Open Management Of The Distal Ureter And Bladder Cuff Following Laparoscopic Radical Nephroureterectomy

During the operation, the anesthetized patient is first placed in a modified 45° lateral decubitus position at the chest and 30° at the pelvis with the table flexed at the flank and no kidney rest. The abdomen, genitalia, and the flank are prepped and

FIGURE4 ■ Surgeon's left hand through hand assist port is used to push hemitrigone upward toward abdominal wall to facilitate bladder cuff resection using the Collins knife.

FIGURE4 ■ Surgeon's left hand through hand assist port is used to push hemitrigone upward toward abdominal wall to facilitate bladder cuff resection using the Collins knife.

draped in the standard surgical fashion. A urinary catheter is placed on the surgical field prior to the start of surgery. Then, a transperitoneal laparoscopic radical nephrectomy is performed. We believe the transperitoneal, rather than the retroperitoneal access is a superior approach for laparoscopic renal cancer surgery. It allows for a wider space to maneuver, thus allowing for a radical nephrectomy to be performed without violating the Gerota's fascia. Early clipping of the ureter immediately following division of the renal pedicle will prevent tumor cells in the urine from flowing down the ureter.

Once the laparoscopic radical nephrectomy and dissection of the ureter down to the bladder have been performed, the trocars are removed and the pneumoperitoneum released. The operating table is then turned laterally so that the patient is more supine. Of note, the patient is not repositioned. The exposure of the bladder is performed by making a classic 12 to 15 cm Gibson. The space of Retzius is entered extraperitoneally. The anterolateral aspect of the bladder and the intramural ureter are dissected. The bladder is filled with 240 mL of sterile water through the urinary catheter until it is visually distended. An anterior 4-cm longitudinal cystotomy is made, and the bladder is exposed with self-retaining retractors. A 3-0 Vicryl (polyglactin 901) suture is placed through the ureteral orifice and tied. With an anterior retraction on the suture, the ureteral orifice with a 2 cm bladder cuff is encircled and dissected with electrocautery. This is performed in a retrograde fashion until the ureteral dissection connects with the plane of the antegrade, or laparoscopic, dissection of the ureter. Once freed, a 10 cm peritoneotomy is made just superior to the bladder. The kidney is grasped and removed intact with the ureter and its bladder cuff en bloc. The ureteral orifice defect and the anterior cystotomy are closed in two layers, followed by closure of the peritoneotomy. An abdominal extraperitoneal drain is placed, and typically removed on postoperative day 2 when the drain output is less than 50 mL per eight hours. The patients are advanced to regular diet as tolerated, and are discharged home by postoperative day 2 or 3. An indwelling urinary catheter

FIGURE 5 ■ Patient in a modified dorsal lithotomy position, allowing simultaneous hand-assisted laparoscopic nephroureterectomy and access to urethra. Source: From Ref . 21.

TABLE 1 ■ Selected Recent Series of Laparoscopic Nephroureterectomy

Management of

Mean follow-up

Recurrence

Recurrence in retro-

Authors

No. of patients

Approach

distal ureter

time (mo)

in bladder (%)

peritoneum (%)

McNeill et al. (2000) (15)

25

Transperitoneal

Pluck

32.9

N/A

N/A

(16% died)

Gill et al. (2000) (17)

42

Retroperitoneal

Transvesical

11.1

23

0

Shalhav et al. (2001) (12)

25

Transperitoneal

Stapled

24

23

15

Jarrett et al. (2001) (27)

24

HAL-NU:20

Open: 20

24.2

16.7

4.2

Transperitoneal: 4

Stapling: 4

Stifelman et al. (2001) (25)

11

HAL-NU

Transvesical

13

27.3

N/A

Klinger et al.(2003) (26)

19

Transperitoneal: 14

Open

22

10.5

N/A

Retroperitoneal: 5

Villicana et al.(2004) (22)

27

HAL-NU

Pluck

13.2

37

0

Abbreviation: HAL-NU, hand-assisted laparoscopic nephroureterectomy.

is left in the bladder for five days, at which time a cystogram is performed. If the cystogram shows no extravasation, it is removed.

The postoperative follow-up protocol includes cystoscopy and urine sampling for cytology every three months for two years, every six months for two years, and then annually if no bladder tumor recurs. Baseline abdominal computerized tomography is performed two to three months postoperatively. Chest X-ray and abdominal computed tomography with intravenous contrast are performed yearly for five years, then biannually.

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