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Upper Urinary Tract Urothelial Tumour Management – Open or Laparoscopic?
Distal Ureter Approach
Figure 1: The Patient in Decubitus and Lithotomy Position
The important message in most reports is that the best technique is
that which is preferred by the surgeon, maintains oncological
principles and prevents the spread of disease. The open approach
to the distal ureter used to be the method with which all others
were compared because of the possibility of removing the distal
ureter with visual confirmation of the resected ureteral orifice,
minimising tumour spread and allowing adequate closure of
the bladder opening. However, despite the choice of resection of the
distal ureter, the important thing in order to be curative is to avoid
leaving fragments and to clip the ureter before endoscopic
manipulation in order to avoid tumour cells seeding and causing local
recurrence and death.
3
In our institution, we prefer LNU as the operative time is shortened
Figure 2: The Patient in the Same Position and 30–45º
and the patient undergoes a better recovery. We do not think
Rotation of the Operating Table
that hand-assisted surgery is really necessary, but it is surgeon-
dependant. We believe that the duration of the procedure may be
shortened independently of the experience with the laparoscopic
technique in relation to the management of the lower ureter. Endoscopic
detachment is used at our centre for all urinary tract tumours that are
located outside the distal ureter to improve and simplify NU. This
decreases the morbidity rate and operating time and maintains the same
oncological radicality.
15,16
The patient is placed in a semi-lithotomy
position with a bag under the lumbar area angled at 30º. With a simple
rotation of 30–40º of the operating table, is possible to apply the
endoscopic approach to the bladder and the laparoscopic approach to
the abdomen (see Figures 1 and 2). In tumours located above the iliac
vessels, we first dissect and clip the distal ureter through a laparoscopic
approach, rotate the table slightly, then proceed to transurethral
resection of the intramural ureter. Finally, we continue with the
laparoscopic nephroureterectomy.
17
We avoid the endoscopic
transurethral approach in patients with previous pelvic surgery or Conclusions
local inflammatory disease that may increase the difficulty in the NU still represents the gold standard for the management of upper
distal dissection or in cases of distal urothelial tumour in order to avoid urinary tract UCC. LNU offers the advantages of minimally invasive
local cell seeding. surgery. LNU requires greater operative time compared with the
standard open procedure, but has benefits such as decreased patient
Follow-up analgaesic requirements, shorter hospitalisation and improved
The tumour stage and grade are the most important prognostic factors.
11,12
aesthetics. This procedure is now established practice. Both procedures
Follow-up of patients with upper urinary tract UCC is recommended to have statistically comparable bladder recurrence and local recurrence
detect local recurrence and distant metastases. The bladder should be also rates, but successful treatment depends on the stage and grade of the
followed up as it is often a site of tumour recurrence.
15
tumour, irrespective of the surgical procedure employed.
11–13
■
1 Palou J, Piovesan LF, Huguet J, et al., Percutaneous 7 Rassweiler JJ, Schulze M, Marrero R, et al., Laparoscopic safety: a multicenter experience, Urology, 1998;52(5):773–7.
nephroscopic management of upper urinary tract transitional nephroureterectomy for upper urinary tract transitional cell 13 Hsueh TY, Huang YH, Chiu AW, et al., A comparison of the
cell carcinoma: recurrence and long-term follow-up, J Urol, carcinoma: is it better than open surgery?, Eur Urol, clinical outcome between open and hand-assisted laparoscopic
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2 Palou J, Rosales A, Ribal MJ, et al., Overview of the results of 8 Kawauchi A, Fujito A, Ukimura O, et al., Hand-assisted carcinoma, BJU Int, 2004;94(6):798–801.
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Arch Esp Urol, 2004;57(3):299–302. open procedure, J Urol, 2003;169(3):890–94. control following laparoscopic nephroureterectomy: seven-year
3 Busby JE, Matin SF, Laparoscopic radical nephroureterectomy 9 Rassweiler J, Fornara P, Weber M, et al., Laparoscopic outcome, J Urol, 2004;172:1805–8.
for transitional cell carcinoma: where are we in 2007?, Curr nephrectomy: the experience of the laparoscopy working group 15 Salvador-Bayarri J, Rodriguez-Villamil L, Imperatore V, et al.,
Opin Urol, 2007;17(2):83–7. of the German Urologic Association, J Urol, 1998;160(1): Bladder neoplasms after nephroureterectomy: does the surgery
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5 Clayman RV, Kavoussi LR, Figenshau RS, et al., Laparoscopic radical nephrectomy and nephroureterectomy and comparison 16 Palou J, Caparros J, Orsola A, et al., Transurethral resection of
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6 Tsujihata M, Nonomura N, Tsujimura A, et al., Laparoscopic nephrectomy for renal cell carcinoma: a five-year experience, 17 Palou J, Rosales A, De Graeve N, Villavicencio H, Laparoscopic
nephroureterectomy for upper tract transitional cell carcinoma: Urology, 1999;53(2):280–86. Radical Nephroureterectomy for Upper Tract Transitional Cell
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EUROPEAN GENITO-URINARY DISEASE 2007 29
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