, followed by placement of a ureteral occlusion balloon. Many other approaches have been advocated for managing the distal ureter.1 An open approach through a low-midline or Gibson incision has been recommended, with the distal ureter and cuff of bladder dissected out en bloc through a transvesical incision.11 Pure laparoscopic techniques such as the ureteral pluck technique do not allow for early clipping of the ureter to prevent tumor cells seeding into the retrovesical space. Gill et al.9,15 described an endoscopic technique in which the ureter is dissected out at the start of the case and closed with an Endoloop to prevent tumor cell seeding. The disadvantage of these endoscopic techniques is that the patient has to be positioned in the dorsal lithotomy position at the beginning of the case, and, after dissection of the distal ureter, they must be repositioned for the laparoscopic approach. Not only is this time-consuming, but if the patient experiences an adverse event, necessitating early cessation of surgery, such as intraoperative myocardial infarction, the surgeon must still remove the functioning kidney in an unstable patient with a nondetached ureter. We chose not to close the bladder in our flexible cystoscopic technique; thus, the theoretical risk of tumor seeding of the retroperitoneum that exists in other techniques also exists in ours.1,13 However, because we use the hand-assisted approach, closing the bladder wall transperitoneally is simple and accessible. UROLOGY 67 (1), 2006
Earlier we described another technique using a laparoscopic port placed through the bladder, allowing a resectoscope to then be inserted transvesically to dissect the distal ureter.16 This technique allows the distal ureter to be managed at the end of the case without repositioning. It takes advantage of the use of the hand for assistance in manipulating the distal ureter and uses rigid instruments, which are easily manipulated and familiar to all urologists. The disadvantage is the additional 12-mm port that must be placed through the bladder with the potential complications of tumor cell seeding through the bladder into the abdominal cavity. Others have advocated stapling the distal ureter from an antegrade laparoscopic approach with an Endo-GIA stapler under cystoscopic surveillance. The problem with this approach is that a small amount of transitional cells are sequestered between the staple lines in a location that is unable to be visually inspected cystoscopically and, therefore, could develop into transitional cell cancer at a later date. Our technique, similar to that of Gonzalez et al.16 and Wong and Leveillee,4 does not require repositioning. Furthermore, positioning the patient on spreader bars with the pelvis tilted at a 30° to 45° angle is a much gentler position than dorsal lithotomy for the patient to be in throughout the length of the procedure and therefore has less potential for peroneal nerve injury or musculoskeletal injury. By using the flexible cystoscope, the distal ureter can be easily visualized in both men and women. Furthermore, our technique allows the kidney to be managed initially, so should the patient experience an adverse event during the operation, the kidney itself may be removed and the distal ureter managed at a later time. Because we open the bladder after freeing up the kidney and ureter, irrigation fluid and urine from the open bladder does not interfere with visualization of the ureter and kidney. Our technique takes advantage of the surgeon’s hand when used with a hand-assisted approach to manipulate the bladder trigone, aiding in circumferential incision of the ureteral cuff; blunt digital dissection also helps to free up the distal ureter. Although we did not choose to close the bladder in any of our cases, it would be possible to suture the opening at the level of the ureteral orifice closed should the surgeon desire. Obviously, our approach has shortcomings. The first is that flexible cystoscopic resection of the distal ureter is more technically demanding than that done with rigid instruments. However, we found that the flexible cystoscope has excellent deflection and a more than adequate working channel to allow circumferential dissection of the distal ureter in approximately 30 minutes, even in the hands of resident urologists. In addition to the technical dif91
ficulty of this flexible endoscopic maneuver, another obvious shortcoming is that we chose to leave the bladder cuff open. Theoretically, this could cause tumor seeding into the retroperitoneum and/or abdominal cavity. We have not found this to be the case in our patients who were closely followed up for an average of 31 months (range 5 to 44). Furthermore, retroperitoneal or abdominal seeding has not been reported in other laparoscopic series. We do advocate clipping the ureter early in this case to prevent downstream tumor cell seeding into the bladder, as well as irrigating the bladder several times with sterile water and working with sterile water during the endoscopic dissection portion of the case. We acknowledge that 6 patients was a small group; nevertheless, the technique was successful in all, as we presented. CONCLUSIONS We believe our flexible cystoscopic technique of distal ureteral management during hand-assisted laparoscopic nephroureterectomy has many advantages. It does not require repositioning, it uses a 15F flexible cystoscope and 5F electrode (familiar to all urologists), and allows for complete resection of the ureter and a cuff of bladder at the end of laparoscopic nephroureterectomy. REFERENCES 1. Steinberg JR, and Matin SF: Laparoscopic radical nephroureterectomy: dilemma of the distal ureter. Curr Opin Urol 14: 61– 65, 2004. 2. McDougall EM, Clayman RV, and Elashry O: Laparoscopic nephroureterectomy for upper tract transitional cell cancer: the Washington University experience. J Urol 154: 975–980, 1995. 3. Stifelman MD, Sosa RE, Andrade A, et al: Hand-assisted laparoscopic nephroureterectomy for the treatment of transi-
92
tional cell carcinoma of the upper urinary tract. Urology 56: 741–747, 2000. 4. Wong C, and Leveillee RJ: Hand-assisted laparoscopic nephroureterectomy with cystoscopic en bloc excision of the distal ureter and bladder cuff. J Endourol 16: 329 –333, 2002. 5. McGinnis DE, Trabulsi EJ, Gomella LG, et al: Handassisted laparoscopic nephroureterectomy: description of technique. Tech Urol 7: 7–11, 2001. 6. Savage SJ, and Gill IS: Laparoscopic radical nephroureterectomy. J Endourol 14: 859 – 864, 2000. 7. Gill IS, Sung GT, Hobart MG, et al: Laparoscopic radical nephroureterectomy for upper tract transitional cell carcinoma: the Cleveland Clinic experience. J Urol 164: 1513–1522, 2000. 8. Clayman RV, Kavoussi LR, Figenshau RS, et al: Laparoscopic nephroureterectomy: initial clinical case report. J Laparoendosc Surg 1: 343–349, 1991. 9. Gill IS, Soble JJ, Miller SD, et al: A novel technique for management of the en bloc bladder cuff and distal ureter during laparoscopic nephroureterectomy. J Urol 161: 430 – 434, 1999. 10. Giovansili B, Peyromaure M, Saighi D, et al: Stripping technique for endoscopic management of distal ureter during nephroureterectomy: experience of 32 procedures. Urology 64: 448 – 452, 2004. 11. Hsu TH, and Hsu S: A novel open surgical approach to transvesical distal ureterectomy in nephroureterectomy. Int Urol Nephrol 36: 155–157, 2004. 12. Klingler HC, Lodde M, Pycha A, et al: Modified laparoscopic nephroureterectomy for treatment of upper urinary tract transitional cell cancer is not associated with an increased risk of tumour recurrence. Eur Urol 44: 442– 447, 2003. 13. McNeill A, Oakley N, Tolley DA, et al: Laparoscopic nephroureterectomy for upper tract transitional cell carcinoma: a critical appraisal. BJU Int 94: 259 –263, 2004. 14. Shalhav AL, Elbahnasy AM, McDougall EM, et al: Laparoscopic nephroureterectomy for upper tract transitional-cell cancer: technical aspects. J Endourol 12: 345–353, 1998. 15. Gill IS: Needlescopic urology: current status. Urol Clin North Am 28: 71– 83, 2001. 16. Gonzalez CM, Batler RA, Schoor RA, et al: A novel endoscopic approach towards resection of the distal ureter with surrounding bladder cuff during hand assisted laparoscopic nephroureterectomy. J Urol 165: 483– 485, 2001.
UROLOGY 67 (1), 2006
NOVEL TECHNIQUE FOR MANAGEMENT OF DISTAL URETER AND EN BLOCK RESECTION OF BLADDER CUFF DURING HAND-ASSISTED LAPAROSCOPIC NEPHROURETERECTOMY ITAY Y. VARDI, JEFFREY A. STERN, CHRIS M. GONZALEZ, SIMON Y. KIMM, AND ROBERT B. NADLER
ABSTRACT 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. UROLOGY 67: 89–92, 2006. © 2006 Elsevier Inc.
M
anagement of the distal ureter during laparoscopic nephroureterectomy continues to be an area of indecision in urology.1 The nephrectomy portion of laparoscopic nephroureterectomy is well established,2 with dissection by way of a hand-assisted,3–5 transperitoneal,2 or retroperitoneal approach.6,7 Intact specimen extraction with the entire ureter and a cuff of bladder is also well established. However, the approach and management of the distal ureter continues to evolve, with each method having distinct benefits and shortFrom the Department of Urology, Northwestern University Feinberg School of Medicine, Chicago, Illinois Reprint requests: Robert B. Nadler, M.D., Department of Urology, Section of Endourology, Laparoscopy, and Stone Disease, Northwestern University Feinberg School of Medicine, 675 North St. Clair Street, Galter 20-150, Chicago, IL 60611. E-mail: [email protected] Submitted: February 15, 2005, accepted (with revisions): July 27, 2005 © 2006 ELSEVIER INC. ALL RIGHTS RESERVED
comings. Initial reports8 used a laparoscopic GIA stapling device transperitoneally, after cystoscopic transurethral incision of ureteral orifice and ureteral tunnel, followed by placement of a ureteral occlusion balloon. With time, several methods to incise the distal ureter and bladder cuff have been used, including transurethral Collins knife incision,9 transvesical laparoscopic detachment and ligation,1 laparoscopic stapling of the distal ureter and bladder cuff,8 the pluck technique,10 and an open approach.11 The principles of surgical oncology dictate that complete “en block” ureteral resection with avoidance of tumor seeding is the preferred method of treating all upper tract urothelial cancers.12,13 We report our experience with a novel flexible cystoscopic approach to excise the distal ureter and bladder cuff. Our technique to excise a cuff of bladder and the distal ureter uses the flexi0090-4295/06/$32.00 doi:10.1016/j.urology.2005.07.053 89
FIGURE 1. Patient placement for right-sided combined hand-assisted nephroureterectomy and bladder cuff resection.
ble cystoscope and is done at the end of the case without patient repositioning. We report our experience with this new technique in 6 patients. MATERIAL AND METHODS Since May 2001, after institutional review board approval and informed consent from the patients, 6 patients have undergone laparoscopic transperitoneal hand-assisted nephroureterectomy using this technique. Five patients had upper tract transitional cell carcinoma and one had long-standing hydroureteronephrosis with a nonfunctioning kidney. The average patient age was 61.3 years, and the male/female ratio was 1:1.
TECHNIQUE Imaging studies and office flexible cystoscopy were performed before the operation to rule out coexisting bladder and lower ureteral tumors. After the patient provided informed consent, a general anesthetic was given. The patient was placed in the lateral decubitus position with the hips at a 45° angle on a foam wedge and the legs supported by spreader bars (Fig. 1). A urethral catheter was inserted and connected to a drainage bag. The pressure points were padded. The ipsilateral arm was raised and suspended in an internally rotated position. A 6 to 8-cm midline periumbilical skin incision was made, and the peritoneum was entered. A hand port was placed and pneumoperitoneum obtained using carbon dioxide. Three 5 to 12-mm trocars were inserted under direct laparoscopic vision (Fig. 2): one lateral port at the right anterior axillary line at the level of the umbilicus, one in the midline between the umbilicus and the xiphoid process. All our cases were right sided, but patient positioning and port placement would be a mirror image for left-sided cases. Transperitoneal hand-assisted laparoscopic nephrectomy was performed.3,5,14 We prefer to place the nondominant hand through the hand port, but that is up to the operating surgeon. First, the line of Toldt was incised and the colon reflected medially, the ureter was identified over the psoas muscle, and two 10-mm clips were placed on the proximal ureter to avoid distal migration of tumor cells. The kidney was dissected free from its surrounding tissues, and the renal artery and vein were then identified, ligated, and divided using a 10-mm Weck clip or vascular Endo-GIA stapler. The kidney was then mobilized with blunt and sharp dissection. Next, the ureter was laparoscopically mobilized over the common iliac vessels toward its insertion in the bladder. A third 12-mm port in the inferior umbilical midline may be necessary to aid with this dissection. Once the kidney and ureter have been freed down to the bladder wall, a 15F flexible cystoscope was inserted into the bladder per urethra using sterile water for irrigation. A 5F electrode (ACMI, Norwalk, Conn) was used to incise a cir90
FIGURE 2. Right-sided nephroureterectomy: placement of umbilical hand port and trocars.
cumferential 2-cm cuff of bladder around the ureteral orifice using cutting and coagulating current. The surgeon’s hand allows excellent manipulation of the ureter and periureteral tissues and provides a means for blunt dissection. The surgeon’s finger also prevents extravasation of fluid from the bladder during cystoscopic ureteral dissection. The nephroureterectomy specimen was removed gently through the abdominal port and extracted intact. We did not use a ureteral stent in our procedure, because it could facilitate efflux of tumor cells and cause edema around the ureteral orifice, making ureteral dissection more difficult. A Jackson-Pratt drain was left adjacent to the bladder to drain the pelvis. We routinely did not close the bladder, and a 20F urethral catheter attached to a drainage bag was left for 1 week. At 7 to 10 days, all the patients underwent cystography, which confirmed no extravasation of urine or diverticula of the bladder wall before catheter removal. Cystoscopic examination every 3 months and upper tract and pelvic imaging with triphasic computed tomography every 6 months were done to rule out tumor recurrence.
RESULTS We have used this technique in 6 consecutive cases of hand-assisted laparoscopic nephroureterectomy. We used this technique for a pure laparoscopic transperitoneal approach for benign disease, but not a retroperitoneal case, although it should be possible. The mean time to resect the distal bladder cuff was 30 minutes (range 22 to 35). The mean surgical time for the complete procedure was 264 minutes (4.4 hours). The mean estimated blood loss during the operation was 254 mL. The mean time to a general diet was 2.6 days. The Jackson-Pratt drain was removed on postoperative day 2 or 3. The mean hospital stay was 6.3 days (range 3 to 10). The urethral catheter was left for 7 to 10 days, and cystography confirmed the absence of extravasation in all cases. The final pathologic examination showed the bladder cuff and ureteral margins UROLOGY 67 (1), 2006
to be negative for cancer in all cases. The mean follow-up time was 31 months (range 5 to 44) and consisted of bladder cystoscopy and computed tomography. One patient, a 70-year-old man, had deep vein thrombosis and pulmonary emboli on postoperative day 4. A second patient had two recurrences of transitional cell carcinoma of the bladder. The first recurrence was 1 year after the procedure (Stage Ta, grade 2) and the second recurrence 3 years after the procedure (Stage Ta, grade 3), both were on the left bladder wall, away from the resected (right) ureteral orifice. COMMENT Nephroureterectomy has become the reference standard treatment for upper urinary tract transitional cell carcinoma. The problem urologists have encountered has been in adhering to the basic oncologic principles of en bloc excision of the ureter with a distal cuff of bladder while maintaining a minimally invasive approach. The original description of laparoscopic nephroureterectomy by Clayman et al.8 used a laparoscopic GIA stapling device transperitoneally, after cystoscopic transurethral incision of ureteral orifice and ureteral tunnel, followed by placement of a ureteral occlusion balloon. Many other approaches have been advocated for managing the distal ureter.1 An open approach through a low-midline or Gibson incision has been recommended, with the distal ureter and cuff of bladder dissected out en bloc through a transvesical incision.11 Pure laparoscopic techniques such as the ureteral pluck technique do not allow for early clipping of the ureter to prevent tumor cells seeding into the retrovesical space. Gill et al.9,15 described an endoscopic technique in which the ureter is dissected out at the start of the case and closed with an Endoloop to prevent tumor cell seeding. The disadvantage of these endoscopic techniques is that the patient has to be positioned in the dorsal lithotomy position at the beginning of the case, and, after dissection of the distal ureter, they must be repositioned for the laparoscopic approach. Not only is this time-consuming, but if the patient experiences an adverse event, necessitating early cessation of surgery, such as intraoperative myocardial infarction, the surgeon must still remove the functioning kidney in an unstable patient with a nondetached ureter. We chose not to close the bladder in our flexible cystoscopic technique; thus, the theoretical risk of tumor seeding of the retroperitoneum that exists in other techniques also exists in ours.1,13 However, because we use the hand-assisted approach, closing the bladder wall transperitoneally is simple and accessible. UROLOGY 67 (1), 2006
Earlier we described another technique using a laparoscopic port placed through the bladder, allowing a resectoscope to then be inserted transvesically to dissect the distal ureter.16 This technique allows the distal ureter to be managed at the end of the case without repositioning. It takes advantage of the use of the hand for assistance in manipulating the distal ureter and uses rigid instruments, which are easily manipulated and familiar to all urologists. The disadvantage is the additional 12-mm port that must be placed through the bladder with the potential complications of tumor cell seeding through the bladder into the abdominal cavity. Others have advocated stapling the distal ureter from an antegrade laparoscopic approach with an Endo-GIA stapler under cystoscopic surveillance. The problem with this approach is that a small amount of transitional cells are sequestered between the staple lines in a location that is unable to be visually inspected cystoscopically and, therefore, could develop into transitional cell cancer at a later date. Our technique, similar to that of Gonzalez et al.16 and Wong and Leveillee,4 does not require repositioning. Furthermore, positioning the patient on spreader bars with the pelvis tilted at a 30° to 45° angle is a much gentler position than dorsal lithotomy for the patient to be in throughout the length of the procedure and therefore has less potential for peroneal nerve injury or musculoskeletal injury. By using the flexible cystoscope, the distal ureter can be easily visualized in both men and women. Furthermore, our technique allows the kidney to be managed initially, so should the patient experience an adverse event during the operation, the kidney itself may be removed and the distal ureter managed at a later time. Because we open the bladder after freeing up the kidney and ureter, irrigation fluid and urine from the open bladder does not interfere with visualization of the ureter and kidney. Our technique takes advantage of the surgeon’s hand when used with a hand-assisted approach to manipulate the bladder trigone, aiding in circumferential incision of the ureteral cuff; blunt digital dissection also helps to free up the distal ureter. Although we did not choose to close the bladder in any of our cases, it would be possible to suture the opening at the level of the ureteral orifice closed should the surgeon desire. Obviously, our approach has shortcomings. The first is that flexible cystoscopic resection of the distal ureter is more technically demanding than that done with rigid instruments. However, we found that the flexible cystoscope has excellent deflection and a more than adequate working channel to allow circumferential dissection of the distal ureter in approximately 30 minutes, even in the hands of resident urologists. In addition to the technical dif91
ficulty of this flexible endoscopic maneuver, another obvious shortcoming is that we chose to leave the bladder cuff open. Theoretically, this could cause tumor seeding into the retroperitoneum and/or abdominal cavity. We have not found this to be the case in our patients who were closely followed up for an average of 31 months (range 5 to 44). Furthermore, retroperitoneal or abdominal seeding has not been reported in other laparoscopic series. We do advocate clipping the ureter early in this case to prevent downstream tumor cell seeding into the bladder, as well as irrigating the bladder several times with sterile water and working with sterile water during the endoscopic dissection portion of the case. We acknowledge that 6 patients was a small group; nevertheless, the technique was successful in all, as we presented. CONCLUSIONS We believe our flexible cystoscopic technique of distal ureteral management during hand-assisted laparoscopic nephroureterectomy has many advantages. It does not require repositioning, it uses a 15F flexible cystoscope and 5F electrode (familiar to all urologists), and allows for complete resection of the ureter and a cuff of bladder at the end of laparoscopic nephroureterectomy. REFERENCES 1. Steinberg JR, and Matin SF: Laparoscopic radical nephroureterectomy: dilemma of the distal ureter. Curr Opin Urol 14: 61– 65, 2004. 2. McDougall EM, Clayman RV, and Elashry O: Laparoscopic nephroureterectomy for upper tract transitional cell cancer: the Washington University experience. J Urol 154: 975–980, 1995. 3. Stifelman MD, Sosa RE, Andrade A, et al: Hand-assisted laparoscopic nephroureterectomy for the treatment of transi-
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UROLOGY 67 (1), 2006