Introduction and Objectives
Urologists are still looking for the best method of accomplishing a nephroureterectomy (NUE). While a laparoscopic nephrectomy (LNE) as a part of NUE is yet broadly accepted, removing the ureter is still problematic – the approach (endoscopic, open, and laparoscopic) and consequence of steps. We present results of a recently described complete laparoscopic NUE (CLNU) with thermosealing system (Tsivian et al: Eur Urol, 2007, 52; 1015–9).
Material and Methods
We start CLNUE in the flank position with standard LNE through 4 (left side) or 5 ports (right side). The ureter is liberated with harmonic scalpel or thermosealing system (Ligasure Advance®) to the urinary bladder. The gonadal vein must to be cut off. Ureter is excised with bladder cuff with thermosealing system (Ligasure Atlas®) introduced through another suprapubic port 10 mm. Specimen is removed in bag through muscle splitting incision of the lower abdomen. A permanent bladder catheter is removed on the 5th postoperative day. From 4/2008 to 6/2009, 19 patients underwent NUE. Three LNUE with an open ureterectomy for an advanced tumour of the distal ureter, one open NUE with a lymphadenectomy for an advanced tumour of pelvis. Fifteen underwent CLNU. They are evaluated in details.
Results
Eight men and seven women, the mean age 68±8 (57–80) years. Five times on the left side, 10× on the right side. Tumour was in the renal pelvis 8×, in ureter 4× (2× in the distal ureter). The mean time of operation was 126±21 (86–160) min. In three cases, CLNUE was preceded 3× with cystoscopy (1× with transurethral resection of urinary bladder tumour) and 3× with diagnostic ureteroscopy, the time of the endoscopies wasn’t included to the time of CLNUE. In one woman, CLNUE was performed ipsilateral to a transplanted kidney to the iliac fossa. The mean blood loss was 62± 57 (0–200) ml. The mean weight of specimen was 478±211 (210–1067) g. The histology was 12× urothelial cancer (1 pT3, 2 pT2, 5 pT1, 4 pTa), 1× clear renal cell carcinoma pT3aG2, 1× oncocytoma and 1× xantogranulomatous pyelonephritis. Complications were rare, only urinary tract infection with B. coli on 6th postoperative day. Fourteen patients were discharged from hospital on 7±2 (5–11) day, patient with transplanted kidney was transferred on 3rd postoperative day to department of nephrology. The mean follow-up is 8 (1–14) months; patient with transplanted kidney underwent TURT for recurrent non-muscle invasive bladder tumour.
Conclusions
CLNUE is mininvasive, fast and safe method without need to change patient's position. It is feasible even ipsilateral to a transplanted kidney. Open approach is reserved for advanced tumours only.We recommend starting NUE always with LNE. Liberation of ureter in pelvis is technically challenging, in case of any problems in pelvis, open ureterectomy can be performed. Long term oncological results are unknown. The work was supported by Czech government research project MSM 0021620819.
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© 2009 European Association of Urology. Published by Elsevier Inc. All rights reserved.
