Adjunctive Procedures During Laparoscopic Radical Nephroureterectomy Lymphadenectomy And Adrenalectomy

Up to one-third of patients who undergo nephroureterectomy may be found to have lymph node metastasis (48). No specific data are available to assess the impact of lym-phadenectomy for upper tract transitional cell carcinoma during laparoscopic radical nephroureterectomy. However, data from open series and data from the treatment of bladder transitional cell carcinoma, from which some of the natural history of disease can be extrapolated, suggest an important role for lymphadenectomy in these cases. In one respect this role may be only limited to staging. This would strongly influence consideration of follow-up imaging and adjuvant strategies because patients with lymph

TABLE4 ■ Histopathologic Results from Eight Contemporary International Single-Institution Series of Laparoscopic Radical Nephroureterectomy

TABLE4 ■ Histopathologic Results from Eight Contemporary International Single-Institution Series of Laparoscopic Radical Nephroureterectomy

McNeill,

Shalhav,

Jarrett,

McGinnis,

Stifelman,

Matsui,

Yoshino,

Matin,

2000 (14)

2000 (15)

2001 (16)

2001 (23)

2001 (44)

2002 (20)

2003 (21)

2004 (35)

Number

25

25

25

30

11

17

23

60

PSM (%)

-

— a

4

0

0

8.3

pTis (%)

-

-

73 (pTa-pT1)

17

6.7

PTa (%)

-

40

23

22

30

pT1 (%)

0

28

27

53 (<pT1)

22

13

pT2 (%)

4

8

10

27 (>pT2)

12

4

5

pT3 (%)

36

20

37

23

30

31.7

pT4 (%)

-

0

0

0

4

8.3

Grade 1

20

28

20

18

6

9

13

Grade 2

24

32

35

52

26

Grade 3

52

52 (>G2)

44

82 (>G2)

59

39

60.7

aFour patients underwent morcellation; surgical margins were negative in all others. Source: Modified from Ref. 28.

node metastasis have a high risk of distant failure and are unlikely to be cured by surgery alone. In another respect, lymphadenectomy may have a therapeutic role in a subset of patients, as those found to have minimal nodal disease are potentially curable (49). As lymphadenectomy adds minimal morbidity and because preoperative imaging can miss minimal nodal disease, our routine practice has been to perform a regional lymphadenectomy in patients undergoing laparoscopic radical nephroureterectomy, either en bloc with the renal specimen or as a separate procedure. Involvement of the adrenal by transitional cell carcinoma, on the other hand, is very unusual. If preopera-tive computed tomography scan shows no abnormalities of the adrenal and if deemed surgically feasible, sparing of the adrenal during laparoscopic radical nephroureterec-tomy appears reasonable in most cases.

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