Pure Laparoendoscopic Nephroureterectomy for Pelvic/Upper Ureteric Malignancy: Points of Technique with Outcome Analysis

Introduction:

The optimal treatment for unilateral pelvic/upper ureteric malignancy with contralateral salvageable renal unit is radical nephroureterectomy with bladder cuff. Although this radical surgical exercise can be well accomplished through a minimally invasive approach, several technical variations of this exercise have been in vogue. ^1,2 We present a video demonstration of our technique of pure laparoendoscopic radical nephroureterectomy, discuss the key aspects of this technique, and analyze the outcome.

Methods:

Patients were evaluated in detail. Imaging included ultrasonogram, computed tomogram urography, or magnetic resonance urogram. Cystoscopy was performed to rule out bladder pathologies. Patients with unilateral pelvic or upper ureteric lesions of probable malignant etiology were offered laparoendoscopic extirpation following the same technique. First, endoscopic management of the ureteric orifice was undertaken. The periureteric resection margin was point mapped, followed by deepening the margin up to full thickness of detrusor. A generous priureteral cuff was generated maintaining some attachment with bladder. Hemostasis was achieved and a three-way 22F Foley's catheter inserted. The position was then changed to lateral decubitus and laparoscopic radical nephroureterectomy undertaken. After colonic reflection, the first exercise was to secure control over the ureterogonadal pedicle by applying a hem-o-loc clip at level of mid/lower ureter confluence. All ureteral handling was avoided till this step. Thereafter, the renal hilum was entered and control was achieved over the vascular pedicle. Radical nephrectomy was completed. Distal ureterectomy was then conducted in steep Trendelenberg decubitus. The remaining attachments of the bladder cuff were lysed. Lymphadenectomy was performed as per merit. Vesicotomy was closed taking care to appose the breached mucosa. A thorough peritoneal wash was given with tumoricidal irrigant. The specimen was extracted through a Pfannenstiel incision. Perurethral catheter was removed after 2 weeks. Postprocedure patients were followed up on a 3-monthly schedule with periodic imaging and surveillance cystoscopy.

Results and Discussion:

Between 2006 and 2011, about 22 similar procedures were performed. Mean age was 57.6 years, mean body mass index was 23.6 kg/m², and 17 were men and 5 women. All procedures could be completed through a laparoendoscopic approach. No major intraoperative or postoperative happenings were recorded. Specimen pathology reported transitional cell carcinoma in all. All surgical margins were tumor-free. Mean hospital stay was 5.5 days. At a median follow-up of 13.4 months (range 5–36 months), all patients are disease-free. Our technique of pure laparoendoscopic radical nephrouretrectomy allows satisfactory extirpation of lesions involving renal pelvis or upper ureter with preservation of goals of minimally invasive access. Minimal handling of the ureter and occlusion of the ureter at mid/lower ureter level before ureteral manipulation are key aspects to avoid translocation of neoplastic cells during renal mobilization. The oncological outcome following this exercise is acceptable.

No competing financial interests exist.

Runtime of video: 7 mins 42 secs