Original Paper
Urologia
Received: July 24, 2008 Accepted: December 2, 2008
Urol Int 2009;83:264–270 DOI: 10.1159/000241664
Internationalis
Antegrade Mini-Invasive Nephroureterectomy: Laparoscopic Nephrectomy, Transurethral Excision of Ureterovesical Junction and Lower Abdominal Incision Milan Hora a Viktor Eret a Tomáš Ürge a Jiří Klečka a Petra Kočovská a Stránský Petr a Ondřej Hes b Jiří Ferda c Departments of a Urology, b Pathology and c Radiology, Charles University Hospital, Plzen, Czech Republic
Key Words Urothelial tumor ⴢ Nephroureterectomy ⴢ Laparoscopy ⴢ Retroperitoneoscopy ⴢ Transurethral resection
Abstract Introduction: We describe another variant of nephroureterectomy – antegrade mini-invasive nephroureterectomy (AMNUE). Methods: AMNUE starts with a laparoscopic nephrectomy in the flank position. The specimen is enclosed in a bag without dividing the ureter, and the patient is positioned to the lithotomy position. Then the ureterovesical junction is excised transurethrally with a Collins knife. Finally, the specimen is removed and the ureter is plucked out through a short lower abdomen incision. Patients: From March 2005 to November 2008, 35 patients underwent nephroureterectomy: 7 as an open procedure, 8 as a laparoscopic nephrectomy with open ureterectomy, 8 as a complete laparoscopic nephroureterectomy, and 12 were admitted into the AMNUE group (7 men and 5 women, mean age 71 8 7 years, range 54–81 years). Results: Tumors were found 6 times on both sides. The mean operation time was 165 8 32 min (105–210 min), and the mean blood loss was 150 8 91 ml (50–400 ml). Histology revealed 11 urothelial cancers and 1 papillary renal cell carcinoma. There was only 1 hematoma of the abdominal wall. Conclusion: AMNUE is a
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fast, safe and easily reproducible technique. It eliminates the risk of spillage of tumorous cells into the urine, which is possible in techniques where the ureter is excised with a Collins knife as the first procedure. The disadvantages of this approach are the necessary repositioning of the patient and that the long-term oncological results are currently unknown. AMNUE can be used when a complete laparoscopic nephroureterectomy is not technically feasible due to problems in the pelvis. Copyright © 2009 S. Karger AG, Basel
Introduction
Nephroureterectomy with the complete removal of the distal ureter (including the bladder cuff) is the standard procedure for patients with transitional cell carcinoma of the upper urinary tract. Since it was first described in 1991 [1], performing a laparoscopic nephrectomy as a part of nephroureterectomy has become generally accepted; however, the approach to the distal ureter and the timing of the ureterectomy are still in dispute. Many techniques have been developed to remove the distal intramural ureter during laparoscopic nephroureterectomy. An excellent review of all techniques has been published recently (table 1) [2]. A high number of recentMilan Hora, MD, PhD Department of Urology, Charles University Hospital Beneše 13, CZ–305 99 Plzeň (Czech Republic) Tel./Fax +420 377 402 171, E-Mail
[email protected]
Table 1. Basic techniques of removing the distal intramural ureter during laparoscopic nephroureterectomy
Name of technique
Description of technique
1
open distal ureterectomy
extravesical or transvesical
2
ureteral stripping
ureter is intussuscepted into itself and removed through the urethra [3]
3 3-1
simple pluck technique (3-1) and its modifications (3-2 to 3-6) pluck technique transurethral intravesical ureteral orifice and tunnel resection through the entire thickness of the bladder wall prior to laparoscopy [4–7] 3-2 pluck technique with occlusion balloon into ureteral catheter is introduced to the renal pelvis, occlusion balloon is filled pyeloureteral junction and excision of ureter follows 3-3 ureteral unroofing technique (Washington distal ureter is dissected over balloon at 12 o’clock, fulguration of distal ureter, University) following nephroureterectomy (occlusion balloon is in the renal pelvis), endoGIA stapler to secure the distal bladder cuff [8] 3-4 pluck technique with occlusion of intramural ureter 3-4-1 pluck technique with cystoscopic loop following partial circumferential excision with Collins knife, ureter is occluded ligation with endoloop, followed by total excision of ureter [9] 3-4-2 pluck technique with Hem-o-lok쏐 clip [10] 3-4-3 Cleveland (Gill’s) technique combined percutaneous transvesical and cystoscopic detachment of the intramural ureter followed by endoloop occlusion prior to renal extirpation [11] 3-5 antegrade pluck technique modified lithotomy position with simultaneous laparoscopic and transurethral access without repositioning [12] 3-6 AMNUE described in this paper 4 4-1 4-2 4-3 5 5-1 5-2
hand-assisted laparoscopic nephroureterectomy hand-assisted laparoscopic nephroureterecdistal ureter is treated through lower abdomen incision, which is used later as a tomy (1) port [13] hand-assisted laparoscopic nephroureterectransvesical excision of ureterovesical junction through 10 mm nephroscope tomy (2) [14] hand-assisted laparoscopic nephroureterecsimultaneous circumferential transurethral excision of the intramural ureter tomy (3) [15, 16] complete laparoscopic nephroureterectomy complete laparoscopic nephroureterectomy complete laparoscopic nephroureterectomy
with stapler with thermosealing systems - Ligasure쏐 [17], EnSeal쏐 [18]
ly published articles about nephroureterectomy are a sign that it is still a topic of considerable interest. Laparoscopic nephrectomy with an open ureterectomy is an excellent technique, but we are looking for a less invasive approach to the distal ureter. Although laparoscopic nephrectomy fulfils the pluck technique, it carries the risk of spilling the tumor cells. Some modifications exclude this risk, but then the technique is no longer as straightforward. The risk of spillage reduces the antegrade modification of the transvesical laparoscopic ureteral dissection (antegrade pluck technique), as mentioned by Tan et al. [19]. In this paper, we describe the results of our modification of the antegrade pluck technique, which we call antegrade miniinvasive nephroureterectomy (AMNUE), and try to find a place for our technique in the area of novel complete laparoscopic nephroureterectomy with thermosealing systems [17, 18]. Antegrade Mini-Invasive Nephroureterectomy
Patients and Methods Until 2003, we used completely open procedures or simple pluck methods followed by open, and later with laparoscopic or retroperitoneoscopic, nephrectomy for radical nephroureterectomy indicated for urothelial tumors of the upper urinary tract. In 2004, we started to use the novel method AMNUE to eliminate the risk of spilling tumor cells present in the pluck technique. We start the procedure with a laparoscopic nephrectomy, while the patient is in the lumbotomic position. Retroperitoneoscopic nephrectomy can be used as well, but we prefer the laparoscopic approach, which is in our opinion easier and quicker. Renal hilar vessels are divided separately with Hem-o-lok쏐 clips or en bloc with a stapler. Next, the kidney is liberated with a Ligasure쏐 V instrument; the ureter is liberated with the same instrument to the external iliac artery. The clip is applied on the ureter as distally as possible, and the kidney specimen is enclosed in a bag without dividing the ureter (fig. 1). Upon completion, the patient is put into the lithotomy position. Following this, the ureterovesical junction is excised transurethrally with a Collins knife; the
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Psoas m. AIC
Fig. 1. Left-sided AMNUE step 1. In the lumbotomic (flank) position, a laparoscopic nephrectomy is performed through 4 ports (10 mm umbilicus, 12 mm left hypogastrium for clips and/or stapler, and 2 ! 5 mm ports; see also fig. 3). The ureter (U) is liberated to the iliac artery (AIC), clipped and locked, and the kidney is enclosed in a bag without dividing the ureter. A drain to the renal bed is introduced through the lateral 5 mm port.
kidney in bag U Psoas m.
paravesical fat tissue must be clearly visible (fig. 2). Subsequently, a short lower abdomen incision is performed, without changing position. The kidney specimen is removed through the incision, and the ureter is blindly plucked with a finger through the same incision. The bladder is not closed, as is usual in the pluck technique. Two drains are introduced, one into the kidney bed and the other into the small pelvis (fig. 3). A permanent bladder catheter is removed on the 5th or 6th postoperative day. From March 2005 to November 2008, 35 patients underwent nephroureterectomy at our institution: 7 as an open procedure due to advanced tumors; 8 as laparoscopic nephrectomy with open ureterectomy (the indications were tumors of the distal ureter or some problems in the pelvis, e.g. transplanted kidney or previous surgery); 8 as a complete laparoscopic nephroureterectomy with Ligasure쏐 (since April 2008; procedure performed as described by Tsivian et al. [17]); 12 patients were admitted to AMNUE and these are evaluated in detail in this paper.
clip U bag
mean blood loss was 150 8 91 ml (50–400 ml); mean weight of the specimen was 541 8 177 g (300–810 g). There were 11 cases of urothelial cancer and 1 case of papillary renal cell carcinoma, and the bladder cuff was histologically negative in all cases. AMNUE was once combined with TURT (transurethral resection) of a small unexpected bladder tumor and once with TURP (transurethral resection of the prostate) of the middle lobe which made an endoscopic ureterovesical excision with Collins knife impossible. Complications were very rare, only 1 hematoma of the abdominal wall in 1 patient was found. The mean follow-up was 21 8 13 months (2–37 months) (table 2).
Discussion Results
The AMNUE group was made up of 7 men and 5 women with a mean age of 71 8 7 years (54–81 years). Only tumors of the upper urinary tract (pelvis up to cT3, infiltration of kidney parenchyma only) and proximal ureter (cTa–2) with a negative finding in the regional lymphatic nodes were considered an indication for AMNUE. Lymphadenectomy was not part of the procedure in any of the cases. Tumors were found 6 times on both sides; mean operation time was 165 8 32 min (105–210 min); 266
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What do we require for a nephroureterectomy? Oncological control is the first and most important concern; additional needs include an operation time that is as short as possible, no necessity to change the patient’s position, a minimal learning curve and low cost of the operation. Urologists indicating their patients for nephroureterectomy must resolve 3 questions: (1) Should I use laparoscopy for nephrectomy or not? (2) How should I access the distal ureter? (3) What is the appropriate timing of the ureterectomy? Laparoscopy for nephrectomy is Hora /Eret /Ürge /Klečka /Kočovská /Petr / Hes /Ferda
Color version available online
incised peritoneum
U
Color version available online Color version available online
Fig. 2. Left-sided AMNUE step 2. The patient is moved into the lithotomy position, and the ureterovesical junction is excised using a Collins knife upon the perivesical tissue.
Fig. 3. Left-sided AMNUE step 3. In the same position as in step 2, through a lower abdomen incision (performed at the site of previous 12 mm port), the specimen in the bed is removed and the ureter is sharply and later blindly removed (plucked) from the pelvis. The pelvis is drained with a 10 mm suction (Redon) drain.
broadly accepted, and open surgery is reserved for advanced cases only. So, we have to decide only how and when to remove the distal ureter. Open distal ureterectomy through a lower abdomen incision (Gibson incision, pararectal, muscle splitting) is
quick and simple, can also be indicated for tumors of the distal ureter, and can be performed even when there is history of previous surgery or radiotherapy of the small pelvis. A relatively high level of invasiveness is the only disadvantage.
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Patients’ initials
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Sex
F M M M F M M M F M F F
69.8 54.1 78.3 77.5 71.0 66.4 70.3 65.7 80.6 72.1 79.7 70.4 71.3 7.4 54.1 80.6
29.03.2005 30.05.2005 30.06.2005 01.12.2005 12.12.2005 14.12.2005 04.09.2006 27.09.2006 24.09.2007 26.09.2007 12.11.2007 22.02.2008
Side right left left left left right right right right left left right
Localization of tumor PU pelvis pelvis pelvis pelvis PU pelvis pelvis pelvis pelvis pelvis pelvis
Histology UC PRCC II UC UC UC UC UC UC UC UC UC UC
Notes
Stage and grade pT2G1 pT1aG2 pT1G2 pT2G2 pT3G1 pTaG1 TURT1 pTaG2 pT1G3 pT3G2 pT3G1 TURP pT3G2 pT3G3
Time, min 190 180 210 125 160 160 155 165 210 140 179 105 164.9 31.7 105.0 210.0
Time to discharge, postop. days 10 9 10 10 8 7 8 13 9 8 10 10 9.3 1.6 7.0 13.0
Blood loss, ml 150 100 400 100 150 100 100 200 50 200 150 100 150.0 90.5 50.0 400.0
Specimen weight, g 460 620 630 550 508 810 300 609 300 691 510 402 532.5 152.8 300.0 810.0
Division of hilar vessels en bloc Weck Weck Weck Weck Weck en bloc en bloc en bloc Weck Weck Weck
Surgeon’s initials P.S. M.H. J.K. M.H. M.H. M.H. M.H.
M.H. M.H. M.H. M.H.
Follow-up duration (to 6.11.2008), months 43.3 41.3 40.3 35.2 34.8 34.8 6.0 25.3 13.4 13.4 11.8 8.5 25.7 14.1 6.0 43.3
WSD WSD WSD WSD WSD repeated TURT died 6.3.07, EP liver metastases WSD WSD WSD died 9.8.08, GE
Status of patient
PU = Proximal ureter; UC = urothelial cancer; PRCC = papillary renal cell carcinoma type II by Delahunt; en bloc = divison with stapler the whole hilum in the same time; Weck = divison renal artery and vein separately with Hem-o-lok® clips; WSD = without signs of disease; EP = embolia pulmonum; GE = generalization; postop. = postoperative. 1 Nephrectomy of the left side for clear renal cell caricnoma pT2G1 (2002), hemodialysis since left side nephroureterectomy.
1 J.Č. 2 J.Č. 3 V.Š. 4 V.Š. 5 J.C. 6 M.M. 7 J.B. 8 V.B. 9 M.H. 10 V.K. 11 R.R. 12 A.S. Mean SD Min. Max.
Age, years
Table 2. Results of our series
Date of operation
268
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Table 3. Time of nephroureterectomy
Gill et al. [29] Klingler et al. [27]1 Rassweiler et al. [28] Ubrig and Roth [12] Hattori et al. [26]2 Lee et al. [30] Muntener et al. [31] Schatteman et al. [32] Tsivian et al. [17] Agarwal et al. [9] Pathak et al. [10] Current study
n
Time of operation, min
42 19 23 6 36 31 116 100 13 13 25 12
225864 198859 (62–310) 200 182.5 (164–210) 306884 236 (120–350) 286 (132–715) 192 (75–359) 215 (170–270) 230 (180–290) 164 (105–235) 165832 (105–210)
1 With lymphadenectomy, which prolonged the operation by 21 min (17–29 min). 2 Data for combined laparoscopy group (pure laparoscopy group: n = 53, time = 258 8 48 min).
The pluck technique has also been broadly accepted. The endoscopic part (transurethral excision of the ureterovesical junction with a diathermic Collins knife) is followed by open [6] or laparoscopic [4, 5, 7] nephrectomy, and the distal ureter is blindly extirpated. The method is quick and simple, but there is a risk of spilling the tumor cells into the urine [20]. Risk of spillage can be eliminated by closing the distal ureter (table 1, items 3–4), but these methods are in our opinion technically complicated. We do not hold a strong opinion on the modified lithotomy position with simultaneous laparoscopic and transurethral access without repositioning [12], which enables an antegrade sequence of nephroureterectomy, as in our AMNUE technique. Stripping has not been mentioned recently in conjunction with laparoscopic nephrectomy. Complete laparoscopic nephroureterectomy has been performed with a stapler. There is a risk of tumor residue in the stapling site [21, 22] and titan clips can cause cystolithiasis formation [23]. Tsivian et al. [17] described a technique of thermosealing the bladder wall with a bipolar coagulation with PC control (Ligasure쏐). Nagele et al. [18] published the same technique with the similar instrument EnSeal쏐 Erbe, and they named this technique ‘thermofused bladder cuff resection in nephroureterectomy’. We think this modification can remove the aforementioned disadvantages, and believe this technique to currently be the best choice in nephroureterectomy. We Antegrade Mini-Invasive Nephroureterectomy
have decided to replace our AMNUE technique with this approach. We plan to start nephroureterectomy with laparoscopic nephrectomy and prolong it with a distal ureterectomy through a laparoscopic approach, excising the bladder cuff with Ligasure쏐. AMNUE can be helpful in cases where laparoscopic ureterectomy is difficult and it is not possible to prolong with laparoscopy. AMNUE also remains more advantageous for less skilled laparoscopic surgeons. Because lymphadenectomy is not broadly accepted as a routine part of nephroureterectomy, we did not perform lymphadenectomy in any of the laparoscopic cases. Some authors have considered the possible curative role of lymphadenectomy [24]. If lymphadenectomy is accepted as a routine part of nephroureterectomy in the future, it will be feasible and safe through the laparoscopic approach [25–27]. When we compared our method with others, we mainly found differences in the duration of the operation. The time of laparoscopic nephroureterectomy with different approaches to the distal ureter was reviewed by Rassweiler et al. [28]. In 324 cases, the mean operating time ranged from 165 to 462 min (mean: 276.7 min). We chose times of operations of selected papers for table 3. The long-term oncological outcome after laparoscopic nephroureterectomy for upper urinary tract transitional cell carcinoma is well within the range of results reported after open surgery [33–36]. Unfortunately, due to the short time of follow-up, we cannot present the oncological results of our technique. However, the purpose of the paper was to describe this novel surgical technique. In conclusion, we recommend starting nephroureterectomy with laparoscopic nephrectomy without dividing the ureter. This phase should be followed by a complete laparoscopic ureterectomy with the sealing system (Ligasure쏐) – the least invasive technique – or with AMNUE when laparoscopic ureterectomy is not technically feasible due to problems in the pelvis. Open ureterectomy is indicated in cases of advanced tumors of the distal ureter only.
Acknowledgments This work was supported by the Czech government research project MSM 0021620819.
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