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

Totally Retroperitoneal One-Position Approach for Laparoscopic Radical Surgery in Upper Urinary Tract Urothelial Carcinoma: A Clinical Trial Evaluation

BACKGROUND

The standard of care for upper tract urothelial carcinoma (UTUC) traditionally involved open nephroureterectomy with bladder cuff excision. Despite the adoption of transabdominal laparoscopic one-stage nephroureterectomy to mitigate this, the persistently high rate of postoperative intestinal obstruction remains a clinical challenge. This study introduces an innovative approach: a single-position, completely retroperitoneal laparoscopic nephroureterectomy coupled with a 75-45-degree positional change for bladder cuff resection in the treatment of UTUC. The study further evaluates the clinical efficacy of this novel surgical technique.

METHODS

A retrospective analysis was conducted on 125 patients diagnosed with UTUC who underwent radical nephroureterectomy at our institution between May 2018 and December 2023. The experimental cohort comprised 65 individuals who received total retroperitoneal one-position laparoscopic nephroureterectomy (TROLN), complete with total intracorporeal bladder cuffing and distal ureterectomy. In contrast, the control cohort included 60 patients who had laparoscopic nephrectomy with a lower abdominal oblique incision for bladder sleeve resection. The study evaluated various perioperative metrics, such as operative duration, blood loss during surgery, incision size, resumption of oral intake postoperatively, drainage tube removal timeline, hospital stay duration, Visual Analogue Scale (VAS) for pain assessment, and complication incidence. In addition, pathological and oncological outcomes were scrutinized.

RESULTS

The TROLN group exhibited pronounced benefits across various surgical outcomes, including reduced operative duration, minimized intraoperative blood loss, shorter incision lengths, lower postoperative pain assessments, expedited return to oral nutrition, swifter drain extraction, and a condensed overall hospitalization period (all P < 0. 05). However, the oncological outcomes showed no significant differences between the TROLN group and the control group.

CONCLUSION

Drawing from our clinical insights, TROLN is a safe and effective modified technique that offers advantages over traditional laparoscopic combined with open surgery for treating UTUC, including reduced invasiveness, less bleeding, fewer complications, and shorter hospital stays. However, additional prospective studies are imperative to validate these observations.

Systematic review and meta-analysis of completely retroperitoneoscopic nephroureterectomy versus traditional retroperitoneoscopic nephroureterectomy in upper tract urothelial carcinoma

BACKGROUND

This systematic review and meta-analysis aim to evaluate the efficacy and safety of completely retroperitoneoscopic nephroureterectomy (CRNU) for the treatment of upper urinary tract urothelial carcinoma (UTUC).

METHODS

A systematic review of PubMed and Web of Science databases was conducted to identify trials comparing the outcomes of CRNU and other surgical procedures. A total of 6 case-control studies were selected for analysis. The efficacy and safety of CRNU were evaluated using mean difference or hazard ratio (HR) with 95% CIs, employing continuous or dichotomous method with a random or fixed-effect model. Meta-analysis was performed using STATA 11.0 software.

RESULTS

The meta-analysis indicated that CRNU in subjects with UTUC was significantly associated with a shorter operation time (standardized mean difference, -1.36; 95% CI, -1.61 to -1.11, P < .001) and lower blood loss (standardized mean difference, -0.54; 95% CI, -0.77 to -0.31, P < .001) when compared to traditionally retroperitoneoscopic nephroureterectomy (TRNU). No significant difference was observed in the occurrence of grade I & II complications (HR, 1.04; 95% CI, 0.49-2.2, P = .915) and total complications (HR, 0.69; 95% CI, 0.38-1.27, P = .238) between CRNU and TRNU.

CONCLUSION

The findings suggest that CRNU is an advanced surgical technique that is safe and effective for the treatment of UTUC. We recommend that CRNU be further employed for patients with UTUC. Further randomized, multicenter trials are needed to validate these results, given the limitations of this study.

Complete retroperitoneal laparoscopic nephroureterectomy with bladder cuff excision for upper tract urothelial carcinoma without patient repositioning: a single-center experience

Objective

This study was performed to evaluate the outcome of complete retroperitoneal laparoscopic nephroureterectomy with bladder cuff excision (RLNU-BCE), which is performed to treat urothelial carcinomas in the renal pelvis or in the ureter higher than the crossing of the common iliac artery without patient repositioning.

Methods

We retrospectively analyzed the clinical data of 48 patients with upper tract urothelial carcinoma who underwent complete RLNU-BCE in our institution from May 2017 to September 2019.

Results

RLNU-BCE was successfully performed in all 48 patients. The median operation time was 110 minutes [interquartile range (IQR), 100–130 minutes], and the median postoperative anesthesia recovery time was 10 minutes (IQR, 7–15 minutes). The median postoperative hospitalization period was 5 days (IQR, 4–6 days). Pathologic examination revealed that the margin of all resected specimens was negative. After a median follow-up of 13 months (IQR, 7–20 months), no local recurrence or distant metastasis was found. No complications occurred during follow-up.

Conclusion

Based on our experience with this technique, RLNU-BCE deserves application and promotion in clinical practice. Long-term comparative studies are required to confirm its superiority over other techniques.

Management of the Distal Ureter in Radical Laparoscopic Nephroureterectomy for Upper Tract Urothelial Carcinoma

Introduction: Management of the distal ureter during laparoscopic nephroureterectomy (LNU) for upper tract urothelial carcinoma (UTUC) is controversial. The aim of this review was to determine whether this affects oncological outcomes. Methods: A literature review was conducted searching MEDLINE, EMBASE, and Cochrane Central Register of Controlled Trials in June 2019. Studies reporting outcomes of LNU in UTUC using either open, laparoscopic, or endoscopic approaches to excise the distal ureter were identified. All eligible studies underwent critical appraisal and were excluded if not of sufficient quality. Cumulative analysis of the results was performed. Results: Nine studies with a total of 383 patients (168 open, 159 laparoscopic, and 56 endoscopic excision of distal ureter) were eligible for inclusion. Study design and outcome reporting were variable between studies. Mean age of patients was comparable (67.7 years versus 65.0 years versus 66.6 years). Mean follow-up duration was comparable between open and laparoscopic groups (46.2 months versus 45.5 months) but reduced in the endoscopic group (33.4 months). The open group had a higher proportion of high grade/G3 tumors and pT2-4 tumors when compared to the laparoscopic and endoscopic groups (P < .001 and P = .002). The open group had a higher rate of intravesical recurrence and the laparoscopic group had a higher rate of distant metastases (P < .001). Conclusion: This review has identified differences in oncological outcomes between different techniques of managing the distal ureter in LNU for UTUC. However, the poor reporting of potentially confounding factors does not enable any one technique to be recommended as superior and requires further research.

Management of distal ureter and bladder cuff at the time of nephroureterectomy: surgical techniques and predictors of outcome

Open radical nephroureterectomy (NU) with removal of the ureter and bladder cuff is the 'gold standard' in the treatment of high-grade urothelial cancers of the upper urinary tract. A salient issue is the management of the distal ureter and bladder cuff at time of surgery. Which technique confers superior oncologic benefit is of particular interest since this disease process is notoriously plagued with high intravesical recurrence rates. Although open radical NU is the 'gold standard', the maturation of minimally invasive surgery formidably challenges approaches considered 'gold standard'. We thus sought to critically review the literature comparing perioperative and oncologic outcomes in the approaches used to manage the distal ureter and bladder cuff in patients undergoing radical NU.

Distal Ureter Management During Nephroureterectomy: Evidence from a Systematic Review and Cumulative Analysis

INTRODUCTION AND OBJECTIVES

Standard of care in upper tract urothelial cancer is nephroureterectomy with bladder cuff excision (BCE). However, alternative techniques such as transurethral incision/resection have been used to simplify distal ureterectomy. The optimum strategy is unclear, and current guidelines do not specify a gold standard technique. The objective of this study was to perform a systematic review of the literature, to compare BCE and transurethral distal ureter methods.

MATERIALS AND METHODS

A Cochrane and PRISMA-guided systematic literature search was conducted on English language articles from January 2000 to present, reporting on centers' experience with either BCE or transurethral distal ureterectomy. A cumulative meta-analysis comparison between the two procedures was performed. Primary outcome was intravesical recurrence. Secondary outcomes were local/distant recurrence, surgical margins, and disease-specific mortality (DSM). Groups were compared using chi-square analysis.

RESULTS

In total, 66 studies were included after excluding 1795. BCE and transurethral groups contained 6130 and 1183 patients, respectively. Mean/median age ranged from 57.5 to 75.2 years, and follow-up from 6.1 to 78 months. Level of evidence was low, with high risk of bias and small sample size (<100 patients) in 41 (62%) and 52 (79%) studies, respectively. Baseline cancer demographic analysis identified significantly higher rates of high grade, advanced stage, node-positive and carcinoma in situ disease in the BCE group. However, intravesical recurrence (23.6% vs 28.7%, p = 0.0002) and local/distant recurrence (17.9% vs 21.6%, p = 0.02) were significantly lower than the transurethral group. No difference was seen regarding surgical margins (3.1% vs 2.4%, p = 0.27) or DSM (16.8% vs 14.3%, p = 0.06).

CONCLUSIONS

No prospective, randomized comparisons exist for distal ureterectomy at nephroureterectomy. In this analysis, patients undergoing BCE had more advanced disease burden compared with the transurethral group. Despite this, the BCE group had statistically lower intravesical and local/distant recurrence. Further prospective research should be encouraged to identify gold standard ureter management.

Laparoscopic Surgery in Urologic Oncology

Background

Techniques in genitourinary oncologic surgery have evolved over the past several years, shifting from traditional open approaches toward minimally invasive routes by laparoscopy.

Methods

We reviewed the literature on laparoscopic surgery for genitourinary cancer, with emphasis on contemporary indications, complications, and oncologic outcome of laparoscopic surgery for urologic malignancies.

Results

All urologic oncology procedures have been performed laparoscopically. Laparoscopic radical nephrectomy is becoming the preferred approach for managing kidney cancer. The initial experience with nephroureterectomy is encouraging. Laparoscopic radical prostatectomy is rapidly becoming the standard in Europe and is the procedure of choice in many centers in the United States.

Conclusions

When following the open oncologic principles for the surgical treatment of malignancies, laparoscopy offers similar oncologic clinical outcomes, less morbidity, improved operative precision, and reduced convalescence time.

Comparison between completely and traditionally retroperitoneoscopic nephroureterectomy for upper tract urothelial cancer

Background

To evaluate the safety and efficacy of the completely retroperitoneoscopic nephroureterectomy (CRNU), a retrospectively comparative study between completely and traditionally retroperitoneoscopic nephroureterectomy (TRNU) was done in a single center.

Methods

From January 2014 to December 2014, 107 patients with upper tract urothelial cancer (UTUC) underwent CRNU. The kidney was retroperitoneoscopically dissected and the bladder cuff was cut by endoscopic gastrointestinal automatic stapler, and the specimen was removed from a 6-cm incision by posterior axillary line. Demographic, perioperative, and follow-up data were collected and compared retrospectively with 110 patients undergoing TRNU.

Results

The patients’ characteristics between the two groups were not statistically different (p > 0.05), and all patients successfully received the procedure. The mean operative time (106 ± 37.9 versus 199 ± 69.1 min, p < 0.0001), the mean estimated blood loss (47.2 ± 82.4 versus 166.9 ± 250.9 ml, p = 0.002), and the mean hospital stay (6.1 ± 3.5 versus 8.1 ± 3.3 days, p = 0.03) of the CRNU group decreased significantly compared to the traditional group. The operative time was not affected by gender. No open conversion and major complications occurred. The surgical margin of the ureter was all negative. The mean follow-up time was 13.4 months for the CRNU group and 37.5 months for the TRNU group. All follow-up patients in the CRNU group were alive without local recurrence. No cases of port site metastasis and local recurrence were observed in both groups. Bladder tumor recurrence occurred in 4 patients of the CRNU group and 21 patients of the TRNU group.

Conclusions

The CRNU using an endoscopic gastrointestinal automatic stapler to manage the bladder cuff is feasible and advantageous in decreasing the operative time, the blood loss, and the hospital stay. However, a larger sample and longer follow-up time will be still required.

Techniques to resect the distal ureter in robotic/laparoscopic nephroureterectomy

Treatment of clinically-organ confined high grade urothelial carcinoma of the upper tract has historically comprised open nephroureterectomy, with the distal ureter and bladder cuff mobilized through a separate open pelvic incision. To decrease morbidity, urologists have increasingly adopted laparoscopy and robotics in performing nephroureterectomy. In many published series of laparoscopic nephroureterectomy, the distal ureter and bladder cuff are detached from the bladder endoscopically by a variation of the “pluck” technique, with the resulting bladder defect left to heal by prolonged indwelling urethral catheter drainage. While the distal ureter and bladder cuff can be excised laparoscopically, it does require advanced laparoscopic skills. With the wrist articulation and stereoscopic vision in robotic surgery, robotic nephroureterectomy (RNU) and bladder cuff excision can be performed in antegrade fashion to mimic the open technique together with the ability to intracorporeally close the bladder defect in a watertight, mucosa to mucosa fashion after excising the bladder cuff. In this review, we discuss the published minimally invasive techniques in resecting the distal ureter and bladder cuff during laparoscopic and RNU.

Pfannenstiel incision for intact specimen extraction in laparoscopic transperitoneal radical nephrectomy: a longitudinal prospective outcome study

OBJECTIVES

To evaluate the intra- and postoperative outcomes of patients undergoing laparoscopic radical nephrectomy with intact specimen extraction through a Pfannenstiel transverse suprapubic incision.

METHODS

Prospective follow-up of 26 laparoscopic transperitoneal radical nephrectomies for suspected renal tumors in which the kidneys were extracted via a Pfannenstiel lower abdominal transverse incision.

RESULTS

The mean operating time was 152.3 (80-255) minutes, and the mean blood loss was 90 (20-300) ml. The mean extraction time was 20.4 (12-35) minutes. The mean weight of the removed specimen was 631.5 (190-1505) grams, and the mean longest diameter of the extracted specimen was 17.4 (9-25) cm. The mean extraction incision size was 10.7 (7-16) cm. No open surgical conversions were necessary. Pain control was excellent, with minimal intravenous morphine equivalent narcotic use by patients: 15.7 (0-31) mg in the recovery room, 33.8 (0-127) mg on the first postoperative day and 8.7 (0-60) mg in the first week after discharge. The patients experienced a short duration to full ambulation and normal dietary intake. Postoperative follow-up visits were recorded for at least six months. The patients reported a high cosmetic satisfaction rate of 97.7% (60-100). No late postoperative complications were observed related to the extraction site.

CONCLUSIONS

The operative specimen can be extracted via a low transverse Pfannenstiel incision during radical laparoscopic nephrectomy. This incision ensures the extraction of large specimens while preserving the aesthetic and functional advantages of laparoscopy without increasing the cancer risk. The absence of muscle cutting maintains the integrity of the abdominal wall and elicits minimal pain. No postoperative incisional hernias or keloid formations were observed.

Delayed ureterectomy after incomplete nephroureterectomy for upper tract urothelial carcinoma: pathologic findings and outcomes

OBJECTIVES

To evaluate the pathologic findings and outcomes after distal ureterectomy for a retained ureteral segment following incomplete nephroureterectomy for urothelial carcinoma of the renal pelvis or ureter.

MATERIALS AND METHODS

After IRB approval, an institutional database identified patients who underwent distal ureterectomy for a retained ureteral segment after assumed complete nephroureterectomy for urothelial carcinoma of the upper ureter or renal pelvis. Clinical and pathologic variables were analyzed.

RESULTS

From January 1993 to July 2007, 12 patients were identified with median age at the time of ureterectomy of 60.5 years (41-85 years). Initial approach to surgery was open in 9 patients and laparoscopic in 3 patients. The median time from nephroureterectomy to distal ureterectomy was 23.5 months (range 2-66). At the time of initial surgery, pathologic stage was Ta, T1, T2, and T3 in 3,4,1, and 4 patients respectively. Initial pathology was urothelial carcinoma; grade 2 in 6 patients and grade 3 in six patients. Pathology from the subsequent surgery demonstrated urothelial carcinoma in the retained ureteral segment in 8 patients, dysplasia or atypia in 3 patients, and 1 patient with chronic inflammation. Local recurrence in 2 patients was present in a segment of ureter discontinuous with the bladder after laparoscopic nephroureterectomy. Three patients (25%), all with initial grade 3 renal pelvis lesions, developed metastatic disease.

CONCLUSIONS

Tumor recurrence in a retained ureteral segment after incomplete nephroureterectomy is a significant problem and may contribute to intravesical recurrence or metastatic disease. Complete, en bloc resection is imperative to minimize these risks.

Total retroperitoneal laparoscopic nephroureterectomy with bladder-cuff resection for upper urinary tract transitional cell carcinoma

BACKGROUND

Open nephroureterectomy (ONU) and bladder cuff resection (ONU-BCR) has been the gold standard of surgical treatment for upper urinary tract transitional cell carcinoma (UUT-TCC). The aim of this study is to introduce a modified total retroperitoneal laparoscopic nephroureterectomy (LNU) with bladder-cuff resection (LNU-BCR) method for treating UUT-TCC and compare its clinical efficacy with ONU-BCR.

METHODS

Sixty-five patients with UUT-TCC, who underwent ONU-BCR (n = 36) or LNU-BCR (n = 29) between January 2008 and June 2012, were analyzed in this retrospective study. Perioperative data as well as incidence of disease recurrence at the primary site or distant metastasis was compared in patients with at least 6 months follow-up.

RESULTS

As compared with patients with ONU-BCR, the patients with LNU-BCR had significantly shorter operative time, lower estimated blood loss, shorter time to oral intake, lower analgesic dose, shorter duration of analgesic use, shorter duration of incision drainage tube, shorter time to ambulation out of bed and reduced postoperative hospital stay (all, p < .05). No significant difference in postoperative complications or incidence of bladder carcinoma recurrence and distant metastasis during the follow-up period was observed.

CONCLUSIONS

The modified LNU-BCR represents an effective and safe alternative technique to ONU-BCR with the advantages of reduced invasiveness, bleeding and hospitalization.

Assessing urology and nephrology research activity in Arab countries using ISI web of science bibliometric database

BACKGROUND

Bibliometric analysis is increasingly being used for research assessment. The main objective of this study was to assess research output in Urology and Nephrology subject from the Arab countries. Original scientific articles or reviews published from the 21 Arab countries in "Urology and Nephrology" subject were screened using the ISI Web of Science database. Research productivity was evaluated based on a methodology developed and used in other bibliometric studies by analyzing the annual productivity, names of journals, citations; top 10 active institution and authors as well as country contribution to Urology and Nephrology research.

RESULTS

Three thousand and seventy six documents in "urology and nephrology" subject category were retrieved from 104 journals. This represents 1.4% of the global research output in "urology and nephrology". Four hundred and two documents (12.66%) were published in Annales D Urologie Journal. The h-index of the retrieved documents was 57. The total number of citations, at the time of data analysis, was 30401 with an average citation of 9.57 per document. Egypt, with a total publication of 1284 (40.43%) ranked first among the Arab countries in "urology and nephrology" subject category. Mansoura University in Egypt was the most productive institution with a total of 561 (15.33%) documents. Arab researchers collaborated most with researchers from the United States of America (226; 7.12%) in urology and nephrology research.

CONCLUSION

The present data reveals a good contribution of some Arab countries to the field of "urology and nephrology". More efforts are needed by some other Arab countries to bridge the gap in urology and nephrology research. Overall, the quality of urology/nephrology research is considered relatively high as measured by h-index. Cooperation in urology/nephrology research should be encouraged in the Arab world to bridge the gap with that from developed countries.

Retroperitoneal hand-assisted laparoscopic nephrectomy and partial nephrectomy

The purpose of the present paper is to describe our technique and experience with retroperitoneal hand-assisted laparoscopic (HAL) nephrectomies as an alternative to the transperitoneal approach. Eight retroperitoneal HAL nephrectomies and one partial nephrectomy were performed. Several excisional techniques were employed incorporating the Harmonic scalpel or Ligasure device. Hemostatic agents were used to cover the renal defect. Surgical bolsters were sutured to the renal capsule with pleget reinforcements to aid in hemostasis. The average operative time was 210 min and estimated blood loss 110 mL. Mean change in hematocrit was 3 units and creatinine was 1 point. No patient required a transfusion. There were no major complications, with a mean follow-up of fourteen months. On average, patients resumed oral intake in 2 days, and were discharged in 3 days. Pathological examination revealed that two lesions were benign and seven malignant. Tumor diameter averaged 3 cm. There were no positive surgical margins. In conclusion, we have demonstrated the feasibility of retroperitoneal laparoscopic hand-assisted nephrectomy and partial nephrectomy surgery for solid renal masses.

Radical cystectomy with W-shaped orthotopic ileal neobladder constructed with non-absorbable titanium staples-long term follow-up

PURPOSES

We retrospectively assessed our experience with the W-shaped orthotopic ileal pouch, which was constructed with non-absorbable titanium staples. For these purpose, we discuss the results of bladder capacity, urinary continence and early and long-term postoperative complications.

MATERIALS AND METHODS

We included in the study 17 patients who underwent radical cystoprostatectomy followed by construction of an orthotopic W-shaped ileal pouch between October 2000 and November 2009. A 65-70 cm segment of ileum was isolated and prearranged into a W-configuration, leaving two 10 cm intact segments on both sides of the ileal fragment. In our technique we entirely anatomized all adjacent limbs in order to create a sphere-shaped pouch. The ureters were directly anastomized to both intact segments of the ileal division. All our patients underwent pouchscopy 6 months after operation and annually.

RESULTS

Mean operative time for neobladder reconstruction and ureteral anastomoses was 87 ± 7.67 minutes. In one patient a leak from the ileo-ileal anastomosis was confirmed on the 3rd day after operation. In 2 cases unilateral stricture of the ureteral-neobladder anastomosis was documented. Staple lines were mostly covered with ileal mucosa after 6 months. The mean functional bladder capacity was 340 ± 27.6 mL and 375 ± 43.4 mL at 6 and 12 months, respectively. First-year daytime and nighttime continence was good and acceptable in 90% and 78% of patients, while it increased to 95% during the 2nd year.

CONCLUSIONS

The long term follow-up shows that non-absorbable titanium staples can be safely used for creation of an orthotopic ileal neobladder. However, these data should be further validated in a larger series of patients.

The technique of single stage pure robotic nephroureterectomy

PURPOSE

To describe a novel technique for a single setup approach for robotic radical nephroureterectomy (RANU) that does not require patient repositioning, port reassignment, or redocking of the robotic arms.

MATERIALS AND METHODS

Twenty consecutive patients underwent RANU at a single institution between January 2009 and January 2012. We implemented a unique port placement strategy based on a modified paramedian line (MPL), which allowed sufficient access to both the upper abdomen and the deep pelvis for radical NU with bladder cuff excision and concomitant lymphadenectomy.

RESULTS

The mean operative time was 161.3 minutes (range 91-330 minutes), mean estimated blood loss was 98.8 (range 50-200), and the mean hospital stay was 3 days (median 2 days, range 1-16 days). None of the procedures were converted to open or required blood transfusions. Lymphadenectomy was performed on 16 out of 20 patients, and the mean number of lymph nodes removed per patient when lymphadenectomy was performed was 14.1 (range 2-35). Three patients had positive lymph nodes. One patient had prolonged postoperative ileus, and one had a hospital course that was complicated by pneumonia. Mean patient follow-up was 13.5 months (range 1-24 months); one patient was found to have a recurrence at 3 month follow-up.

CONCLUSION

The use of our MPL line for novel port placement allows for an effective, efficient, and reproducible method for RANU without the need for repositioning of the patient or the robot.

Surgical management for upper urinary tract transitional cell carcinoma (UUT-TCC): a systematic review

Surgical management of upper urinary tract transitional cell carcinoma (UUT-TCC) has significantly changed over the past two decades. Data for several new surgical techniques, including nephron-sparing surgery (NSS), is emerging. The study systematically reviewed the literature comparing (randomised and observational studies) surgical and oncological outcomes for various surgical techniques MEDLINE, EMBASE, Cochrane Library, CINAHL, British Nursing Index, AMED, LILACS, Web of Science, Scopus, Biosis, TRIP, Biomed Central, Dissertation Abstracts, ISI proceedings, and PubMed were searched to identify suitable studies. Data were extracted from each identified paper independently by two reviewers (B.R. and B.S.) and cross checked by a senior member of the team. The data analysis was performed using the Cochrane software Review manager version 5. Comparable data from each study was combined in a meta-analysis where possible. For dichotomous data, odds ratios with 95% confidence intervals (CIs) were estimated based on the fixed-effects model and according to an intention-to-treat analysis. If the data available were deemed not suitable for a meta-analysis it was described in a narrative fashion. One randomised control trial (RCT) and 19 observational studies comparing open nephroureterectomy (ONU) and laparoscopic NU (LNU) were identified. The RCT reported the LNU group to have statistically significantly less blood loss (104 vs 430 mL, P < 0.001) and mean time to discharge (2.30 vs 3.65 days, P < 0.001) than the ONU group. At a median follow-up of 44 months, the overall 5-year cancer-specific survival (CSS; 89.9 vs 79.8%) and 5-year metastasis-free survival rates (77.4 vs 72.5%) for the ONU were better than for LNU, respectively, although not statistically significant. A meta-analysis of the observational studies favoured LNU group for lower urinary recurrence (P < 0.001) and distant metastasis. The meta-analyses for local recurrence for the two groups were comparable. One retrospective study comparing ONU with a percutaneous approach for grade 2 disease reported no significant differences in CSS rates (53.8 vs 53.3 months). Three retrospective studies compared NSS and radical NU, and reported no significant differences in overall CSS and recurrence-free survival between the two approaches. Five retrospective studies compared various techniques of en bloc excision of the lower ureter. No technique was reported to be better (operative and oncological) than any other. This review concludes that there is a paucity of good quality evidence for the various surgical approaches for UUT-TCC. The techniques have been assessed and reported in many retrospective single-centre studies favouring LNU for better perioperative outcomes and comparable oncological safety. The reported observational studies data is further supported by one RCT.

Transperitoneal laparoscopic nephroureterectomy for native upper tract urothelial carcinoma in renal transplant recipients

PURPOSE

To analyze the safety and clinical outcome of laparoscopic nephroureterectomy (LNUT) for native upper tract urothelial carcinoma (UC) in renal transplant (RT) recipients.

METHODS

We conducted a retrospective analysis of 956 RT recipients from January 2003 to December 2010 to evaluate the benefit of LNUT for patients who were diagnosed with de novo UC after renal transplantation.

RESULTS

Women predominated (10/11, 91 %) in the 11 patients with upper tract UC who underwent LNUT. Five patients underwent LNUT ipsilateral to the transplanted kidney, 4 patients underwent contralateral LNUT, and 2 patients underwent bilateral LNUT. Nine were operated with LNUT combining resection of bladder cuff, 2 with right ureteral cancer underwent open ureterectomy with bladder cuff due to severe adhesions attached to the lesion. The mean surgical duration was 184.2 min (105-305), the mean blood loss was 182.3 ml (20-500), and the mean hospitalization time was 6.7 days (5-9). The mean levels of preoperative and postoperative serum creatinine were 0.99 mg/dl (0.78-1.16) and 1.01 mg/dl (0.89-1.18), respectively. No intraoperative complications occurred. One patient died of multiple metastases at 13 months after LNUT. The mean follow-up of the remaining 10 patients after diagnosis was 21.7 months (3-48). Two patients had recurrent bladder cancer and underwent transurethral resection of the tumor. Eight patients showed no evidence of disease during the follow-up.

CONCLUSIONS

LNUT is a safe and effective approach with low morbidity in transplant recipients, and this therapy provides less trauma, quicker recovery, and acceptable oncological outcomes.

Laparoscopic versus open nephroureterectomy for the treatment of upper urinary tract urothelial carcinoma: a systematic review and cumulative analysis of comparative studies

CONTEXT

Laparoscopic nephroureterectomy (LNU) has increasingly been used as a minimally invasive alternative to open nephroureterectomy (ONU), but studies comparing the efficacy and safety of the two surgical procedures are still limited.

OBJECTIVE

Evaluate the oncologic and perioperative outcomes of LNU versus ONU in the treatment of upper urinary tract urothelial carcinoma.

EVIDENCE ACQUISITION

A systematic review and cumulative analysis of comparative studies reporting both oncologic and perioperative outcomes of LNU and ONU was performed through a comprehensive search of the Medline, Embase, and the Cochrane Library electronic databases. All analyses were performed using the Review Manager (RevMan) v.5 (Nordic Cochrane Centre, Copenhagen, Denmark) and Meta-analysis In eXcel (MIX) 2.0 Pro (BiostatXL) software packages.

EVIDENCE SYNTHESIS

Twenty-one eligible studies (1235 cases and 3093 controls) were identified. A significantly higher proportion of pTa/Tis was observed in LNU compared to ONU (27.52% vs 22.59%; p = 0.047), but there were no significant differences in other stages and pathologic grades (all p>0.05). For patients who underwent LNU, the 5-yr cancer-specific survival (CSS) rate was significantly higher, at 9% (p = 0.03), compared to those who underwent ONU, while the overall recurrence rate and bladder recurrence rate were notably lower, at 15% (p = 0.01) and 17% (p = 0.02), respectively. However, there were no statistically significant differences in 2-yr CSS, 5-yr recurrence-free survival (RFS), 5-yr overall survival (OS), 2-yr OS, and metastasis rates between LNU and ONU (all p>0.05). Moreover, there were no significant differences between LNU and ONU in terms of intraoperative complications, postoperative complications, and perioperative mortality (all p>0.05). The results of our study were mainly limited by the retrospective design of most of the individual studies included as well as selection biases based on different management of regional lymph nodes and pathologic characteristics.

CONCLUSIONS

Our data suggest that LNU offers reliable perioperative safety and comparable oncologic efficacy when compared to ONU. Given that some limitations cannot be overcome, well-designed prospective trials are needed to confirm our findings.

Conversions in laparoscopic renal surgery: causes and outcomes

PURPOSE

We examined conversions in laparoscopic renal surgery, evaluating the causes and outcomes.

PATIENTS AND METHODS

A single institution review of all laparoscopic renal surgeries, excluding renal donors, over a nine-year period was performed. Cases were evaluated for intraoperative results, conversions, and complications.

RESULTS

399 laparoscopic renal surgeries were identified (394 available for review) with 41 conversions (31 open, 8 hand-assisted, 2 retroperitoneal). Intraoperative and postoperative complications occurred in 3.0% and 12.2%, respectively. The most common reason for conversion was a lack of progress (20), followed by difficult anatomy (8), tumor thrombus (5), and bleeding (4). Open conversion rates for hand-assisted laparoscopic (HAL), transperitoneal laparoscopic, retroperitoneal laparoscopic (RPL), and robot-assisted were 17.1%, 6.9%, 13.2%, and 1.8%, respectively, although HAL and RPL were more often used for bilateral procedures, previous abdominal surgery, and large specimens (P<0.05). Surgical indication significantly impacted perioperative outcome, where autosomal dominant polycystic kidney disease and partial nephrectomy were associated with the highest rate of open conversion (13%), while nephroureterectomy had the highest rate of complications (40%). Cases in which there were large specimens weighing over 1500 g were converted in 40% of cases vs 8.2% for smaller specimens, P<0.001. Previous abdominal surgery did not impact conversion rate (11.9% without vs 9.3% with previous surgery, P=0.401). Cases that were converted had a significantly higher blood loss, operative time, transfusion rate, hospital stay, and complication rate (P<0.05).

CONCLUSIONS

Rate of conversion to an open procedure is significantly impacted by surgical indication, specimen size, and surgical technique. Any conversion is associated with an increased perioperative morbidity.

Laparoendoscopic single-site nephrectomy using a modified umbilical incision and a home-made transumbilical port

PURPOSE

To assess the clinical utility of laparoendoscopic single-site surgery (LESS) nephrectomy using a modified umbilical incision and home-made transumbilical port in cases requiring extirpative surgery.

MATERIALS AND METHODS

Initial consecutive 18 patients underwent LESS nephrectomies that were performed by a single surgeon. A home-made port was placed through a modified umbilical incision, the length of which had preoperatively been determined. The laparoscopic transperitoneal nephrectomy procedures were performed with various combinations of standard and articulating laparoscopic instruments. Patient characteristics and perioperative outcomes, including pathologic results, were recorded prospectively.

RESULTS

All 18 extirpative surgeries, including simple nephrectomy (eight cases), radical nephrectomy (nine cases), and nephroureterectomy (one case), were completed successfully. The median operation time was 167 min (range 82-220), and the median blood loss was 250 mL (range 0-1050). All specimens were extracted intact through a modified umbilical incision (median length 2.5 cm, range 1.5-6.0). Final pathological analysis revealed a nonfunctioning kidney in five cases, a dysplastic kidney in three cases, a mixed epithelial and stromal tumor in one case, renal cell carcinoma in eight cases (T1: five cases, T3: three cases), and Ta ureter transitional cell carcinoma in one case.

CONCLUSION

LESS nephrectomy using a home-made port and modified umbilical incision is feasible with both minimal incision and cost-effective. Our technique may be more useful for extirpative procedures in which a specimen needs to be removed intact, because incision length can be freely adjusted. Prospective comparisons are warranted to more clearly elucidate the utility of this surgical technique.

[A novel technique for distal ureterectomy and bladder cuff excision]

INTRODUCTION

We describe a novel endoscopic approach and provide a literature review for the "en bloc" dissection of the distal ureter and bladder cuff during laparoscopic radical nephroureterectomy using a transvesical single port approach under pneumovesicum.

MATERIALS AND METHODS

The procedure was performed in an 80-year old male with a history of gross hematuria due to left renal pelvic TCC and no history of prior bladder TCC. Laparoscopic radical nephroureterectomy was performed and the ureter was dissected down to the bladder and clipped. A single-port device was inserted transvesically and pneumovesicum established. A full thickness incision of the bladder around the ureter was performed with progressive intravesical mobilization of the distal ureter. Subsequently, a water-tight closure of the bladder defect was achieved. The distal ureter, together with the bladder cuff, was then delivered en bloc laparoscopically with the specimen.

RESULTS

The operating time (LESS radical nephroureterectomy, RPLND, and bladder cuff excision) was 6hours and 15minutes. The bladder cuff time was 45minutes. There were no intra or postoperative complications and the catheter was removed after 6 days. Histopathological analysis showed kidney-invasive papillary urothelial cancer, pT3 pN0 (0/7) G3.

CONCLUSION

The distal ureter and bladder cuff techniques have not yet been standardized. Management of the bladder cuff with a single port is feasible. Additional studies are needed to identify the best approach for management of the distal ureter at the time of laparoscopic nephroureterectomy.

Initial experience with laparoendoscopic single-site nephrectomy and nephroureterectomy in children

OBJECTIVES

To assess the clinical utility and safety of laparoendoscopic single-site surgery (LESS) nephrectomy and nephroureterectomy in children by analyzing 6 consecutive cases performed by a single surgeon.

METHODS

Since March 2009, we have been performing LESS nephrectomy and nephroureterectomy in children. The indications have been recurrent pyelonephritis related to vesicoureteral reflux with an atrophic kidney and continuous urinary incontinence related to an ectopic ureter. A homemade port was placed through an umbilical incision, and the laparoscopic transperitoneal nephrectomy procedures were performed using various combinations of standard and articulating laparoscopic instruments. The patients undergoing a LESS procedure were evaluated prospectively, and the data were collected during and after surgery.

RESULTS

A total of 6 procedures, including nephrectomy (4 cases) and nephroureterectomy (2 cases), were completed without intraoperative or postoperative complications. The median operation time was 112 minutes (range 90-148), and the median blood loss was 0 mL (range 0-50). All patients received only oral ibuprofen syrup for pain control and were discharged on postoperative day 2. As the surgeon gained experience, the length of the umbilical incision was decreased from 2.0 to 1.0 cm.

CONCLUSIONS

Pediatric LESS nephrectomy and nephroureterectomy can be performed safely with a very small incision. LESS performed by an experienced laparoscopic surgeon has the potential to become an alternative first-line therapy for ablative procedures in children.

Retroperitoneal laparoscopic nephroureterectomy with bladder cuff excision for native upper tract transitional cell carcinoma ipsilateral to a transplanted kidney

OBJECTIVES

We present preliminary experience of retroperitoneal laparoscopic nephroureterectomy (RPLNU) with bladder cuff excision by combining cystoscopic resection with open transperitoneal dissection for native upper urinary tract transitional cell carcinoma (UUT-TCC) ipsilateral to a transplanted kidney.

METHODS

Thirteen renal recipients with native UUT-TCC ipsilateral to a transplanted kidney were operated on with RPLNU between November 2005 and August 2008. Retroperitoneal laparoscopic nephrectomy was performed first and followed by cystoscopic excision of ipsilateral ureteral orifice with bladder cuff. A 6-cm midline lower abdominal incision was made. The distal ureter was dissected transperitoneally into the intramural segment, and the intact specimen was removed manually via the same incision. The cystostomy was generally not sutured.

RESULTS

The mean operation time was 264 minutes. The mean estimated blood loss was 256 mL. Three patients needed blood transfusion. No open conversion was required. Two patients experienced minor complications. Pathologic findings confirmed UUT-TCC in all patients with 8 of the pelvis and 7 of the ureter. Four were involved with bladder TCC. With the mean follow-up of 30 months, none of the patients developed retroperitoneal recurrence or distant metastasis, 2 of the 4 patients with bladder TCC had recurrence in the bladder, and 2 had contralateral UUT-TCC after the first unilateral nephroureterectomy.

CONCLUSIONS

RPLNU with bladder cuff excision by combining cystoscopic resection with open transperitoneal dissection might be a safe and feasible alternative for native UUT-TCC ipsilateral to a transplanted kidney with acceptable oncological outcomes.

Does the surgical technique for management of the distal ureter influence the outcome after nephroureterectomy?

Study Type - Therapy (case series) Level of Evidence 4 What's known on the subject? and What does the study add? The resection of the distal ureter and its orifice is an oncological principle during radical nephroureterectomy which is based on the fact that it represents a part of the urinary tract exposed to a considerable risk of recurrence. After removal of the proximal part it is hardly possible to image or approach it by endoscopy during follow-up. Recent publications on survival after nephroureterectomy do not allow the conclusion that removal of distal ureter and bladder cuff are useless. Several techniques of distal ureter removal have been described but they are not equivalent in term of oncological safety. • The standard treatment of upper urinary tract urothelial carcinomas (UUT-UCs) must obey oncological principles, which consist of a complete en bloc resection of the kidney and the ureter, as well as excision of a bladder cuff to avoid tumour seeding. • The open technique is the 'gold standard' of treatment to which all other techniques developed are necessarily compared, and various surgical procedures have been described. • The laparoscopic stapling technique maintains a closed system but risks leaving behind the ureteric and bladder cuff segments. • Transvesical laparoscopic detachment and ligation is a valid approach from an oncological stance but is technically difficult. The major inconvenience of the transurethral resection of the ureteric orifice and intussusception techniques is the potential for tumour seeding. • Management of the distal ureter via the robot-assisted laparoscopic method is technically feasible, but outcomes from these procedures are still preliminary. • Therefore, prospective comparative studies with more thorough explorations of these techniques are needed to solve the dilemma of the management of the distal ureter during nephroureterectomy. However, bladder cuff excision should remain the standard of care irrespective of the stage of the disease.

A novel bulldog clamp technique for management of a distal ureter and bladder cuff during laparoscopic nephroureterectomy

A novel technique for achieving complete laparoscopic excision of the intramural ureter with a bladder cuff is presented using the bulldog clamp without opening the urinary tract.

A sealed bladder cuff technique during laparoscopic nephroureterectomy utilizing the LigaSure electrosurgical device: laboratory and clinical experience

INTRODUCTION

Laparoscopic nephroureterectomy (LNU) is a safe, minimally invasive approach for management of upper tract urothelial tumors. Controversy exists over the optimal technique for the distal ureter and bladder cuff (DUBC) excision. We examined the novel technique of using the LigaSure bipolar electrosurgical device in laboratory investigations and during clinical LNU to manage the DUBC.

PATIENTS AND METHODS

Initial investigations were undertaken in the porcine model. Areas of both normal porcine ureters and bladders, and ex vivo human ureters from radical nephrectomy specimens were sealed with the LigaSure and stained with nicotinamide adenine dinucleotide (NADH) and hematoxylin and eosin to examine the length of treatment effect and the viability of the ablated tissue. Clinically, we performed 22 LNU for proximal urothelial tumors using the LigaSure for the management of the DUBC. Intraoperative cystoscopy assessed cuff resection and bladder leakage. On postoperative day 10, a cystogram was performed.

RESULTS

In the porcine model, the technique sealed the bladder effectively with a mean burst pressure of 14 mm Hg. Cellular staining revealed no viable urothelial tissue in the seal area and an additional 2 mm outside this area. Eighteen patients had a successful seal/ablation intraoperatively. Cystoscopy revealed cautery artifact and blanching over the former position of the ureteral orifice.

CONCLUSION

The LigaSure device ablates and seals urothelial tissue with no viable cells in the clamped and adjacent blanched tissue. Our technique is technically feasible, removes an adequate bladder cuff, typically maintains a closed urinary system, and adheres to sound oncological principles. This procedure could be performed in both laparoscopic and open nephroureterectomy for proximal upper tract transitional cell tumors.

[Hand-assisted laparoscopic nephroureterectomy for the treatment of upper urinary tract transitional cancer]

OBJECTIVE

To report our series of patients undergoing hand-assisted laparoscopic nephroureterectomy (HALNU) using the pluck-off procedure.

MATERIALS AND METHODS

Twenty patient undergoing HALMU for upper urinary tract urothelial tumors from November 2002 to December 2007 were assessed. Demographic, clinical, surgical, and oncological data were assessed.

RESULTS

Mean patient age was 69 years. Mean operating time and mean intraoperative bleeding were 176 min and 381 mL respectively. Twenty percent of patients required transfusion of blood products. Conversion to open surgery was not required in any patient. Major and minor complications occurred in 25% and 30% of patients respectively.Mean time to oral intake was 48 hours, and mean hospital stay was 5 days.Pathological study revealed transitional cell carcinoma in all cases: grade I in 5%, grade II in 60%, and grade III in 35% of patients. Clinical stage was pTa in 5%, pT1 in 20%, pT2 in 25%, pT3 in 40%, and pT4 in 10% of patients. A bladder recurrence rate of 30% and a 49% overall survival were seen after a mean follow-up of 33 months (5-73). Six-year cancer-specific survival was 67%. No patient developed either peritoneal or surgical bed recurrence.

CONCLUSIONS

HALMU using the pluck-off procedure is a feasible, safe, and effective surgery. Both surgical and oncological results are similar to those of open surgery and pure laparoscopy.

Treatment of upper urinary tract urothelial carcinoma

Upper urinary tract urothelial carcinoma (UUTUC) is relatively rare, occurring in only 5% of all urothelial cancers. It has not been as extensively studied and reviewed as carcinoma of the bladder. UUTUC has a propensity for multifocality, local recurrence, and development of metastases, which argues for an aggressive treatment approach. Open radical nephroureterectomy (ORNU) with removal of an ipsilateral bladder cuff still remains the gold standard treatment for patients with UUTUC and a normal contralateral kidney, which, however, is being challenged by minimally invasive approaches, such as endoscopic and laparoscopic approaches. They are rapidly evolving as reasonable alternatives of care depending on grade and stage of disease. Adjuvant therapy seems to be safe, although its efficacy is debatable. Immunotherapy appears to be most effective in patients with upper-tract carcinoma in situ. Chemotherapy and radiotherapy also show some improvement in recurrence rates, but there have been no randomized, prospective trials. Gene and molecular-targeted therapy is expected. Several controversies remain in our management, including a selection of endoscopic versus laparoscopic approaches, management strategies on the distal ureter, the role of lymphadenectomy, and the value of immunotherapy, chemotherapy, radiotherapy and genetics and molecular markers in UUTUC. Aims of this paper are to critically review the treatment of UUTUC.

Laparoscopic nephroureterectomy for upper urinary tract transitional cell carcinoma

OBJECTIVE

Open radical nephroureterectomy has been the standard treatment for upper urinary tract transitional cell carcinoma (TCC). Laparoscopic nephroureterectomy (LN) offers the advantages of a minimally invasive approach. We report our experience with both hand-assisted LN (HALN) and total LN.

MATERIAL AND METHODS

A retrospective review was performed of all patients who underwent HALN and LN for the treatment of localized upper urinary tract TCC between 2001 and 2005. Histology of the operative specimen confirmed urothelial carcinoma in all cases. Their demographic data, perioperative parameters and follow-up data were assessed.

RESULTS

There were 31 patients with a median age of 71 years (range 39-82 years). The mean operating time was 236 min (range 120-350 min) and mean blood loss was 365 ml (range 200-2000 ml). There were no conversions to open surgery. The mean length of hospitalization was 7 days (range 3-30 days). Clear oncological margins were achieved in 27 cases. The mean duration of follow-up was 28 months (range 2-55 months).

CONCLUSIONS

HALN and LN are safe and effective alternatives to open surgery for the treatment of upper urinary tract TCC. Medium-term follow-up showed favourable oncological results. A larger sample size and a longer follow-up period are required before HALN and LN can be considered standard treatments for upper urinary tract TCC.

Long-term outcome of hand-assisted laparoscopic nephroureterectomy for pathologic T3 upper urinary tract urothelial carcinoma

PURPOSE

To determine the feasibility and long-term outcomes of hand-assisted laparoscopic nephroureterectomy (HALNU) compared with open nephroureterectomy (ONU) in the management of pT(3)N0 upper urinary tract urothelial carcinoma (UUT-UC).

PATIENTS AND METHODS

Between January 1994 and December 2005, 21 patients who underwent HALNU for stage pT(3)N0 UTT-UC were matched and compared with 31 patients who underwent ONU. The oncologic out-comes, including bladder recurrence, recurrence-free survival, cancer-specific survival, and overall survival, were statistically analyzed.

RESULTS

The median follow-up period in the HALNU group was 72 months (range 33-111 months) and 115 months in the ONU group (range 24-161 months). Patient age, sex, body mass index, tumor size, specimen weight, and American Society of Anesthesiologists classification showed no significant difference between the two groups. The HALNU group had statistically less blood loss than the ONU group (113 mL versus 487 mL; P = 0.02). The average hospital stay and doses of narcotic analgesics were significantly less in the HALNU group than the ONU group. The complication and bladder recurrence rates were similar between the two groups. The 5-year recurrence-free survival, cancer-specific survival, and overall survival were also comparable in both groups.

CONCLUSIONS

HALNU is a safe and efficacious procedure with comparable long-term oncologic outcomes in comparison with ONU in treating patients with locally advanced pT(3)N0UUT-UC.

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.