Summary

It is now accepted that laparoscopic radical nephroureterectomy results in less blood loss, less postoperative pain, faster oral intake recovery, shorter hospitalization, and a more rapid recovery than does open nephroureterectomy (14,15,18,20,27,44,61). The morbidity rate after laparoscopic radical nephroureterectomy in this classically high-risk population likewise appears consistently favorable. No studies have shown a clear-cut advantage of the transperitoneal or retroperitoneal approach. Differences in perioperative outcomes between laparoscopic techniques have been investigated in a limited number of retrospective studies (Table 1), but it is still unclear how clinically significant these differences are. Limited published data suggests that hand-assisted laparoscopic radical nephroureterectomy is more expensive but that the cost may be offset by shorter operative times.

The most challenging aspect of laparoscopic radical nephroureterectomy is excision of the distal ureter and bladder cuff. A variety of endoscopic, laparoscopic, and open methods may be used, but they have not been prospectively studied. The high prevalence of multifocal disease and carcinoma in situ in patients with upper tract transitional cell carcinoma should be considered in planning any endourologic or laparoscopic approach to the distal ureter and bladder cuff (4,7,35,62). Caution is warranted with transurethral resection procedures, as these are the most commonly associated with disseminated recurrence. Even with the open approach, complete excision is not guaranteed if performed blindly. Despite the considerable improvement in perioperative outcomes with laparoscopic radical nephroureterectomy, long-term oncologic follow-up data are not yet available, and intermediate-term follow-up data remain limited. The data suggest that survival rates for patients with low-stage, low-grade disease are favorable, whereas patients with high-stage, high-grade disease continue to experience markedly diminished survival, a finding consistent with results found with open surgery. If one were to extrapolate recent bladder cancer treatment data on the optimal use of neoadjuvant therapy for patients at high risk, it would seem that patients with high-grade, high-stage tumors are probably best served by neoadjuvant chemotherapy, considering especially the significant reduction of renal reserve that occurs following nephrectomy, necessitating lower doses of chemotherapy and thus lower treatment efficacy. The role of laparoscopic radical nephroureterectomy in the postchemotherapy setting is largely uninvestigated, and will probably be evaluated at only a few centers of excellence.

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