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Transurethral Resection of the Intramural Ureter as the First Step of Nephroureterectomy
0022-5347/95/1541-0043$03.00/0 TIiE JOURpiAL OF UROLOGY Copynght 0 1995 by AMERICAN
Vol 1 5 4 , 4 3 4 4 . July 1995 Pnnted i n U S A .
UROLOCICAL ASsoCUnON. hc.
TRANSURETHRAL RESECTION OF THE INTRAMURAL URETER AS THE FIRST STEP OF NEPHROURETERECTOMY J. PALOU,* J. CAPARR6S, A. ORSOLA, B. XAVIER AND J. VICENTE From the Department
of
Urology, Fundacidn Puigvert Universitat Autbnoma de Barcelona, Barcelona, Spain
ABSTRACT
Nephroureterectomy is the standard surgical approach for upper urinary tract carcinoma. In 1952 a modified technique was described based on a prior endoscopic disconnection of the intramural ureter as a n initial step for subsequent nephroureterectomy via a single lumbar incision. Since October 1989 we performed 31 nephroureterectomies with this technique in 26 men and 5 women (average age 64.5 years). Of the patients 9 had prior bladder carcinoma. The predominant pathological diagnosis of the nephroureterectomy specimens was high grade infiltrating tumor. There were no intraoperative complications except for 1 case of intra-abdominal extravasation detected in the immediate postoperative period and treated conservatively. With an average followup of 20 months, tumor has not recurred at either the resected trigonal area or the retroperitoneum. We believe that our experience assesses the feasibility of this technique to improve and simplify nephroureterectomy, thus, decreasing the morbidity rate and operating time while maintaining the same oncological radicality. Kcr WOWS: ureter, ureteral neoplasms, carcinoma, nephrectomy, lumbosacral region
The need for total excision of the ipsilateral urinary tract was established by Kimball and Ferris in 1943,when they found a high incidence of tumor in the remaining ureter after simple nephrectomy for upper urinary tract transitional cell carcin0rna.l Nephroureterectomy is performed to treat the local lesion more effectively and eradicate it completely due to the possibility of m u l t i f d disease within the ipsilateral collecting system. Macroscopic and microscopic multicentricity, corroborated by McCarron et al,2 (more common in high grade tumors) confirms this indication. Traditionally, 2 incisions are made, includmg a lumbar incision for nephrectomy and a lower abdominal incision for ureterectomy. Others make only a single extended anterior and distal lumboabdominal incision. In 1952 McDonald et al described a nephroureterectomy technique based on the endoscopic resection of the ureteral orifice from the bladder with completion of the operation through a single loin incision.3 Accordingly, we offer our experience with ureteral endoscopic disconnectionfollowed by nephroureterectomyvia a lumbar incision.
Cross section of intramural
rtion of ureter.A, normal. E , aRer
partial resection. C, after CompEte transurethral resection of ureter
up to periveeical fat.
technique, except for the ureteral dissection. &r ligation, the ureter and periureteral tissue are mobilized and dissected under direct vision up to the level of the iliac vessels. Thereafter, manual blunt dissection and gentle traction on the free distal ureter permit the specimen to be excised MATERIALS AND METHODS completely. Finally, a lumbar tube is left indwehg. The Surgical technique. The patient is placed in a lithothomy patient is followed with urine cytology studies and cystoscopy position for an initial endoscopic approach. Generous endo- every 3 months for the first 2 years and every 6 months scopic resection of the ureteral meatus and its intramural thereafter, as well as yearly excretory mgraphy and abdomtract is performed until perivesical fat is visualized around inal computerized tomography. the resected ureter (see figure). Attention should be paid to Patients. Since October 1989,we performed 31 nephroureidentification and resection of the distal ureter. "he reliabil- terectomies with this technique in 26 men and 5 women ity of this procedure may be facilitated by 2 maneuvers: 1) (average age 64.5 years, range 31 to 88). Nine patients had prior injection of indigo carmine to resect the "blue tract" previous bladder carcinoma (3isolated and 6 multiple). thoroughly and 2) placement of a ureteral catheter, proceeding first to resection of the anterior surface of the ureter over RESULTS the catheter and, after its removal, then to resection of the There were no intraoperative complications and only 1 posterior aspect of the ureter. In our series this was not patient had a complication that could be ascribed to the necessary in any case, although it might be useful when first surgical endoscopic technique (intra-abdominal extravasalearning this technique. Careful coagulation of the resected tion of irrigating possibly due to unnoticed peritoneal area and ureteral stump is performed, and an indwelling perforation). The fluid, extravasation resolved after placement of urethral catheter is placed. an intraperitoneal catheter and an indwelling urethralstent. Nephrectomy is then performed following the traditional To date (average followup 20 months, range 6 to 40),there have been no recurrent tumors either at the resected trigonal Accepted for ublication December 16,1994. * Current adkss: Fundaci6n F'uigvert, Universitat Autbnoma de area or retroperitoneum. A total of 11 patients had recurrent bladder tumor at other sites (3 single and 8 multiple). Two Barcelona, Cartagena 340350,08025 Barcelona, Span 43
44
TRANSURETHRAL RESECTION OF INTRAMURAL URETER
patients died: 1 of metastasic disease and 1( a surgical high nephrectomy.3~10 This method requires a n apprenticeship risk patient) of cardiorespiratory failure in the immediate period, since the ureter folds over itself perivesically and hinders removal unless a good invagination is achieved. postoperative period. Laparoscopic nephroureterectomy h a s recently been reThe predominant pathological diagnosis i n the nephroureterectomy specimens was high grade infiltrating tumor ported with more complex endoscopic time for dissection". 12 (stage pT3, grade 3 in 13 patients, stage pT3, grade 2 in 1, (Bentson guide wire, ureteral expansion balloon, catheter stage pT2, grade 3 in 2, stage pT2, grade 2 in 2, stage pT1, with occlusion balloon and Amplatz guide wire) followed by grade 3 in 2, stage pT1, grade 2 in 7, stage pTa, grade 2 in 2, sealing of t h e bladder hole with a stapler. Rassweiler e t al inverted papilloma in 1 and adenocarcinoma in 1). One pa- suggested a similar technique with transurethral circumcitient underwent nephroureterectomy for suspected renal pel- sion of the intramural ureter.'" They performed this procevic tumor, which actually was a kidney adenocarcinoma in- dure in more than 40 cases when the nephrectomy was via a n open tract, with excellent results and no local recurrence vading the urinary tract. within 4 years. We assessed t h e feasibility of this combined endoscopic and DISCUSSION surgical technique. Endoscopic resection of the intramural The standard approaches for nephroureterectomy are eiureter, followed by its traction and removal via a lumbar t h e r by means of 2 incisions or a n extended lumboabdominal incision, i s a surprisingly easy a n d rapid procedure. I t imincision, with both causing greater trauma to the abdomiproves and simplifies nephroureterectomy, decreasing the nal wall and, therefore, prolonged postoperative pain a n d morbidity rate and operating time while achieving t h e same more discomfort for the patient. Although the technique of oncological radicality. Moreover, t h e method lessens postopendoscopic ureteral dissection a s a means of facilitating erative discomfort and convalescence. Therefore, we recomnephroureterectomy is relatively simple and rapid to permend i t i n patients with upper urinary tract tumors who are form, curiously few studies emphasize its usefulness. The candidates for a radical operation. main goal of this technique is to allow intravesical as well as extravesical ureteral removal without leaving a n intramural ureteral stump. REFERENCES McDonald3 and Cat+ e t al advise endoscopic coagulation of t h e ureteral stump once disconnected to ease its retraction 1. Kimball, F. N. and Ferris, H. W.: Papillomatous tumor of the renal pelvis associated with similar tumors of the ureter and and sealing, and thus prevent cellular implantation. Furbladder: review of literature and report of two cases. J. Urol., thermore, this maneuver provides for easier identification of 31: 257, 1934. t h e distal ureter from t h e lumbar incision once t h e proximal 2. McCarron, J. P., Jr., Chasko, S. B. a n d Gray, G. F., Jr.: Systemportion i s pulled taut, ensuring its complete removal. atic mapping of nephroureterectomy specimens removed for The possibility of a peritoneal perforation is remote, since urothelial cancer: pathological findings and clinical correlat h e resection should be limited to the lateral trigonal area. If tions. J. Urol., 128 243, 1982. this should happen, management (as with bladder rupture or 3. McDonald, H. P., Upchurch, W. E. and Sturdevant, C. E.: perforation during resection of a bladder tumor) consists of Nephro-ureterectomy: a new technique. J. Urol., 67: 804, 1952. placing an intraperitoneal catheter a n d a n indwelling ure4. Carr, T., Powell, P. H., Ransden, P. E. and Hall, R. R.: Nephroureterectomy. Brit. J. Urol., 5 9 99, 1987. thral stent.5 Duplication of the upper urinary tract, which 5. Montesinos Baillo, A., Bands Gassol, J. M., Palou Redorta, J., occurred in 1 of our patients, requires greater care and exNogueron Castro, M. and Macias Gimenez, N: Physiopatholperience in t h e endoscopic procedure but it is not a contraogy and surgical treatment of extravasated peritoneal fluid indication to this technique. a h r transurethral resection. Eur. Urol., 1 0 183, 1984. We advise against use of this technique for tumors of the 6. Hetherington, J. W., Ewing, R. and Philp, N. H.: Modified distal ureter, since it does not allow for local lymph node nephroureterectomy: a risk of tumour implantation. Brit. J. dissection except if a laparoscopic procedure is done. SomeUrol., 5 8 368, 1986. thing similar happens in patients with previous pelvic sur7. Jones, D. R. and Moisey, C. U.: A cautionary tale of the modified gery or local inflammatory disease because traction of the "pluck" nephroureterectomy. Brit. J. Urol., 71: 486, 1993. distal ureter may be difficult and result in serious complica8. Abercrombie, G. F., Eardley, I., Payne, S. R., Walmsley, B. H. and Vinnicombe, J.: Modified nephro-ureterectomy. Long-term tions. follow-up with particular reference to subsequent bladder tuHetherington e t al reported the development of a n invasive mours. Brit. J. Urol., 61: 198, 1988. bladder tumor at the ureteral orifice in 2 of 5 patients who 9. Valdivia, G., Gomez, J., Sanchez, M. and Villarroya, S.: Ureterunderwent this technique, and so they advised against it." In ectomia endoscopica: nota preliminar a proposito de 2 casos. both patients the invasive tumor was in the renal pelvis (1 Arch. Esp. Urol., 3 5 183, 1982. poorly differentiated and 1 well differentiated) with sections 10. Isorna. S., Suarez Hevia, E. and Miguelez, E.: Ureterectomia of the lower ureter free of tumor. Apparently, disease reendoscopica en urotelioma renal. Actas Urol. Esp., 11: 485, curred a t the resected ureteral orifice within a few months ( 4 1987. and 9).Recently, Jones and Moisey reported a new case but 11. Chandhoke, P. S., Clayman, R. V., Kerbl. K.. Figenshau, R. S., McDougall, E. M., Kavoussi. L. R. and Stone, A. M.: Laparothe tumor appeared a t the same area of resection within 3 scopic ureterectomy: initial clinical experience. J. Urol.. 1 4 9 months, and pathological study of the surgical specimen 992, 1992. revealed poorly differentiated transitional cell carcinoma a t the distal resected edge of the ureter.' In the series of 12. Kerbl, K., Clayman, R. V., McDougall, E. M.. Urban, D. A.. Gill, I . and Kavoussi. L. R.: Laparoscopic nepliroureterectoni).: evalAbercrombie" and C a r ' et al, with more cases than in our uation of first clinical series. E u r . Urol., 23: 431. 1992. series, this possible relationship was not confirmed. 13. Rassweiler, d. J., Henkel. T. 0.. Potempn, D. M., Coptrnot. M. Another combined open endoscopic technique differs in the and Alken. P.: The trchnitruis of' transueritnncal Iaoaroscooic ureterectomy procedure from that described. that is endonephrectomy. adrennlectoniv and nt.ph~ourrterrctomv Eur. scopic intusseception and excision of the ureter after simple Urol , 23: 425, 1993
Vol 1 5 4 , 4 3 4 4 . July 1995 Pnnted i n U S A .
UROLOCICAL ASsoCUnON. hc.
TRANSURETHRAL RESECTION OF THE INTRAMURAL URETER AS THE FIRST STEP OF NEPHROURETERECTOMY J. PALOU,* J. CAPARR6S, A. ORSOLA, B. XAVIER AND J. VICENTE From the Department
of
Urology, Fundacidn Puigvert Universitat Autbnoma de Barcelona, Barcelona, Spain
ABSTRACT
Nephroureterectomy is the standard surgical approach for upper urinary tract carcinoma. In 1952 a modified technique was described based on a prior endoscopic disconnection of the intramural ureter as a n initial step for subsequent nephroureterectomy via a single lumbar incision. Since October 1989 we performed 31 nephroureterectomies with this technique in 26 men and 5 women (average age 64.5 years). Of the patients 9 had prior bladder carcinoma. The predominant pathological diagnosis of the nephroureterectomy specimens was high grade infiltrating tumor. There were no intraoperative complications except for 1 case of intra-abdominal extravasation detected in the immediate postoperative period and treated conservatively. With an average followup of 20 months, tumor has not recurred at either the resected trigonal area or the retroperitoneum. We believe that our experience assesses the feasibility of this technique to improve and simplify nephroureterectomy, thus, decreasing the morbidity rate and operating time while maintaining the same oncological radicality. Kcr WOWS: ureter, ureteral neoplasms, carcinoma, nephrectomy, lumbosacral region
The need for total excision of the ipsilateral urinary tract was established by Kimball and Ferris in 1943,when they found a high incidence of tumor in the remaining ureter after simple nephrectomy for upper urinary tract transitional cell carcin0rna.l Nephroureterectomy is performed to treat the local lesion more effectively and eradicate it completely due to the possibility of m u l t i f d disease within the ipsilateral collecting system. Macroscopic and microscopic multicentricity, corroborated by McCarron et al,2 (more common in high grade tumors) confirms this indication. Traditionally, 2 incisions are made, includmg a lumbar incision for nephrectomy and a lower abdominal incision for ureterectomy. Others make only a single extended anterior and distal lumboabdominal incision. In 1952 McDonald et al described a nephroureterectomy technique based on the endoscopic resection of the ureteral orifice from the bladder with completion of the operation through a single loin incision.3 Accordingly, we offer our experience with ureteral endoscopic disconnectionfollowed by nephroureterectomyvia a lumbar incision.
Cross section of intramural
rtion of ureter.A, normal. E , aRer
partial resection. C, after CompEte transurethral resection of ureter
up to periveeical fat.
technique, except for the ureteral dissection. &r ligation, the ureter and periureteral tissue are mobilized and dissected under direct vision up to the level of the iliac vessels. Thereafter, manual blunt dissection and gentle traction on the free distal ureter permit the specimen to be excised MATERIALS AND METHODS completely. Finally, a lumbar tube is left indwehg. The Surgical technique. The patient is placed in a lithothomy patient is followed with urine cytology studies and cystoscopy position for an initial endoscopic approach. Generous endo- every 3 months for the first 2 years and every 6 months scopic resection of the ureteral meatus and its intramural thereafter, as well as yearly excretory mgraphy and abdomtract is performed until perivesical fat is visualized around inal computerized tomography. the resected ureter (see figure). Attention should be paid to Patients. Since October 1989,we performed 31 nephroureidentification and resection of the distal ureter. "he reliabil- terectomies with this technique in 26 men and 5 women ity of this procedure may be facilitated by 2 maneuvers: 1) (average age 64.5 years, range 31 to 88). Nine patients had prior injection of indigo carmine to resect the "blue tract" previous bladder carcinoma (3isolated and 6 multiple). thoroughly and 2) placement of a ureteral catheter, proceeding first to resection of the anterior surface of the ureter over RESULTS the catheter and, after its removal, then to resection of the There were no intraoperative complications and only 1 posterior aspect of the ureter. In our series this was not patient had a complication that could be ascribed to the necessary in any case, although it might be useful when first surgical endoscopic technique (intra-abdominal extravasalearning this technique. Careful coagulation of the resected tion of irrigating possibly due to unnoticed peritoneal area and ureteral stump is performed, and an indwelling perforation). The fluid, extravasation resolved after placement of urethral catheter is placed. an intraperitoneal catheter and an indwelling urethralstent. Nephrectomy is then performed following the traditional To date (average followup 20 months, range 6 to 40),there have been no recurrent tumors either at the resected trigonal Accepted for ublication December 16,1994. * Current adkss: Fundaci6n F'uigvert, Universitat Autbnoma de area or retroperitoneum. A total of 11 patients had recurrent bladder tumor at other sites (3 single and 8 multiple). Two Barcelona, Cartagena 340350,08025 Barcelona, Span 43
44
TRANSURETHRAL RESECTION OF INTRAMURAL URETER
patients died: 1 of metastasic disease and 1( a surgical high nephrectomy.3~10 This method requires a n apprenticeship risk patient) of cardiorespiratory failure in the immediate period, since the ureter folds over itself perivesically and hinders removal unless a good invagination is achieved. postoperative period. Laparoscopic nephroureterectomy h a s recently been reThe predominant pathological diagnosis i n the nephroureterectomy specimens was high grade infiltrating tumor ported with more complex endoscopic time for dissection". 12 (stage pT3, grade 3 in 13 patients, stage pT3, grade 2 in 1, (Bentson guide wire, ureteral expansion balloon, catheter stage pT2, grade 3 in 2, stage pT2, grade 2 in 2, stage pT1, with occlusion balloon and Amplatz guide wire) followed by grade 3 in 2, stage pT1, grade 2 in 7, stage pTa, grade 2 in 2, sealing of t h e bladder hole with a stapler. Rassweiler e t al inverted papilloma in 1 and adenocarcinoma in 1). One pa- suggested a similar technique with transurethral circumcitient underwent nephroureterectomy for suspected renal pel- sion of the intramural ureter.'" They performed this procevic tumor, which actually was a kidney adenocarcinoma in- dure in more than 40 cases when the nephrectomy was via a n open tract, with excellent results and no local recurrence vading the urinary tract. within 4 years. We assessed t h e feasibility of this combined endoscopic and DISCUSSION surgical technique. Endoscopic resection of the intramural The standard approaches for nephroureterectomy are eiureter, followed by its traction and removal via a lumbar t h e r by means of 2 incisions or a n extended lumboabdominal incision, i s a surprisingly easy a n d rapid procedure. I t imincision, with both causing greater trauma to the abdomiproves and simplifies nephroureterectomy, decreasing the nal wall and, therefore, prolonged postoperative pain a n d morbidity rate and operating time while achieving t h e same more discomfort for the patient. Although the technique of oncological radicality. Moreover, t h e method lessens postopendoscopic ureteral dissection a s a means of facilitating erative discomfort and convalescence. Therefore, we recomnephroureterectomy is relatively simple and rapid to permend i t i n patients with upper urinary tract tumors who are form, curiously few studies emphasize its usefulness. The candidates for a radical operation. main goal of this technique is to allow intravesical as well as extravesical ureteral removal without leaving a n intramural ureteral stump. REFERENCES McDonald3 and Cat+ e t al advise endoscopic coagulation of t h e ureteral stump once disconnected to ease its retraction 1. Kimball, F. N. and Ferris, H. W.: Papillomatous tumor of the renal pelvis associated with similar tumors of the ureter and and sealing, and thus prevent cellular implantation. Furbladder: review of literature and report of two cases. J. Urol., thermore, this maneuver provides for easier identification of 31: 257, 1934. t h e distal ureter from t h e lumbar incision once t h e proximal 2. McCarron, J. P., Jr., Chasko, S. B. a n d Gray, G. F., Jr.: Systemportion i s pulled taut, ensuring its complete removal. atic mapping of nephroureterectomy specimens removed for The possibility of a peritoneal perforation is remote, since urothelial cancer: pathological findings and clinical correlat h e resection should be limited to the lateral trigonal area. If tions. J. Urol., 128 243, 1982. this should happen, management (as with bladder rupture or 3. McDonald, H. P., Upchurch, W. E. and Sturdevant, C. E.: perforation during resection of a bladder tumor) consists of Nephro-ureterectomy: a new technique. J. Urol., 67: 804, 1952. placing an intraperitoneal catheter a n d a n indwelling ure4. Carr, T., Powell, P. H., Ransden, P. E. and Hall, R. R.: Nephroureterectomy. Brit. J. Urol., 5 9 99, 1987. thral stent.5 Duplication of the upper urinary tract, which 5. Montesinos Baillo, A., Bands Gassol, J. M., Palou Redorta, J., occurred in 1 of our patients, requires greater care and exNogueron Castro, M. and Macias Gimenez, N: Physiopatholperience in t h e endoscopic procedure but it is not a contraogy and surgical treatment of extravasated peritoneal fluid indication to this technique. a h r transurethral resection. Eur. Urol., 1 0 183, 1984. We advise against use of this technique for tumors of the 6. Hetherington, J. W., Ewing, R. and Philp, N. H.: Modified distal ureter, since it does not allow for local lymph node nephroureterectomy: a risk of tumour implantation. Brit. J. dissection except if a laparoscopic procedure is done. SomeUrol., 5 8 368, 1986. thing similar happens in patients with previous pelvic sur7. Jones, D. R. and Moisey, C. U.: A cautionary tale of the modified gery or local inflammatory disease because traction of the "pluck" nephroureterectomy. Brit. J. Urol., 71: 486, 1993. distal ureter may be difficult and result in serious complica8. Abercrombie, G. F., Eardley, I., Payne, S. R., Walmsley, B. H. and Vinnicombe, J.: Modified nephro-ureterectomy. Long-term tions. follow-up with particular reference to subsequent bladder tuHetherington e t al reported the development of a n invasive mours. Brit. J. Urol., 61: 198, 1988. bladder tumor at the ureteral orifice in 2 of 5 patients who 9. Valdivia, G., Gomez, J., Sanchez, M. and Villarroya, S.: Ureterunderwent this technique, and so they advised against it." In ectomia endoscopica: nota preliminar a proposito de 2 casos. both patients the invasive tumor was in the renal pelvis (1 Arch. Esp. Urol., 3 5 183, 1982. poorly differentiated and 1 well differentiated) with sections 10. Isorna. S., Suarez Hevia, E. and Miguelez, E.: Ureterectomia of the lower ureter free of tumor. Apparently, disease reendoscopica en urotelioma renal. Actas Urol. Esp., 11: 485, curred a t the resected ureteral orifice within a few months ( 4 1987. and 9).Recently, Jones and Moisey reported a new case but 11. Chandhoke, P. S., Clayman, R. V., Kerbl. K.. Figenshau, R. S., McDougall, E. M., Kavoussi. L. R. and Stone, A. M.: Laparothe tumor appeared a t the same area of resection within 3 scopic ureterectomy: initial clinical experience. J. Urol.. 1 4 9 months, and pathological study of the surgical specimen 992, 1992. revealed poorly differentiated transitional cell carcinoma a t the distal resected edge of the ureter.' In the series of 12. Kerbl, K., Clayman, R. V., McDougall, E. M.. Urban, D. A.. Gill, I . and Kavoussi. L. R.: Laparoscopic nepliroureterectoni).: evalAbercrombie" and C a r ' et al, with more cases than in our uation of first clinical series. E u r . Urol., 23: 431. 1992. series, this possible relationship was not confirmed. 13. Rassweiler, d. J., Henkel. T. 0.. Potempn, D. M., Coptrnot. M. Another combined open endoscopic technique differs in the and Alken. P.: The trchnitruis of' transueritnncal Iaoaroscooic ureterectomy procedure from that described. that is endonephrectomy. adrennlectoniv and nt.ph~ourrterrctomv Eur. scopic intusseception and excision of the ureter after simple Urol , 23: 425, 1993