LAPAROSCOPIC NEPHROURETERECTOMY FOR UPPER TRACT TRANSITIONAL CELL CANCER: THE WASHINGTON UNIVERSITY EXPERIENCE

Complications of transperitoneal laparoscopic nephrectomy: a single-center experience

OBJECTIVES

To present the incidence of complications of transperitoneal laparoscopic nephrectomy performed for various indications during a 6-year period.

METHODS

From 2002 to 2007, 505 transperitoneal laparoscopic nephrectomies were performed, consisting of 125 live donor, 212 radical, 80 simple, and 28 partial nephrectomies and 60 nephroureterectomies. We retrospectively analyzed the factors related to perioperative complications, including the type of operation, body mass index, history of abdominal surgery, and American Society of Anesthesiologists score.

RESULTS

The overall complication rate was 13.7% (69/505). Major complications requiring open conversion or reoperation occurred in 15 patients (3.0%). The remaining 54 patients experienced minor surgical or postoperative medical problems. The mortality rate in our series was 0%. The complication rates by the type of operation were not significantly different. Patients with a history of abdominal surgery demonstrated slightly greater complication rates (19.2% vs 12.6%, P = .069). When stratified by a body mass index of <25 kg/m(2) and <25 kg/m(2), no statistically significant difference was found in the complication rates (13.1% vs 15.6%, respectively, P = .067). Patients with greater American Society of Anesthesiologists scores had greater complication rates (P = .038). The intraoperative complication rates decreased as our experience with laparoscopic surgery increased (P = .042); however, the total complication rates remained constant throughout the study period.

CONCLUSIONS

In consideration of the contributing factors, the complication rates of transperitoneal laparoscopic nephrectomy were not related to the type of operation, body mass index, or history of abdominal operation but to the American Society for Anesthesiologists score. Complications unique to laparoscopic nephrectomy exist but they decrease with experience.

Laparoscopic nephroureterectomy and management of the distal ureter: a review of current techniques and outcomes

Laparoscopic nephroureterectomy (LNU) is becoming an increasingly common alternative treatment for transitional cell carcinoma (TCC) of the renal pelvis and ureter due to decreased perioperative morbidity, shorter hospitalization, and comparable oncologic control with open nephroureterectomy (ONU). Mobilization of the kidney and proximal ureter may be performed through a transperitoneal, retroperitoneal, or hand-assisted approach. Each technique is associated with its own benefits and limitations, and the optimal approach is often dictated by surgeon preference. Our analysis of the literature reflects equivalent cancer control between LPN and OPN at intermediate follow-up with significantly improved perioperative morbidity following LPN. Several methods for bladder cuff excision have been advocated, however, no individual technique for management of the distal ureter proved superior. Overall, complete en-bloc resection with minimal disruption of the urinary tract should be optimized to maintain oncologic outcomes. Longer follow-up and prospective studies are needed to fully evaluate these techniques.

Not so "simple" laparoscopic nephrectomy: outcomes and complications of a 7-year experience

INTRODUCTION

Laparoscopic radical nephrectomy has quickly evolved as an oncologic standard of care. The "Simple" nephrectomy implies an easier procedure than perhaps its radical counterpart and one that budding laparoscopists may approach with more confidence. Though, strict indications for simple nephrectomy are few, these cases tend to have infectious or inflammatory pathology sometimes making the procedure more difficult than its radical counterpart.

METHODS

A retrospective review of our experience with laparoscopic simple nephrectomy (LSN) over a 7-year period was performed. A total of 42 patients (12 males/ 30 females) with a mean age 47.5 years underwent LSN: 25 retroperitoneal (RP), 17 transperitoneal (TP). Indications for nephrectomy included poorly functioning kidneys associated with pain+/-hydronephrosis, recurrent infections, renal arterial stenosis induced malignant hypertension, XGP with stones.

RESULTS

Forty-two of 45 attempted simple nephrectomies were completed laparoscopically. Three patients had open conversions: two for non-progression and one endovascular stapler malfunction. Three patients were converted from RP to TP due to severe scarring (two having prior nephrostomy tubes). Median operative time was 202.5 minutes (98-399). Eight patients were discharged within 23 hours with no complications, all having RP approaches and morcellated specimens. Mean post-operative oral intake was 17.8 hours and bowel function return was 1.3 days. Median estimated blood loss 100 ml (30-4500). Creatinine levels did not alter significantly. Median specimen weight was 88.9 grams (28-672). Fourteen complications occurred in nine patients (21.4%): five minor (flank ecchymosis and mild ileus) and nine major (re-intubation, flank hernia, wound opening requiring readmission, retroperitoneal infections, trocar fistula formation, bleed requiring transfusion). Four patients were transfused: one for post-op bleed from the ureteral stump, two for chronic anemia with minimal intraoperative blood loss, and one for intraoperative blood loss.

CONCLUSIONS

Laparoscopic simple nephrectomy has few indications and includes a complicated patient population. The results show its efficacy and overall safety despite a moderate complication rate. Utilizing a retroperitoneal approach with specimen morcellation can reduce hospital stay. One should approach a laparoscopic nephrectomy for non-malignancy with caution for infectious or inflammatory indications.

Comprehensive management of upper tract urothelial carcinoma

Urothelial carcinoma of the upper urinary tract represents only 5% of all urothelial cancers. The 5-year cancer-specific survival in the United States is roughly 75% with grade and stage being the most powerful predictors of survival. Nephroureterectomy with excision of the ipsilateral ureteral orifice and bladder cuff en bloc remains the gold standard treatment of the upper urinary tract urothelial cancers, while endoscopic and laparoscopic approaches are rapidly evolving as reasonable alternatives of care depending on grade and stage of disease. Several controversies remain in their management, including a selection of endoscopic versus laparoscopic approaches, management strategies on the distal ureter, the role of lymphadenectomy, and the value of chemotherapy in upper tract disease. Aims of this paper are to critically review the management of such tumors, including endoscopic management, laparoscopic nephroureterectomy and management of the distal ureter, the role of lymphadenectomy, and the emerging role of chemotherapy in their treatment.

Mechanical circular stapler device loaded with nonabsorbable titanium staples for ileo-prostate capsuloplasty following prostate capsule sparing cystectomy: initial experience in cadavers

PURPOSE

Mechanical linear staplers have been safely used in urology with an acceptable 0% to 7.9% rate of stone formation in long-term follow-up. We sought to evaluate the feasibility of using mechanical circular stapler devices to perform ileocapsuloplasty following cystoadenomectomy in cadavers.

MATERIAL AND METHOD

Three unfrozen cadavers were used in this study. The prostate was enucleated and removed along with the bladder, leaving an ample cavity wherein the 21-mm anvil could be easily accommodated. A 2-0 purse string suture was then placed at the prostate capsule rim and tightly tied around the anvil. Following this, the circular stapler device was introduced into the neobladder through its opened limb and the center rod of the stapler device was passed through an opening made at the most dependent portion of the pouch where another purse string suture was placed and tied around it. Finally, the center rod of the stapler was connected to the anvil and fired, thus completing the anastomosis.

RESULTS

The procedure was feasible in all cases and 2 intact rings of prostatic capsule and bowel tissue were obtained, thus attesting the integrity of the anastomoses. Retrograde injection of methylene blue reassured that a watertight anastomosis was achieved whereas cystoscopic and macroscopic examination of the anastomotic site demonstrated a wide patent anastomosis in all cases.

CONCLUSIONS

Use of mechanical circular stapler to perform ileocapsuloplasty in cadavers is feasible and has potential advantages such as decreased anastomotic time, diminished chances of urinary extravasations, and reduced degree of difficulty.

Laparoscopic nephroureterectomy: oncologic outcomes and management of distal ureter; review of the literature

Introduction. Laparoscopic radical nephroureterectomy (LNU) is being increasingly performed at several centers across the world. We review oncologic outcomes after LNU procedure and the techniques for the management of distal ureter. Materials and Methods. A comprehensive review of the literature was performed on the oncological outcomes and management of distal ureter associated with LNU for upper tract transitional cell carcinoma (TCC). Results and Discussion. LNU for upper tract TCC is performed pure laparoscopically (LNU) or hand-assisted (HALNU). The management of the distal ureter is still debated. LNU appears to have superior perioperative outcomes when compared to open surgery. Intermediate term oncologic outcomes after LNU are comparable to open nephroureterectomy (ONU). Conclusions. Excision of the distal ureter and bladder cuff during nephroureterectomy remains controversial. Intermediate term oncologic outcomes for LNU compare well with ONU. Initial long-term oncologic outcomes are encouraging. Prospective randomized comparison between LNU and open surgery is needed to define the role of these modalities in the current context.

Laparoscopic nephroureterectomy: the distal ureteral dilemma

Transitional cell carcinoma affecting the upper urinary tract, though uncommon, constitutes a serious urologic disease. Radical nephroureterectomy remains the treatment of choice but has undergone numerous modifications over the years. Although the standard technique has not been defined, the laparoscopic approach has gained in popularity in the last two decades. The most appropriate oncological management of the distal ureteral and bladder cuff has been a subject of much debate. The aim of the nephroureterectomy procedure is to remove the entire ipsilateral upper tract in continuity while avoiding extravesical transfer of tumor-containing urine during bladder surgery. A myriad of technical modifications have been described. In this article, we review the literature and present an overview of the options for dealing with the lower ureter during radical nephroureterectomy.

Comparing lymphadenectomy during radical nephroureterectomy: open versus laparoscopic

OBJECTIVES

Laparoscopic nephroureterectomy (LNU) is an accepted treatment for tumors of the ureter and renal pelvis, although the ability to perform a regional lymphadenectomy has been criticized. We compared the quality of lymphadenectomy with LNU with that involving open nephroureterectomy (ONU) to determine whether oncologic principles are maintained.

METHODS

We searched our institutional database for patients who had undergone ONU from 1990 to 2005. These were compared with a series of patients from January 2003 to April 2007 who underwent LNU. From each patient's medical records, we assessed the number of lymph nodes removed, the number of positive nodes removed, and the density of positive nodes. The differences between groups were analyzed using the Wilcoxon rank sum statistical test.

RESULTS

We identified 106 patients who underwent ONU with lymphadenectomy and 28 who underwent LNU with lymphadenectomy. The median number of nodes removed, median number of positive nodes, and median density of positive nodes were, respectively, 3, 0, and 0 for the ONU group; and 6, 0, and 0, for the LNU group. There was a statistically significant difference between groups with respect to the number of nodes removed (P = 0.01) but not with respect to the number of positive nodes removed (P = 0.61) or the lymph node density (P = 0.42).

CONCLUSIONS

Offsetting the benefits of laparoscopy could be a flawed oncologic technique. We have demonstrated that lymphadenectomy, which is a potentially important component of nephroureterectomy, can be performed as well during LNU as it is with ONU when a dedicated effort is made.

Hand-assisted laparoscopic nephroureterectomy (HALNU): an assessment of the impact of obesity in 50 procedures

OBJECTIVE

The aims of this study was to review our experience with hand-assisted laparoscopic nephroureterectomy (HALNU) and to evaluate the impact of body-mass index (BMI) on outcomes.

METHODS

We retrospectively analyzed 50 HALNU patients. Twenty had body mass indices (BMIs) <25 (normal cohort), 18 had BMIs between 25 and 29.9 (overweight cohort), and 12 had BMIs >/=30 (obese cohort).

RESULTS

The cohorts had similar operative times: 349, 326, and 320 minutes, respectively. Most patients (38) underwent a total HAL distal ureterectomy, but 9 underwent an initial transurethral ureteral dissection (5 [25%], 2 [11%], and 2 [17%]). Five patients were converted to open and 1 had a planned open ureterectomy. The cystotomy was sutured closed in most but left open in 6 (3 [15%], 2 [11%], and 1 [8%]), and a stapled ureteral division was performed in 7 (3 [15%], 2 [11%], and 2 [17%]). Increased BMI was associated with delayed oral intake (P = 0.034). No significant cohort differences were observed for estimated blood loss (EBL), transfusion rate, complication rate, surgical margin status, distant metastases, or death rate. The obese cohort demonstrated trends toward increased hospitalization and bladder cancer recurrence (P = 0.083, P = 0.097). Patients with prior open surgery had longer hospitalizations (P = 0.024). Patients without prior surgery were more commonly alive with persistent disease (P = 0.027). EBL was greater for patients who had transurethral ureteral dissection (P = 0.030). Patients undergoing a stapled ureteral division had delayed oral intake, bowel function, and discharge (P = <0.001, P = 0.034, and P = 0.034).

CONCLUSIONS

HALNU is an effective surgical treatment for patients with BMIs as great as 45.

Neoplasms of the upper urinary tract: a review with focus on urothelial carcinoma of the pelvicalyceal system and aspects related to its diagnosis and reporting

Tumors of the renal pelvis account for approximately 7% to 8% of all renal malignancies, greater than 90% of these are of urothelial (transitional cell) origin. These tumors more typically occur in the sixth to eight decade with a slight male preponderance. Varying risk factors for urothelial carcinomas of the upper tract are recognized including environmental and occupational hazards, chemotherapeutic exposure, and previous history of urinary bladder or ureteral carcinomas. Tumor multifocality is frequent and additional tumors may arise in the ureter, bladder, or on the contralateral side. The histopathologic nuances presented by urothelial carcinoma in this region are generally similar to those in the urinary bladder. Though the World Health Organization 2004/International Society of Urological Pathology system used in the bladder is customarily also employed for grading of urothelial tumors of this region, its prognostic significance at this site is not entirely clear as most tumors are treated with nephroureterectomy irrespective of the grade of the tumor. Histologic grade may be an independent prognostic factor in papillary pT1 tumors; however, most pT2 and higher stage tumors tend to be nonpapillary and of higher grade. Despite advances in treatment modalities with sophisticated endoscopic techniques, tumor stage remains the most important prognostic factor. There are several confounding issues related to staging such as the variable presence and thickness of subepithelial connective tissue and muscularis in the renal calyces, renal pelvis, and the ureter; intratubular pagetoid cancer spread (pTis vs. pT3); and assessing invasion in papillary neoplasms with endophytic or inverted growth. Careful gross examination with adequate sampling and understanding the microanatomy of the pelvicalyceal wall are crucial for accurate stage assignment. Poor fixation of large friable tumors and processing artifacts may compound difficulties in accurate staging. This review focuses on urothelial carcinoma of the upper tract highlighting issues related to its diagnosis, staging, and reporting.

Nephroureterectomy for transitional cell carcinoma - the value of pre-operative histology

INTRODUCTION

Nephroureterectomy with excision of a cuff of bladder remains the standard for managing upper tract transitional cell carcinoma (TCC). Increasing use of diagnostic upper tract endoscopy has underlined the importance of obtaining a pre-operative histological diagnosis in order to avoid under-treating high-grade or multifocal disease and over-treating low-grade disease, which could, in selected cases, be managed conservatively. We review nephroureterectomy at our institution over a 10-year period with particular reference to a pre-operative histological diagnosis.

PATIENTS AND METHODS

Nephroureterectomy was performed in 113 patients from February 1994 to February 2004. Of these cases, 58 were for upper tract TCC and 50 of these 58 had intravenous urography (IVU): 9 had only IVU, 28 had an additional CT scan, 5 had an additional ultrasonography and 8 had additional CT + ultrasonography for pre-operative work-up. Thirty-four of the 58 cases had retrograde pyelography. Nineteen (32.7%) of the 58 cases had a pre-operative ureteroscopy (URS) and biopsy; 14 of these had rigid URS for tumours in the lower (11) and middle (3) thirds of the ureter and 5 had flexible URS for pelvicalyceal tumours by an experienced endourologist. Thirty-one (53%) of the 58 tumours were within the pelvicalyceal system and 27 within the ureter (upper, 5; middle, 3; lower, 19). Forty-eight patients underwent a total nephroureterectomy: 40 had a two incision approach and 8 had an endoscopic resection of the lower ureter. Five of the 58 cases had a sub-total nephroureterectomy and 5 a laparoscopic nephroureterectomy with open excision of lower ureter.

RESULTS

Nineteen (32.7%) of the 58 patients had a pre-operative histological diagnosis - 17 G2pTa, 1 G1pTa, and 1 G2pT1. Fourteen (74%) biopsies matched the final postoperative histology, but 1 was down-staged, 3 up-staged and 1 up-graded compared to the original histology. Five (12.8%) of 39 patients without pre-operative histology had no TCC in the final surgical specimen: 4 (10.25%) had benign pathology such as capillary haemangioma, urothelial cysts and reactive urothelial changes while one had renal cell carcinoma (RCC).

CONCLUSIONS

This study underlines the importance of obtaining a pre-operative histological diagnosis in cases with presumed upper tract TCC. Failure to do so can result in unnecessary ablative surgery for benign disease. Such an approach can also help identify multifocality and grade of disease so that treatment of upper tract TCC can be tailored more appropriately with ablative surgery for high-grade or multifocal disease and conservative (endoscopic) therapy for low-grade disease in selected cases. Patients with suspected TCC of the upper tract should be managed at centres where facilities for the comprehensive evaluation of such tumours exist.

Bladder cancer following upper tract urothelial carcinoma

Upper tract urothelial carcinoma (UTUC) is uncommon relative to primary bladder transitional cell carcinoma, with notable differences at the genetic, molecular and clinical levels. A variety of management options with similar oncologic outcomes are available for UTUC. Regardless of upper tract treatment modality, recurrence in the bladder consistently occurs in 20-50% of patients, thus presenting a significant clinical challenge. The initial intravesical relapse typically occurs within the first 2 years following upper tract therapy, but the risk is lifelong and repeat episodes are common. The identification of variables that allow accurate risk stratification of UTUC patients with regards to future bladder relapse is crucial. Unfortunately, to date, no variables have been identified that can reliably predict such bladder recurrences. A history of bladder cancer prior to UTUC resection and upper tract tumor multifocality are frequently reported clinical risk factors. Candidate molecular markers, such as E-cadherin, also hold promise for improving patient risk stratification. The impact of bladder recurrences on patient survival is still poorly defined. The risk of progression to invasive bladder disease is not well documented but appears to be an infrequent event. This article highlights important recent observations and key current issues regarding UTUC and subsequent bladder cancer. In addition, we suggest a bladder surveillance regimen following UTUC and provide recommendations for managing patients with intravesical recurrences.

Urothelial carcinoma of the upper urinary tract: surgical approach and prognostic factors

OBJECTIVES

Open radical nephroureterectomy (O-RNU) has been the gold standard for the treatment of upper urinary tract urothelial carcinoma (UUT-UC) for decades. With the advances in laparoscopic techniques and endourologic procedures, this concept has been increasingly challenged. Oncologic outcome prediction is mainly based on stage and grade. With progress in medical treatment, adjuvant therapies may gain importance in the future. This review assesses the values of the variety of available treatments as well as prognostic factors that may become relevant regarding patient selection for future adjuvant treatment trials.

METHODS

We performed a systematic literature research using MEDLINE with emphasis on open surgical, laparoscopic, and endourologic (ureteroscopic or percutaneous) techniques and prognostic contents.

RESULTS

Overall, no evidence level 1 information from prospective randomised trials is available for treatment of UUT-UC. Laparoscopic radical nephroureterectomy (L-RNU) is increasingly challenging open surgery. Currently, L-RNU should be reserved for low-stage, low-grade tumours. Ureteroscopy and percutaneous nephron-sparing techniques show favourable survival data but high local recurrence rates. Regarding prognosis, estimation of outcome still relies mainly on stage and grade because no additional parameters have been introduced in a routine clinical setting.

CONCLUSIONS

O-RNU still represents the gold standard for the treatment of UUT-UC. The laparoscopic approach is not yet standard of care and should be reserved for low-stage, low-grade tumours. Endourologic nephron-sparing treatments are still experimental in elective indications due to high local recurrence rates. For prognosis, no parameters in addition to stage and grade have been standardised.

Incidence of local recurrence and port site metastasis after laparoscopic radical nephroureterectomy

OBJECTIVES

To address the incidence of local recurrence and port site metastasis in patients who underwent laparoscopic radical nephroureterectomy (RNU) for upper tract transitional cell carcinoma (TCC).

METHODS

Between August 1993 and February 2006 116 laparoscopic RNU were performed in 115 patients at our institution. A traditional open excision, a laparoscopic stapler resection or a different approach was used for the management of the distal ureter in 76, 27, and 11 cases, respectively. Clinical follow-up as well as perioperative and pathologic data were retrospectively collected.

RESULTS

Perioperative and pathologic data were available in all 116 cases. Clinical outcomes were available in 107 patients with a mean follow-up of 30.5 months (range 1 to 148). Six patients (5.6%) had a local recurrence develop, including 1 patient with port site metastasis (0.9%) at an average of 5.7 months. In 2 of these patients, violation of the ipsilateral urinary tract was noted perioperatively.

CONCLUSIONS

We report, in this large single-center series of laparoscopic RNU, a low incidence of local recurrence. Our results confirm that a laparoscopic approach to upper tract TCC does not result in a clinically significant increased risk of tumor spillage provided that principles of oncologic surgery are followed.

A Sealed Laparoscopic Nephroureterectomy: A New Technique

OBJECTIVES

To describe a purely laparoscopic nephroureterectomy approach that avoids the disadvantages of transurethral bladder cuff excision and open/laparoscopic distal ureterectomy using the EndoGIA.

METHODS

A standard transperitoneal laparoscopic nephrectomy is carried out through three or four ports in the flank. The ureter is dissected caudally into the pelvis. Two additional (5- and 10-mm) trocars are placed in the ipsilateral lower abdomen. Caudal ureteral dissection continues until the detrusor muscle fibers at the ureterovesical junction are identified. A 1-cm area of bladder adventitia around the ureterovesical junction is cleared. The ureter is retracted upward and laterally, tenting up the bladder wall. The bladder cuff is excised using a 10-mm LigaSure Atlas and detached from the bladder. A 6-cm lower-quadrant incision is used to remove the specimen in an Endocatch bag. An indwelling 16F Foley catheter is then placed.

RESULTS

Thirteen adult patients with suspected upper-tract transitional cell carcinoma underwent this surgical technique (operative time: 170-270 min): none had local recurrence, and two had recurrence remote from the bladder cuff scar (follow-up: 1-23 months).

CONCLUSIONS

The described procedure adheres strictly to oncologic principles (removal of the affected renal unit without opening the urinary tract), and circumvents the need for transurethral/intraureteral instrumentation and patient repositioning.

Management of patients with upper urinary tract transitional cell carcinoma

Multiple therapeutic options are available for the management of patients with upper urinary tract transitional cell carcinoma (TCC). Radical nephroureterectomy with an ipsilateral bladder cuff is the gold-standard therapy for upper-tract cancers. However, less invasive alternatives have a role in the treatment of this disease. Endoscopic management of upper-tract TCC is a reasonable strategy for patients with anatomic or functional solitary kidneys, bilateral upper-tract TCC, baseline renal insufficiency, and significant comorbid diseases. Select patients with a normal contralateral kidney who have small, low-grade lesions might also be candidates for endoscopic ablation. Distal ureterectomy is an option for patients with high-grade, invasive, or bulky tumors of the distal ureter not amenable to endoscopic management. In appropriately selected patients, outcomes following distal ureterectomy are similar to that of radical nephroureterectomy. Bladder cancer is a common occurrence following the management of upper-tract TCC. Currently, there are no variables that consistently predict which patients will develop intravesical recurrences. As such, surveillance with cystoscopy and cytology following surgical management of upper-tract TCC is essential. Extrapolating from data on bladder TCC, both regional lymphadenectomy and neoadjuvant chemotherapy regimens are likely to be beneficial for patients with upper-tract TCC, particularly in the setting of bulky disease.

Intermediate follow-up of hand-assisted retroperitoneoscopic nephroureterectomy for management of upper urinary tract urothelial carcinoma: comparison with open nephroureterectomy

OBJECTIVES

To evaluate the oncologic outcomes of hand-assisted retroperitoneoscopic nephroureterectomy (HARNU) for upper urinary tract urothelial carcinoma and compare them with the data from conventional open surgery.

METHODS

We collected the data from 25 patients who underwent HARNU at our institution from January 1999 to December 2003 for upper urinary tract urothelial carcinoma. The clinical data were collected retrospectively by reviewing the medical records. The convalescence results and oncologic outcomes were analyzed and compared with the corresponding data from 41 contemporary conventional open nephroureterectomy (ONU) procedures.

RESULTS

The median follow-up period in the HARNU group was 32 months (range 21 to 43) and was 62 months (range 8 to 88) in the ONU group. Patient age, sex, body mass index, tumor size, specimen weight, and American Society of Anesthesiologists classification showed no significant differences between the two groups. The HARNU group required a longer operation time (252 versus 212 minutes; P = 0.02). Significantly less blood loss (212 versus 408 mL; P = 0.03) was noted in the HARNU group. The complication rates between the HARNU group and ONU group were similar (12% and 7.3%, respectively, P = 0.67). No open conversion was required in the HARNU group. The average hospital stay, days to oral intake, days to ambulation, and dose of parenteral narcotic analgesics were significantly less in the HARNU group. No significant differences were found in the 3-year bladder recurrence-free survival rate, cancer-specific survival rate, or overall survival rate between the two groups.

CONCLUSIONS

The results of our study have shown that HARNU, with an open method for the removal of the distal ureter and bladder cuff, is a less-invasive technique and provides comparable oncologic outcomes as ONU for upper urinary tract urothelial carcinoma.

Transitional-Cell Carcinoma Recurrence Rate after Nephroureterectomy in Patients Who Undergo Open Excision of Bladder Cuff v Transurethral Incision of the Ureteral Orifice

BACKGROUND AND PURPOSE

The gold standard treatment for upper-tract transitional-cell carcinoma is radical nephroureterectomy, but management of the distal ureter is not standardized. Two treatment options to detach the distal ureter are open cystotomy (OC) and excision of a bladder cuff or transurethral incision of the ureteral orifice (TUIUO). We compared the clinico-pathologic outcomes of these two techniques.

PATIENTS AND METHODS

Hospital records were reviewed on all 51 patients who had undergone open or laparoscopic nephroureterectomy at our institution between 1 January 1990 and 30 June 2005. Patient demographics, intraoperative parameters, and pathology data were collected. The mean follow-up was 23.2 months (range 4.5-75 months) and 22.1 months (range 1-50 months) for the OC and TUIUO groups, respectively. There were no significant differences in sex, age at operation, American Society Anesthesiologists risk score, previous transitional-cell tumors, pathologic tumor grade and stage, or metastatic disease status in the two groups.

RESULTS

Five patients had an unplanned incomplete ureterectomy. The bladder recurrence rates were similar in the OC group (22.2%; 6/27) and the TUIUO group (26.3%; 5/19). There were no pelvic recurrences in either group. Four of the five patients who had an incomplete ureterectomy had tumor recurrences, three in the form of metastatic disease.

CONCLUSION

Management of the distal ureter by TUIUO in appropriate patients offers the same rate of bladder recurrence as OC. Incomplete ureterectomy results in a significantly higher rate of recurrence, often associated with the development of metastatic disease.

Case Report: Laparoscopic Partial Cystectomy with Endo-GIA Stapling Device in Bladder Diverticular Carcinoma

BACKGROUND AND PURPOSE

The incidence of bladder diverticular carcinoma is low, ranging from 0.8% to 10%. Traditionally, treatment consisted of open surgical excision or transurethral resection. More recently, laparoscopic surgery has become widely accepted. We report here a case of bladder diverticular carcinoma treated with laparoscopic partial cystectomy.

CASE REPORT

A 56-year-old man presented with gross hematuria and was found to have transitional-cell carcinoma in a bladder diverticulum. We performed transurethral resection of the tumors and laparoscopic partial cystectomy. A 45-mm Endo-GIA stapler (U.S. Surgical Corp., Norwalk, CT) was used for direct resection of the diverticular tissue, and the specimen was removed en bloc. Suture of the seromuscular layer was performed with the intracorporeal knotting technique. Lymph-node dissection also was performed. At 3-month follow-up, it was noted that there was tumor recurrence that was not at the original diverticular site, and transurethral resection was carried out. After 1 year, cystoscopy and CT scans showed neither recurrence nor metastasis. No encrustation or erosion was induced by the staples.

CONCLUSION

Laparoscopic partial cystectomy can be an alternative treatment for bladder diverticular carcinoma.

[Bladder neoplasm after nephroureterectomy for upper urinary tract tumor. Does distal ureter surgery influx on the evolution?]

OBJECTIVE

To compare evolution in patients with urothelial upper tract tumor (UUTT) in whom we performed the classic open approach to the distal ureter with those in whom whe performed the endoscopic approach. We study the bladder recurrences in each group and the factors which may influx on the evolution.

MATERIAL AND METHODS

Retrospective review of nephroureterectomies in our department in the last 20 years. Group A (n:24): double incision (lumbar and pelvic incision), Group B (n:29): endoscopical approach of the distal ureter and classic lumbar incision. A descriptive study is first performed in which we review: sex, and patients age, background transuretral resection of bladder tumor (TURBT), UUTT side, and UUTT location (calices, pelvis or urether). Pathological stage and tumor grade are also exposed. Secondly, a review of the bladder recurrences in each group is performed. In order to find differences between de groups we used the Fisher's Exact test.

RESULTS

We observed that in terms of bladder recurrence there is a statistically significant difference between the two groups favoring Group B (p < 0.036), which means that there are less bladder recidives when perform endoscopic approach of distal ureter. Noneless due to the groups inhomogeneity in tumor stage, grade, and location, this differences seem to be associated to these sigues, more than to the approach to the ureter as an independant variable. In that concerning to the eventual relationship between bladder recidive and background of previous TURBT, we have not found any differences between the two groups but there are statystically significant difference in the global series. The small number of recurrences (13) does not allow us to establish a well based conclusion on this issue, but it seems that the background of previous TURBT is an important factor that may influx in posterior bladder recurrences.

CONCLUSIONS

In our results, endoscopic approach of distal ureter in nephroureterectomy for UUTT does seems to positively influx in the posterior chance of bladder recurrences. But the studied sample is small and the two groups have not been aleatorized because of ethical reasons. May the low number of cases affect the test's statistical potency. It seems that previous TURBT may conditionate these recurrences, as we show in global serie. It should be necessary a prospective and statistically analised multicenter trial to understand if distal ureter approach influx on the evolution of these tumors.

Long-Term Outcome of Hand-Assisted Laparoscopic Radical Nephroureterectomy for Upper-Tract Urothelial Carcinoma: Comparison with Open Surgery

PURPOSE

To evaluate the efficacy and long-term outcome of hand-assisted laparoscopic radical nephroureterectomy (HALNU) in treating upper urinary-tract transitional-cell carcinoma (UT-TCC).

PATIENTS AND METHODS

We analyzed the data from 39 patients who underwent HALNU in our institution between January 1999 and December 2002 for urothelial carcinoma of the ureter or kidney. Preoperative and perioperative data were collected retrospectively by reviewing medical records. The oncologic outcomes, including bladder recurrence-free survival, cancer-specific survival, and overall survival, were compared with those of 36 contemporary patients undergoing conventional open radical nephroureterectomy (ONU). The median follow-up was 48 months (range 6 2 months) in the HALNU group and 59.5 months in the ONU group (range 8 8 months). Patients ages, sex, body mass index, pathologic parameters, and American Society of Anesthesiologists (ASA) classification showed no significant difference between the groups.

RESULTS

The HALNU group had statistically less blood loss (183 mL v 422 mL; P = 0.02). The average hospital stay and dose of narcotic analgesics were significantly less in the HALNU group. The complication rates were similar (12.8% for HALNU and 8.3% for ONU; P = 0.53). The 5-year bladder recurrence-free survival, cancer-specific survival, and overall survival were similar in the two groups.

CONCLUSIONS

The HALNU is a less-invasive technique with 5-year bladder recurrence-free survival, cancer-specific survival, and overall survival rates similar to those of ONU for patients with UT-TCC.

Long-Term Oncologic Outcome after Laparoscopic Radical Nephroureterectomy for Upper Tract Transitional Cell Carcinoma

OBJECTIVE

To assess the long-term oncologic efficacy of laparoscopic radical nephroureterectomy (RNU).

METHODS

Between August 1993 and May 2001, 39 patients underwent laparoscopic RNU for upper tract transitional cell carcinoma (TCC) at our institution. The medical records of these patients were retrospectively reviewed.

RESULTS

Clinical outcomes were available in all 39 patients with an actual follow-up ranging from 60 to 148 mo (median: 74). During this time 27 patients (69%) developed at least one TCC recurrence. Eighteen patients had urothelial recurrences, and 9 patients had nonurothelial recurrences. Of these latter patients, 2 patients (5%) had local recurrences. No patient developed a port site metastasis. Eleven patients ultimately had disease progression and died from TCC 7-59 mo (median: 31) after the operation. On statistical analysis, tumor stage was the only factor significantly associated with death from the disease, and tumor location (ureter) was the only factor significantly associated with disease recurrence.

CONCLUSIONS

The long-term overall and disease-specific survival rates after laparoscopic RNU for upper tract TCC are well within the range of results reported after open surgery. Thus, the results of the present study support the continued development of laparoscopic techniques in the management of this aggressive disease.

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.

Pneumovesicum Method in en-Bloc Laparoscopic Nephroureterectomy with Bladder Cuff Resection for Upper-Tract Urothelial Cancer

BACKGROUND AND PURPOSE

A novel technique for managing the distal ureter and bladder cuff during laparoscopic nephroureterectomy is introduced.

TECHNIQUE

The procedure consists of three steps: (1) cystoscopy and PediPort (Tyco) insertion; (2) establishment of pneumovesicum and intramural ureter mobilization; and (3) laparoscopic nephroureterectomy. The use of PediPorts, a 5-mm lens, and Ski needles greatly facilitates the pneumovesicum. The ureteral orifice is closed, and the intramural ureter is dissected out with the patient in the lithotomy position. Laparoscopic nephroureterectomy is then accomplished with the patient in the lateral position.

RESULTS

The postoperative course was uneventful, and the pathology examination showed clear margins.

CONCLUSION

Pneumovesicum is a minimally invasive approach that provides an excellent endoscopic view. It is an oncologically sound method, as the ureteral orifice is closed early, and the chance of cancer-cell spillage is minimized by the use of gas instead of liquid in the bladder. Moreover, the procedure is not technically demanding.

[Results of laparoscopic nephroureterectomy for transitional cell carcinoma]

OBJECTIVE

To report our experience of laparoscopic nephroureterectomy and to compare our results to those published in the literature.

PATIENTS AND METHOD

Between 1997 and 2005, 15 laparoscopic nephroureterectomies were performed by 2 surgeons, in 12 men and 3 women for upper urinary tract transitional cell carcinoma. The mean age of the patients was 66 years. Three to five trocars were used depending on intraoperative findings in order to meet oncological imperatives: primary control of the renal pedicle before any contact with the tumour dissection in the plane of the radical nephrectomy. The operative specimen was extracted in a sealed bag via an infraumbilical mini-laparotomy that allowed pelvic ureterectomy and resection of the bladder cuff.

RESULTS

The mean operating time was 210 min. The procedure was converted to open lumbar laparotomy in 3 patients. The mean hospital stay was 13 days. The final histological stage showed 8 invasive tumours (pT2-pT3), 4 superficial tumours (pTa-pT1), 2 CIS and a benign tumour. Two patients died from local progression of the disease. The mean follow-up was 41 months (range: 12-96 months).

CONCLUSION

Laparoscopic nephroureterectomy for upper urinary tract transitional cell carcinoma, still under evaluation, is indicated in selected cases. Apart from patient selection, which remains difficult preoperatively, the cancer control results depend on compliance with the principles of this surgery.

Laparoscopic radical nephroureterectomy for transitional cell carcinoma: where are we in 2007?

PURPOSE OF REVIEW

Nephroureterectomy has undergone critical changes during the past 15 years with the advent of the laparoscopic approach. New data supporting laparoscopic nephroureterectomy (LNU) continue to emerge as new techniques are developed and current approaches refined. The purpose of this study was to investigate the findings within LNU from the past 2 years as an evolving although proven modality for treatment of upper-tract transitional cell carcinoma (TCC).

RECENT FINDINGS

Intermediate outcomes continue to be published equating the oncologic efficacy and perioperative parameters (i.e. blood loss and pain medication requirements) of LNU to those of open nephroureterectomy, allaying previous arguments against the minimally invasive approach. Newer approaches to the nephrectomy segment of LNU have been described, including robot assistance in retroperitoneoscopic cases and hand-assisted laparoscopic nephrectomy without the use of a hand-port. Data supporting specific approaches to the distal ureter have been published, including implementing robotics and flexible cystoscopy.

SUMMARY

Findings over the past 2 years show both the continued progress of LNU and the need for further evolution to optimize patient morbidity and oncologic outcomes. As laparoscopic training is integrated into urologic residency programs, standardizing the variables within LNU will be paramount.

Comparative Study of Oncologic Outcome of Laparoscopic Nephroureterectomy and Standard Nephroureterectomy for Upper Urinary Tract Transitional Cell Carcinoma

OBJECTIVES

To determine the oncologic safety of laparoscopic nephroureterectomy (LNU), we compared the long-term oncologic outcome of LNU versus open nephroureterectomy (ONU) in patients with upper tract transitional cell carcinoma.

METHODS

A total of 367 nephroureterectomy procedures were performed at our institutes for upper tract transitional cell carcinoma without distant metastases. Of 224 patients without concomitant or previous bladder cancer, 58 underwent LNU with open intact specimen retrieval plus open distal ureter and bladder cuff removal and 166 underwent ONU. Their data were reviewed and analyzed retrospectively. The mean follow-up was 13.6 months (range 14 to 34) for the LNU group and 28.0 months (range 14 to 36) for the ONU group.

RESULTS

Bladder recurrence was recognized in 19 patients (32.8%) after LNU at a median follow-up of 5.6 months compared with 63 patients (38.0%) after ONU. Local recurrence only developed in 2 patients (1.1%) after ONU. One port site metastasis occurred in a patient who had undergone LNU. Distant metastases developed in 10 patients (17.2 %) after LNU and 33 patients (19.9%) after ONU. The frequency of bladder recurrence, local recurrence, and distant metastases did not differ significantly between the two groups. The actual disease-free 2-year survival rates were similar (75.6% versus 81.7%). In all patients, the risk of metastases and death increased with advanced tumor stage and grade, but not by surgical procedure.

CONCLUSIONS

In the surgical management of upper tract transitional cell carcinoma, LNU does not negatively affect long-term oncologic control and can be considered an alternative modality. Tumor stage and grade are, however, important prognostic factors in the incidence of metastases and cancer-specific mortality.

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.

Laparoscopic-assisted nephroureterectomy after radical cystectomy for transitional cell carcinoma

OBJECTIVE

To report our experience with laparoscopic-assisted nephroureterectomy for upper tract transitional cell carcinomas after radical cystectomy and urinary diversion.

MATERIALS AND METHODS

Seven patients (53-72 years-old) underwent laparoscopic-assisted nephroureterectomy 10 to 53 months after radical cystectomy for transitional cell carcinoma at our institution. Surgical technique, operative results, tumor features, and outcomes of all patients were retrospectively reviewed.

RESULTS

Mean operative time was 305 minutes with a significant amount of time spent on the excision of the ureter from the urinary diversion. Estimate blood loss and length of hospital stay averaged 180 mL and 10.8 days, respectively. Intraoperative and postoperative complications occurred in two patients each. There was one conversion to open surgery. Pathology confirmed upper-tract transitional cell carcinoma in all cases. Metastatic disease occurred in two patients after a mean follow-up of 14.6 months.

CONCLUSIONS

Nephrouretectomy following cystectomy is a complex procedure due to the altered anatomy and the presence of many adhesions. A laparoscopic-assisted approach can be performed safely in properly selected cases but does not yield the usual benefits seen with other laparoscopic renal procedures.

Robot-assisted laparoscopic nephroureterectomy

BACKGROUND

Laparoscopic nephroureterectomy for upper-tract urothelial tumors is a minimally invasive approach that parallels the open technique in oncologic efficacy. Multiple approaches to manage the distal ureter have been described. We developed a new technique using the daVinci robot system to perform a transvesical excision of the distal ureter and bladder cuff.

PATIENTS AND METHODS

Ten consecutive patients with upper-tract urothelial cancer underwent a laparoscopic nephroureterectomy. The daVinci robot was docked through the umbilical, ipsilateral lateral rectus, and an additional contralateral lateral rectus port. The bladder was clam-shelled in a coronal orientation at the dome and the distal ureterectomy performed.

RESULTS

Our technique was successful in all ten patients. The mean operative time for the entire case was 4.4 hours. The average hospital stay was 3 days.

CONCLUSIONS

Robot-assisted laparoscopic nephroureterectomy is a safe, minimally invasive approach to upper- tract urothelial cancer that reduces the technical challenge of excision of the distal ureter.

Laparoscopic nephroureterectomy for upper urinary tract transitional cell carcinoma: results of a Belgian retrospective multicentre survey

OBJECTIVES

To evaluate the technical and oncologic feasibility of laparoscopic nephroureterectomy for upper urinary tract transitional cell carcinoma.

METHODS

A retrospective survey of 100 patients, treated with laparoscopic nephroureterectomy in 10 Belgian centres, was performed. Most procedures were performed transperitoneally. The distal ureter was managed by open surgery in 55 patients and laparoscopically in 45 patients. The mean follow-up was 20 mo.

RESULTS

Mean operation time was 192 min and mean blood loss 234 ml. The conversion rate was 7%. Important postoperative complications were seen in 9%. Pathologic staging was pTa in 31 patients, pT1 in 23, pT2 in 12, pT3 in 33, and pT4 in 1, concomittant pTis in 3. Pathologic grade was G1 in 24 patients, G2 in 28, and G3 in 48. Negative surgical margins were obtained in all but one patient. Twenty-five patients developed progressive disease (24%) at a mean postoperative time of 9 mo (local recurrence in 8%, metastases in 11%, both in 5%). Progression was 0% for pTa, 17% for pT1, 17% for pT2, 51% for pT3, and 100% for pT4. Cancer-specific survival was 100% for pTa, 86% for pT1, 100% for pT2, 77% for pT3, and 0% for pT4.

CONCLUSION

Laparoscopic nephroureterectomy appears to be a technically and oncologically feasible operation. To prevent tumour seeding, one should avoid opening the urinary tract and should extract the specimen with an intact organ bag. The high local recurrence rate in this study probably reflects the high percentage of high-grade and high-stage tumours in this study.

[Radical laparoscopic nephroureterectomy]

As with the increasingly common presence of laparoscopic surgery in renal adenocarcinoma, the same situation is also occurring with radical management of tumours of the upper urothelium. In this type of clinical condition, it is important to emphasize the different ways to mobilise the distal ureter (with transuretral resection or unroofing, pure laparoscopy, or open), and to take into account that this tumour has the highest risk of implantation at the ports of entry. Here, we conduct a literature review and up-date of the different approaches to the distal urethra.

Laparoscopic-assisted radical cystectomy with U-shaped orthotopic ileal neobladder constructed using nonabsorbable titanium staples

INTRODUCTION

Recently, nonabsorbable staples have been safely used in a variety of urologic open and laparoscopic extirpative and reconstructive procedures. We report the surgical steps of our technique of U-shaped orthotopic ileal neobladder created with titanium staples.

TECHNICAL CONSIDERATIONS

Using stay stitches, a 45 to 50-cm ileal segment is arranged in a U shape with two segments of approximately 20 cm and an afferent limb of 5 or 10 cm. An opening is made at the lowest point of the U-ileal segment on its antimesenteric border. The jaws of the 80 x 3.5-mm nonabsorbable mechanical stapler are accommodated within the bowel loop and fired twice, bringing together and detubularizing approximately 15 cm of each arm of the U. To complete the pouch detubularization, another small opening is made at the bottom of the chimney on its medial border. After this, a third nonabsorbable mechanical stapler had its jaws introduced through this opening and through the open end of the bowel segment on the right side and the stapler is fired, completing the U pouch. Subsequently, the open ends of the U segment and the opening made at the base of the afferent limb are closed with absorbable running sutures.

CONCLUSIONS

Our technique is feasible and may represent an alternative to expand the spectrum of continent urinary reservoirs that could be expeditiously created with nonabsorbable staples. Continued surveillance is mandatory to determine the lithiasis-inducing potential of these titanium staples within the urinary tract.

Laparoscopic nephroureterectomy for transitional cell carcinoma of renal pelvis and ureter: Nagoya experience

OBJECTIVES

To evaluate the efficacy of retroperitoneoscopic nephroureterectomy for transitional cell carcinoma of the renal pelvis and ureter, we analyzed the clinical outcomes and long-term cancer control of 89 patients.

METHODS

In 36 patients, the kidney was retroperitoneoscopically dissected and the ureteral end was resected with open procedure (combined laparoscopy group). In 53 patients, the ureteral end with a bladder cuff was transected using an endoscopic stapler (pure laparoscopy group). Sixty patients underwent open nephroureterectomy (open group). The median follow-up period was 35, 31, and 17 months in the open, combined, and pure laparoscopy groups, respectively.

RESULTS

The average operative time and bleeding volume was 5.4 hours and 665 mL in the open group, 5.1 hours and 580 mL in the combined laparoscopy group, and 4.3 hours and 354 mL in the pure laparoscopy group, respectively. The cause-specific patient survival rate at 3 years was 81% in the open group, 86% in the combined laparoscopy group, and 80% in the pure laparoscopy group. The bladder recurrence-free rate at 3 years was 51% in the open group, 65% in the combined laparoscopy group, and 45% in the pure laparoscopy group. The extravesical recurrence-free rate at 3 years was 71% in the open surgery group, 76% in the combined laparoscopy group, and 71% in the pure laparoscopy group. No statistically significant difference was seen in patient survival, bladder recurrence, or extravesical recurrence rates among the three groups.

CONCLUSIONS

Our retroperitoneal laparoscopic nephroureterectomy is less invasive than open surgery and is a safe and effective alternative.

Use of titanium knot placement device (TK-5) to secure dorsal vein complex during laparoscopic radical prostatectomy and cystoprostatectomy

INTRODUCTION

We evaluated the feasibility and describe the surgical technique of using the Ti-Knot device TK-5 to secure the dorsal vein complex (DVC) during 20 consecutive cases of laparoscopic radical prostatectomy and cystoprostatectomy.

TECHNICAL CONSIDERATIONS

Bloodless DVC ligation and transection was successfully achieved in 19 (95.03%) of 20 cases. In only 1 case, venous bleeding occurred after DVC transection. However, in this case, the two stitches used to ligate the DVC were tightly tied, and the bleeding probably occurred because the stitches were passed too superficially on the DVC. In another case, a third stitch had to be placed and tied with the aid of the Ti-Knot device because the second 2-0 Vicryl stitch placed at the DVC broke. In only 1 case did we experience some degree of trouble with the knotting process because one of the ends of the Vicryl suture slipped back into the abdominal cavity. The time to tie each suture with the Ti-Knot device, defined after the moment the needle was passed underneath the DVC to the moment the titanium knot was crimped and the Vicryl suture trimmed, was less than 1 minute (median 50 seconds, range 45 to 56) in all cases, except the case described above. No cases of the Ti-Knot device misfiring or malfunction occurred in this series.

CONCLUSIONS

In our experience, the Ti-Knot titanium knot placement device proved to be safe and efficient during laparoscopic ligation and control of the DVC.