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COMMENTARY

J. deKernion

Department of Urology, UCLA Medical School, Los Angeles, California, U.S.A.

Laparoscopic nephroureterectomy is a natural outgrowth of the parent procedure laparoscopic radical nephrectomy. Currently, in practice locations that have the necessary expertise, it is the method of choice for confined tumors of the renal pelvis and ureter. The procedure has not received the same warm embrace as laparoscopic nephrectomy, primarily because of the requirement for complete removal of the ureter with a cuff of bladder. Nonetheless, at our institution, barring any specific contraindications, it is the preferred method of managing these kinds of malignancies.

The authors of the chapter discuss the benefits and limitations quite thoroughly. In my view, the primary benefits are the more rapid recovery and return to normal activity and less postoperative pain. We and others have modified the open operation to minimize morbidity. In my experience, unless the tumor is very large and invading outside of the collecting system, blood loss is very minimal, and I doubt that the laparoscopic technique has any significant advantage over the open method in that respect. A small flank incision, combined with a small muscle-splitting or midline suprapubic incision, is often adequate for these tumors. However, even with the modified incisions and modern improved pain management, there is a slightly longer hospitalization and longer interval of disability than one sees with laparo-scopic nephroureterectomy.

As nicely discussed in this chapter, the potential "Achilles' heel" of the procedure is the necessity for the removal of the bladder cuff. Many methods have been described. I am very concerned about simply pulling up the bladder and applying a staple line. I have suggested a modification, which is basically the technique I use when performing the open procedure. The ureter is kept under traction and carefully dissected down into the muscle of the bladder until a large funnel-shaped section of the bladder mucosa is free circumferentially. One can then apply a clamp and divide the bladder mucosa with certain removal of not only the ureteral orifice but also of the surrounding bladder mucosa and submucosa. An alternative method is to simply make a small, muscle-splitting, McBurney-type incision for removal of the kidney and dissect the distal ureter through the same incision. Whatever technique is utilized, the laparoscopic nephroureterectomy is only acceptable if it achieves the same cancer control end result as can be achieved by the open technique.

Another issue of concern to me is that of the regional lymph node dissection. For renal pelvic tumors on the left side, this is very straightforward and requires only the removal of the hilar and periaortic lymph nodes. However, on the right side, the lymph node drainage of the kidney is such that the nodes behind the cava and in the interaortocaval region are the ones that would be most likely involved. This poses greater technical difficulty for the laparo-scopist. The same concerns exist for tumors in the mid or distal ureters, because the adjacent lymph nodes should be excised. Certainly, node dissection is only important in patients with high-grade or large invasive tumors.

Tumors that seem to invade through the renal pelvis or the ureter still may be managed best by the open technique, which would allow for more extensive dissection and frozen-section monitoring. However, as the laparoscopic surgeons gain more skill, they may indeed be able to manage such patients with equal success as the traditional surgeon.

As for the future, some consensus has to be reached about the most appropriate methods for managing the distal ureter and its insertion into the bladder. Those techniques that assure complete removal of the ureter, including the orifice and a cuff of bladder, should be adopted, and the others should be abandoned. The issue of lymph node dissection must be confronted. The development of more sensitive and accurate radiolabeling imaging techniques may resolve this issue for us. Until then, the laparoscopic surgeon must be willing to perform appropriate staging, regional lymph node dissection for patients with high-grade tumors. Admittedly, the value of modern adjuvant chemotherapy in these circumstances has not been clearly defined, but knowledge of the lymph node status gives the urologic oncologist valuable information for making that decision. Large, high-grade lesions, which may invade through the ureter or collecting system, should probably still be managed by the open technique, because inadvertent spillage of tumor in these patients can result in local recurrence.

Laparoscopic nephroureterectomy has already largely replaced the open technique in most institutions. It is the method of choice for patients in whom there is no contraindication, and who harbor tumors that are amenable to the laparoscopic approach.

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