Laparoendoscopic Single-Site Plus One Port Nephroureterectomy: Single Center Initial Experience

Introduction

Urothelial carcinoma (UC) of the upper urinary tract is not common. The standard treatment is radical nephroureterectomy (NU), including excision of the renal unit and the ureter with bladder cuff, as well as regional lymph nodes dissection. ¹

Technologic advances have allowed transferring the benefits of minimally invasive surgery to more technically complex surgical procedures. For instance, the traditional open techniques of NU were successfully replicated using laparoscopic ² and robot-assisted approaches with a variety of bladder cuff excision techniques. ³ Recently, a large experience of 101 laparoendoscopic single-site (LESS) NUs, encompassing the experience of 15 centers, has been reported, ⁴ highlighting the paucity of data on this innovative procedure on one hand and demonstrating the wide variations of techniques, at least in part because of difficult ergonomics inherent to LESS surgery.

Our technique of radical NU has been refined over the years, transitioning from open to laparoscopic and then to the LESS approach. We report on our initial experience with a standardized technique of LESS plus one port (POP) NU for the management of upper tract UC in a single center.

Patients and Methods

After approval from the Institutional Review Board, we retrospectively reviewed our initial experience with consecutive cases of LESS-POP NU for upper tract UC.

All procedures were performed by a single surgeon (AT) between 2011 and 2012. Informed consent was obtained from all patients after detailing the alternatives, the potential risks, and benefits of the procedure. We retrieved demographic, clinical, perioperative, and pathologic data.

Data are presented as median (interquartile range) and number (percent) unless otherwise specified.

Surgical technique

Under general anesthesia, the patient is placed in the lateral flank decubitus position. After proper prepping and draping, a semicircular incision is made at the umbilicus for insertion of the LESS port (Octo™Port, Dalim Surgnet, Seoul, Korea). Pneumoperitoneum was established at 15 mm Hg CO₂ pressure. Under visual guidance, an additional 12-mm laparoscopic port was placed in the lower abdominal quadrant. (Fig. 1) We use a 30-degree rigid camera and standard reusable laparoscopic instruments (Storz, Tutlingen, Germany).

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FIG. 1.

Trocars placement.

After inspection of the abdominal cavity, the bowel is reflected off the wall along the line of Toldt, exposing the kidney. The ureter was identified at the lower pole of the kidney, and dissection proceeded to expose the renal vessels. Once carefully dissected, renal vessels are controlled en-bloc using the EndoGIA™ (Covidien, Mansfield, MA) vascular stapler through the 12-mm port.

After hilar control, the ureter is dissected distally, exposing the detrusor fibers. The bladder cuff is created and resected extravesically in a sealed manner using the LigaSure™ (Covidien) device.

Lymph node dissection was performed as follows. For distal ureteral tumors, a pelvic lymph node dissection was performed; for tumors of the upper ureter and/or renal pelvis, para-aortic (left-sided) or paracaval (right-sided) lymph nodes were harvested.

The specimens were extracted using an EndoCatch™ (Covidien) bag either through a 2-cm vertical extension of the umbilical incision, or, in some cases, through an extension of the 12-mm port in the lower quadrant. In our initial cases, we retrieved the specimens through the lower quadrant, as we do with our standard laparoscopic NU. In the latter cases, we began extracting the specimen through a 2-cm extension of the umbilical incision. On verification of adequate hemostasis, the ports are extracted, and wounds are closed.

Results

A total of 10 consecutive patients underwent LESS POP NU between March 2011 and November 2012. Patient and tumor characteristics are detailed in Table 1. Seven patients were men; median age was 70 years, ranging from 55 to 84 years. Six procedures were left-sided and four were on the right side. Concomitant cholecystectomy was performed in two patients and previous simultaneous diagnostic ureteroscopy in three. Pelvic lymph node dissection was performed in four patients (10–18 nodes), para-aortic in three (3–22 nodes), and paracaval in two (6 and 12 nodes harvested). In one patient, lymph node dissection was not performed because of intraoperative discovery of overt metastatic disease to the fallopian tubes in the setting of T₄ local disease. In five patients, the specimens were extracted through the umbilical incision, whereas in the remainder, we used an extension of the port incision in the lower abdominal quadrant.

All 10 procedures were completed successfully without conversion to an open procedure or placement of additional laparoscopic ports. Median operative time was 217 minutes; range, 180 to 257 minutes. Cosmetic results are depicted in Figure 2.

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FIG. 2.

Postoperative appearance of the surgical scars after laparoendoscopic single-site plus one port nephroureterectomy (NU). (A) Left NU, postoperative day (POD) 1, specimen extracted through umbilical incision, Jackson-Pratt drain positioned through the additional port site. (B) Left NU, POD 6, specimen extracted through a 2-cm extension of the umbilical incision. (C) 1 year after right NU, umbilical specimen extraction. (D) 1 year after left NU, specimen extracted through extension of the additional port site.

Pathologic data are summarized in Table 1. Pathologic stage was distributed as follows: T_a in 2 patients, T₁ in 2, T₂ in 2, T₃ in 3, and T₄ in 1. High-grade TCC was identified in five patients. Two patients had node-positive disease (N₂), and one had metastatic spread (M₁).

Postoperatively, one patient experienced a urine leak and umbilical wound dehiscence (Clavien grade IIIb). The remaining nine patients had unremarkable postoperative courses. None of the patients needed opioid analgesics. Patients were routinely discharged on postoperative day 4 to 5 after cystography and catheter removal.

Discussion

LESS NU is a novel procedure and is still undergoing technical refinement. The largest to date report on LESS NU totals 101 cases performed with a variety of techniques and approaches, including robot assistance, placement of additional ports, as well as diverse techniques of bladder cuff management. In this report, we describe our single institution, single surgeon experience with LESS POP NU that addresses the challenging ergonomic aspects of the procedure while adhering to sound oncologic principles. In this initial series of 10 patients, LESS POP NU was feasible and safe offering a reproducible technique that could be replicated elsewhere.

LESS POP technique entails placing a working channel in the lower abdomen in addition to the multichannel umbilical port. While this may seem a deviation from the definition of LESS, we believe this adjustment serves a dual purpose. On one hand, it mitigates the ergonomic aspects of the procedure (i.e., triangulation, access to the intramural ureter); on the other hand, it maintains the minimally invasive nature of the procedure. In fact, the additional port site can be used for specimen extraction and/or for a drain if deemed necessary. Inoue and associates ⁵ have compared LESS POP donor nephrectomy to a standard LESS procedure and found that the addition of another port facilitated the ergonomics, significantly reduced operative time, and enabled the use of nonspecialized instruments. In fact, in a study of 101 LESS NUs, Park and colleagues ⁴ reported using an additional port in 28.7% of cases.

In this series, bladder cuff excision was performed in an extravesical manner, dissecting the intramural ureter and transecting the cuff with a LigaSure device. We have previously reported on this approach to the bladder cuff in our laparoscopic nephroureterectomy technique. ⁶ This technique allows for maintaining a sealed urinary tract, avoids additional abdominal incisions and transurethral instrumentation while not necessitating patient repositioning. There are a variety of modalities for management of bladder cuff in LESS NU. ³ In the study of Park and coworkers, ⁴ bladder cuff was not excised in 20.8% of LESS NU procedures.

Similarly, lymph node dissection was performed in all but one patient (T₄, metastatic disease) in our series. We believe that replicating the open technique is of paramount importance to preserve the oncologic principles of the procedure. In our experience, lymph node dissection, both pelvic and para-aortic/paracaval, can be safely accomplished with this technique. We harvested a median of 11 lymph nodes (3–22) with 1 to 6 nodes positive in two patients. While the templates for lymph node dissection are not well defined, hilar and para-aortic/paracaval lymphadenectomy should be performed as recommended for upper ureter and renal pelvis tumors. ¹

The limitations of the present study need to be acknowledged. First, this is but an initial series of 10 patients, and the results should be interpreted accordingly. While the reported multicenter experience is that of 101 procedures, however, these represent a variety of approaches and techniques, whereas in our study, the technique is reproducible and standardized. Second, while the purported advantages of LESS compared with conventional or robot-assisted laparoscopy are yet to be demonstrated, we believe that such advantages exist and await to be demonstrated in clinical trials. In addition, although this technique represents an oncologically sound procedure, long-term follow-up data are needed to confirm cancer control outcomes. Finally, the learning curve for this procedure is uncertain, and comparisons with standard or robot-assisted LESS NU are lacking.

Despite the limitations of this study, we report on a standardized, minimally invasive technique of LESS POP NU. We believe that this technique can extend the advantages of LESS surgery to patients needing radical NU, without compromise on the oncologic principles of extirpative surgery. Currently, LESS POP NU represents a standard treatment option for upper tract UC in our center.

Conclusions

In this initial series, LESS POP NU was feasible and safe. This minimally invasive NU technique can be considered among the other options for the treatment of patients with upper tract UC. These encouraging results need to be confirmed in larger studies, and a larger body of research is needed before widespread adoption of this technique.