Review Article Management of Distal Ureter in Laparoscopic Nephroureterectomy—A Comprehensive Review of Techniques Amanda M. Macejko, Joseph F. Pazona, Stacy Loeb, Simon Kimm, and Robert B. Nadler Approximately 5% of all urothelial tumors in adults arise from the upper tracts. While the gold standard treatment is open nephroureterectomy, laparoscopic nephroureterectomy is becoming increasingly popular. Oncologic principles dictate that complete excision of the transmural ureter and bladder cuff and avoidance of urine spillage are paramount. This can be challenging laparoscopically and multiple techniques have been described. We review described surgical techniques, published oncologic data, as well as advantages and disadvantages for each technique including open excision, cystoscopic detachment and ligation, laparoscopic stapling, ureteral intussusception, transurethral resection of ureteral orifice (TURUO) and modifications of TURUO. To date, no controlled studies have been performed demonstrating one technique’s superiority. UROLOGY 72: 974 –981, 2008. © 2008 Elsevier Inc.
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pproximately 5% of all urothelial tumors in adults arise from the upper tracts (renal pelvis and ureter).1 The first laparoscopic nephroureterectomy (LNU) was performed in 1991 at Washington University.2 With the advancement of minimally invasive techniques, LNU is becoming an effective option for the treatment of upper tract transitional cell carcinoma (TCC). Studies have demonstrated that patients undergoing LNU might have decreased blood loss, postoperative pain, and length of hospitalization and a more rapid return to normal activities compared with those undergoing open nephroureterectomy (ONU).3-5 More importantly, LNU appears to have comparable oncologic outcomes to the open surgical approach. Despite concerns of intra-abdominal tumor seeding and port site metastases, very few cases have been reported.6,7 Studies to date have reported that the margin-free rates and local recurrence rates after LNU are equivalent to those after open procedures.8,9 Additionally, studies comparing LNU and ONU have demonstrated similar disease-specific survival between the 2 procedures.10,11 A wide variety of techniques have been used to perform LNU. The first step involves the mobilization of the kidney, which can be performed using several approaches, including transperitoneal LNU (TPLNU), hand-assisted LNU (HALNU), and retroperitoneal LNU (RPLNU). The second, and more challenging and controversial, aspect of LNU is the management of the distal
From the Department of Urology, Northwestern University Feinberg School of Medicine, Chicago, Illinois; and Department of Urology, Johns Hopkins Medical Institutions, Baltimore, Maryland Reprint requests: Robert B. Nadler, M.D., Northwestern Medical Faculty Foundation, 675 North Saint Clair Street, Suite 20-150, Chicago, IL 60611. E-mail:
[email protected] Submitted: October 15, 2007, accepted (with revisions): April 6, 2008
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© 2008 Elsevier Inc. All Rights Reserved
ureter and ipsilateral bladder cuff. The importance of a complete excision is highlighted by reports of tumor recurrence in ⱕ30% of inadequately resected distal ureters.12,13 As such, multiple techniques of ureter and bladder cuff resection have been described, including open excision, cystoscopic detachment and ligation, transurethral resection of the ureteral orifice (TURUO) with various modifications, laparoscopic stapling, and ureteral intussusception. Each technique has inherent advantages and disadvantages; however, thus far, no prospective, randomized trials have compared the different approaches. We present a review of the different methods of distal ureteral and bladder cuff resection.
APPROACHES Open Excision Open excision of the distal ureter and bladder cuff after LNU is similar to the technique used during ONU. After complete mobilization of the kidney and more proximal ureter, transvesical or extravesical excision of the distal ureter and bladder is performed. A variety of incisions can be made to provide adequate exposure of the perivesical space (lower midline, Pfannenstiel, or Gibson). Alternatively, if HALNU is performed, the hand port can be removed and a self-retaining retractor used. In the largest published series of patients who underwent open bladder cuff resection during LNU, Hsueh et al.14 showed comparable outcomes to those with ONU. Their technique involved placing the hand-assist device into a Gibson incision and performing retroperitoneal HALNU. After 16 months of follow-up, the rates of bladder recurrence, local recurrence, and metastatic disease were statistically similar to the corresponding rates from a similarly matched open cohort. The inves0090-4295/08/$34.00 doi:10.1016/j.urology.2008.04.022
tigators did report 1 port site recurrence, however, which might have been because a specimen retrieval bag was not used. The same group recently reported an updated analysis of the long-term survival outcomes for these patients and found that the 5-year disease-specific survival was similar stage-for-stage between the LNU and ONU groups.15 Reports from other institutions have confirmed the similar outcomes between LNU and ONU when open bladder cuff resection is used.8,16 The benefits of the open technique are its familiarity and adherence to the oncologic principles of treating upper tract TCC. The risk of tumor spillage is minimized, and direct visualization decreases the likelihood of incomplete bladder cuff excision. The open technique can also be the method of choice in patients with distal ureteral TCC. Because an incision already exists for HALNU, or must be made for specimen extraction in RPLNU or TPLNU, the additional morbidity with this approach is usually minimal. During dissection of the ipsilateral bladder cuff or during closure of the bladder defect, a potential for injury to the contralateral trigone and ureter exists.17 Also, dissection might prove difficult in patients who are obese or have unfavorable pelvic anatomy (ie, history of pelvic surgery or radiotherapy). Occasionally, it might be necessary to extend the midline hand port incisions caudally to provide adequate exposure.
Endoscopic Excision Numerous endoscopic excision methods have been used to facilitate the dissection of the distal ureter. Ureteral Intussusception. First described more than 50 years ago, ureteral intussusception and extraction by way of the urethra is an option for ureterectomy in both ONU and LNU.18-20 At the onset of the procedure, a Chevassu ureteral catheter is placed endoscopically. Standard nephroureterectomy is then performed, minimizing the mobilization of the lumbar ureter. Next, the proximal ureter is secured to the Chevassu ureteral catheter. After repositioning the patient, cystoscopy is performed and the ureteral catheter retracted through the urethra under direct vision. The ureter is “stripped” under light tension until the mucosa is completely everted, and the ureter is tented. Transurethral resection is then performed circumferentially around the everted ureteral orifice. A Foley catheter is left in place to allow for secondary bladder healing. Concomitant bladder or ureteral tumors are a contraindication to this technique because of the risk of tumor cell extravasation after bladder cuff resection and the potential for incomplete excision of invasive ureteral tumors. Ureteral intussusception should be reserved for patients undergoing nephroureterectomy for renal collecting system tumors or benign disease (ie, reflux nephropathy). Other contraindications include conditions that increase the risk of incomplete ureteral excision (ie, UROLOGY 72 (5), 2008
history of radiotherapy, previous ureteral surgery, ureteral calculi, ureteral duplication, or ureteral strictures). Many concerns surround the ureteral stripping technique. In the largest published single-institutional series involving 32 patients, the failure rate (defined as an inability to strip the entire ureteral mucosa and muscularis) was 18.7%. Moreover, 5 patients with retained ureters required a separate Gibson incision to complete the ureterectomy. In reviewing published series of 146 patients who underwent ureteral stripping during nephroureterectomy, the mean failure rate was 13.3% (range 0%-26.3%).19-27 Thus, ⱕ1 of every 4 patients might not only require an additional incision for ureteral excision, but will also be at an increased risk of tumor seeding of the retroperitoneum and perivesical space. The mean bladder and locoregional recurrence rate in the same series was 22.6% (range 12.5%-50%) and 3.1% (range 0%-6.2%), respectively.19-27 In a comparative study of ureteral intussusception and open distal ureterectomy during ONU, the intravesical recurrence rates at 1 and 3 years were significantly greater in the ureteral intussusception group.28 In addition to these concerns, ureteral intussusception has primarily been used in the ONU setting and might be more difficult to perform during LNU. The dissection of the kidney during LNU, especially HALNU and TPLNU, is aided by mobilizing the ureter and retracting it anteriorly to identify the proper posterior plane of dissection. The ureter is also used as an anatomic landmark and guide to the renal hilum. Despite these concerns, in 2002, Tobias-Machado et al.29 reported on 3 patients who successfully underwent ureteral intussusception in conjunction with RPLNU. Nonetheless, because successful ureteral intussusception requires an immobilized lumbar ureter, the routine use of the ureteral stripping technique during LNU is not recommended. Transurethral Resection of Ureteral Orifice. The original TURUO technique, also called the “pluck” technique, was originally used during ONU and subsequently adapted for LNU.4,30 Patients are initially placed in the lithotomy position and undergo rigid cystoscopy with aggressive resection of the ureteral orifice and intramural ureter into the perivesical fat. Patients are then repositioned for the laparoscopic portion of the procedure. Once the proximal specimen is mobilized, the previous transurethral resection eases the subsequent bladder cuff excision. One disadvantage of this technique is the increase in procedure length caused by the need for repositioning. Although operative times are important, oncologic outcomes should dictate the appropriateness of the procedure. Several concerns exist regarding the oncologic efficacy of this technique. First, the potential for incomplete resection of the intramural ureter exists; thus, this procedure should not be performed in patients with distal ureteral tumors.17 Furthermore, because of the multifocality of TCC, the potential risk of extravesical seed975
ing is present, even in the absence of known distal tumors. Multiple case reports of extravesical tumor implantation after the “pluck” technique have been reported.6,31 Modified TURUO. As described, the original TURUO was performed at the onset of the procedure, allowing for the potential extravasation of urine with tumor cells into the retroperitoneum. To decrease this risk, it was suggested that performing transurethral resection at the conclusion of the procedure, in conjunction with HALNU, might decrease the likelihood of tumor spillage and thereby result in more favorable long-term oncologic outcomes.4,32-34 This technique involves early ligation of the proximal ureter before distal ureteral excision, further decreasing the potential for tumor spillage. Many investigators have used this modified technique, with subtle differences in how the bladder cuff is excised. In many of these techniques, the patient remains in the lateral decubitus position for the duration of the procedure, thereby eliminating the need for repositioning. In 2006, Vardi et al.33 described a version of this technique, which involves endoscopic resection of the bladder cuff using a flexible cystoscope and Bugbee electrode during HALNU. The patient is placed in the lateral decubitus position with the hips supported at 45° and their legs on spreader bars. The proximal ureter is clipped on identification, followed by dissection of the kidney and proximal ureter. A 15F flexible cystoscope is then introduced into the bladder per urethra by the assistant. A 1-cm bladder cuff around the ipsilateral ureteral orifice is excised using the cutting current of a 5F Bugbee electrode. Throughout this portion of the procedure, the surgeon’s hand, by way of the hand port, can be used to stabilize the bladder and aid in the resection. The cystostomy is typically not sutured closed, and a urethral catheter is left in place for 1 week until cystography is performed to exclude a bladder leak. In this series, the mean resection time of the distal ureter and bladder cuff was 30 minutes. As discussed, the main advantages of this technique are the lack of patient repositioning and the tactile sensation during bladder cuff resection allowed by the hand port device. The main disadvantage of this procedure is the technical difficulty of endoscopic resection using a flexible cystoscope and Bugbee electrode. Although the hand port aids in the dissection, precise resection might be more difficult than in techniques involving rigid endoscopy. Wong and Laveillee34 had previously described a similar technique using rigid cystoscopy and the Collins knife. Again, the surgeon’s hand provides stabilization of the bladder while the assistant performs the endoscopic dissection of the bladder cuff. Thus, depending on surgeon preference, either technique can be used with similar outcomes expected. Cystoscopic Detachment and Ligation. Gill et al.35 initially described cystoscopic detachment and ligation 976
technique in 1999 and have reported extensively on their follow-up data. Used primarily in conjunction with RPLNU, they described resection of the bladder cuff and distal ureter with a combination of endoscopic cautery and needlescopic suprapubic retraction. First, the patient is placed in the dorsal lithotomy position and two 2-mm needlescopic ports are inserted into the bladder suprapubically using cystoscopic guidance. Next, a 2-mm Endoloop is placed through one of the needlescopic ports such that the loop surrounds the ureteral orifice of interest. A 6F ureteral catheter and guidewire is then placed into the ureteral orifice up to the renal pelvis, and the cystoscope is removed. A 24F resectoscope with a Collins knife is placed alongside the ureteral catheter, and resection of the bladder cuff is performed. Once the bladder cuff starts to release from the rest of the bladder mucosa, a 2-mm needlescopic grasper can be inserted through the other 2-mm trocar to help place anteromedial traction on the bladder cuff. Excision of the intramural ureter is then completed with the Collins knife using the 6F ureteral catheter as a guide. Once 3-4 cm of extramural ureter is mobilized to the level of the perivesical fat, the ureteral catheter and guidewire are removed, and the Endoloop is cinched around the ureter. This occludes the ureteral lumen, and prevents potential tumor spillage along with subsequent cauterization of the resected orifice. A 1-cm margin of bladder mucosa surrounding the resection site is then coagulated to ensure hemostasis. After the distal ureteral resection, a 24F urethral catheter is inserted, the patient is placed in the flank position, and RPLNU is performed, as previously described.36 The bladder excision site is not closed, and a Foley catheter is left in place for 2 weeks. More than any other laparoscopic technique, this method adheres most closely to the oncologic principles of ONU. The ureteral catheter minimizes the risk of inadvertent entry into the intramural ureter and subsequent incomplete resection of the distal ureter. Occlusion of the ureteral lumen with the Endoloop and electrocautery helps to minimize the risk of seeding the perivesical space with tumor cells. The 2-year follow-up data from patients treated with this technique have shown a lower rate of positive margins and local recurrence than with the laparoscopic stapling technique.37 However, patients with concomitant or recent bladder tumors were considered at high risk of tumor seeding with the transvesical needlescopic technique. Thus, this might have introduced a selection bias, in that their patients who were treated with the laparoscopic stapling technique might have had an inherently greater risk of positive margins and local recurrence. In a retrospective review comparing RPLNU and ONU, the rates of local recurrence and metastatic disease were not significantly different.38 A distinct advantage of this technique is that RPLNU can be performed without the need for a separate incision or entry into the peritoneal cavity. The main drawbacks to this approach are the long resection times (mean 1 hour) and steep learning UROLOGY 72 (5), 2008
curve. Although the local recurrence rates to date have been excellent, similar results would be expected with other, simpler techniques of bladder cuff excision. The investigators also commented on 1 patient who had significant irrigant extravasation requiring open drainage and medical treatment of dilutional hyponatremia. This occurred in an obese patient in whom a 5-mm (rather than 2-mm) suprapubic port was used. This complication has not been reported in series that used 2-mm needlescopic ports. As such, the investigators suggested this technique should not be used in obese patients or those with a history of pelvic radiotherapy or surgery because of the risk of improper suprapubic port placement. Cystoscopic Unroofing With Laparoscopic Stapling. Initially described at Washington University, cystoscopic unroofing with laparoscopic stapling involves initial endoscopic dissection of the bladder cuff in preparation for laparoscopic stapling of the distal ureter.39 After placement of a 0.035-Bentson guidewire into the renal pelvis, a 7F, 5-mm ureteral balloon dilator is advanced over the guidewire and inflated to ⬍1 atm. The ureteral orifice is incised at the 12-o’clock position, then the balloon dilator is removed, and the posterior aspect of the ureteral lumen is fulgurated. With the ureteral tunnel unroofed, a 7F, 11.5-mm ureteral occlusion balloon is placed to the level of the ureteropelvic junction. This portion of the procedure takes approximately 50 minutes and aids in the subsequent intraoperative identification of the ureter before stapling the bladder cuff. Furthermore, the placement of the occlusion balloon limits spillage into the extraperitoneal space. Next, either TPLNU or RPLNU is performed, as previously described.2,40 After mobilization of the kidney, the ureter is dissected to the level of the ureterovesical junction. A grasping forceps is then used to retract the ureter superolaterally, and a 12-mm laparoscopic GIA tissue stapler (EndoGIA, AutoSuture, Norwalk, CT) is used secure the bladder cuff. A mixture of indigo carmine and saline can be used to perform intraoperative cystography to rule out any bladder leakage, which can be sutured closed at this time. Routinely, a second cystogram is performed on postoperative day 2 before Foley catheter removal. Concerns have been raised about the safety of the laparoscopic stapling technique. It has been shown in porcine models that cells within the staple line remain viable and therefore could be a nidus for recurrence.41 Additionally, recent retrospective data have suggested that the laparoscopic stapling technique is associated with greater positive margin and local recurrence rates than the open or transvesical approaches.37 This is concerning, because positive surgical margins and recurrence have been associated with decreased survival. Although no cases have been reported, a theoretical risk of stone encrustation along the staple line exists, as well as a risk of compromising the contralateral hemitrigone with stapler placement.42 In an effort to decrease UROLOGY 72 (5), 2008
the risk of stone development or tumor cell entrapment on or within the staple line, Tsivian et al.7 recently reported on a technique that uses the Ligasure Atlas device rather than the EndoGIA (Valleylab, Tyco Healthcare UK, Gosport, UK). They performed this technique on 13 patients with upper tract TCC and reported no local recurrence at a mean follow-up of 11.6 months. This method does avoid some of the disadvantages of using the EndoGIA stapler; however, it does not address the issue of possible incomplete distal ureteral resection. Larger studies with longer follow-up are needed to determine whether this method is superior to laparoscopic stapling. Extravesical En Bloc Excision In 2001, McGinnis et al.43 described yet another technique for dissection of the distal ureter during HALNU. No cystoscopic resection, additional incisions, or patient repositioning are needed. The procedure is performed with the patient in the modified flank position. The proximal ureter is clipped on identification. After the nephrectomy portion of the procedure, the distal ureter is dissected into the pelvis. An additional 10-mm trocar is then placed in the lower abdomen. With retraction of the ureter, a harmonic scalpel is used to enter the bladder anteriorly. The remainder of the bladder cuff is then excised. Cystostomy closure is performed with the Endostitch device (U.S. Surgical, Norwalk, CT). With their initial 29 patients, they reported no positive surgical margins or local recurrences. Robotic-assisted Excision Nanigian et al.44 recently published their experience with 10 patients who underwent robotic-assisted nephroureterectomy. The patient is placed in a modified flank/lithotomy position. A double-J stent is placed, followed by transperitoneal laparoscopic mobilization of the kidney and ureter. A ligating suture or clip is then placed on the ureter. The robot is docked, with the patient in a steep Trendelenburg position. After filling the bladder by way of the urethral catheter, a transverse incision is made in the bladder dome. A traction suture is then placed through the ureteral orifice and stent, followed by transvesical excision of the ureter. The ureteral orifice and bladder dome are then closed in 2 layers, and the specimen is removed by way of a Gibson incision. In their series, no patient had positive surgical margins, and 9 patients had no evidence of disease at 6 months of follow-up. Thus, they concluded this procedure is technically feasible, with encouraging short-term oncologic outcomes. Nevertheless, in the editorial comment, Strup expressed concerns regarding the fluid leakage on bivalving the bladder.44 Because the patient is placed in the steep Trendelenburg position, the escaping fluid could come into contact with, and potentially seed, remote aspects of the abdomen. Also, if a Gibson incision is already being used for specimen extraction, it is unclear whether ro977
botic-assisted dissection of the distal ureter offers any additional value. Furthermore, the cost of using the robot might not be justified for dissection of the distal ureter.
RETROSPECTIVE COMPARISON OF DIFFERENT TECHNIQUES No randomized controlled studies have compared the outcomes of different approaches to the excision of the distal ureter. However, Brown et al.45 recently published a retrospective comparison of their outcomes with different management techniques for the distal ureter during HALNU. Patients underwent either open excision (n ⫽ 3), TURUO (n ⫽ 16), stapled division (n ⫽ 7), or hand-assisted extravesical en bloc excision (n ⫽ 29). In their series, TURUO was associated with longer operative times, greater blood loss, more open conversions, and a longer catheterization duration. Nevertheless, the hand-assisted extravesical en bloc resection group and stapled division group had a positive surgical margin rate of 10% and 29%, respectively. In contrast, no positive surgical margins were found in either the TURUO or open group. Although this study is unique in its comparison of multiple procedures, it does not provide an answer as to which technique is superior. Table 1 lists a compilation of outcomes from several series of ONU and LNU using different techniques of distal ureter and bladder cuff management.
DOES CYSTOSTOMY NEED TO BE CLOSED? Not only the optimal method for excision of the distal ureter debated, but also whether the bladder cuff must be closed is controversial. In patients with known TCC of the bladder, the cystostomy should be closed. However, in patients without bladder disease, this debate stems from theoretical concerns of extravesical exposure to urine and possible tumor seeding in the pelvis or peritoneum. Recently, Kurzer et al.46 performed a retrospective review of patients undergoing HALNU with early ligation of the proximal ureter and cystoscopic excision of the distal ureter and bladder cuff. In all 49 cases, the cystostomy was left open, and the patients later underwent cystography before catheter removal to ensure complete bladder closure. After a median follow-up of 10 months, the investigators reported that the oncologic outcomes were similar to those after open excision. They did not identify any cases of pelvic or abdominal recurrence postoperatively. Thus, they concluded that leaving the bladder cuff open provided a safe and effective method for distal ureteral management. However, many patients were lost to follow-up, and the median follow-up period was relatively short. Furthermore, only 25 patients underwent abdominal and pelvic imaging at a median of 6 months after surgery. Although routinely performed at many institutions, it is not possible to definitively state from presented data whether leaving the bladder cuff 978
open places the patient at an increased risk of extravesical tumor seeding.
ROLE OF LYMPH NODE DISSECTION Although lymph node dissection (LND) is routinely performed for lower tract TCC, the role of LND is also controversial during nephroureterectomy. Kondo et al.47 recently reported that the right renal pelvis drains primarily to the right renal hilar, paracaval, and retrocaval nodes, and the left renal pelvis drains to the left renal hilar and para-aortic nodes. The upper two thirds of the right ureter drain to the retrocaval and interaortocaval nodes and the upper two thirds of left ureter drain to the para-aortic nodes. Distal ureteral tumors primarily drain to the aortic bifurcation. Using these drainage patterns to determine the extent of LND, Brausi et al.48 recently reported that patients undergoing ONU with LND had significantly longer disease-free and overall survival. Furthermore, Roscigno et al.49 recently reported that the extent of LND during ONU was an independent predictor of disease-free and cancer-specific survival in patients with muscle-invasive disease. Historically, LND has not been routinely performed during LNU; however, Busby and Matin50 have reported that it is possible to yield a similar number of lymph nodes using LNU as with ONU. Additional study is warranted regarding whether to perform LND during LNU and the optimal extent of dissection.
CONCLUSIONS Since its original description in 1991, LNU has become more common for the treatment of upper tract TCC. The procedure can be viewed as having 2 separate stages: (a) nephrectomy with mobilization of the proximal ureter and (b) distal ureterectomy with bladder cuff excision. In terms of convalescence and morbidity, LNU provides superior results to the open approach.2,3,38,51 Nevertheless, as with other laparoscopic procedures, adherence to sound oncologic principles should never be compromised to reduce short-term patient morbidity. Recent reviews have demonstrated 2-, 5-, and 7-year cancer-specific survival and recurrence rates after LNU comparable to those after ONU.52,53 However, the optimal approach to excision of the distal ureter and bladder cuff is open to debate, and no prospective, controlled trials have been done to compare the various techniques. The classic open technique is most familiar to surgeons and allows for safe excision of the distal ureter and bladder cuff. As such, this remains the reference standard from an oncologic standpoint. Ureteral intussusception or stripping should not be performed except in rare situations because of the failure rates and the potential for incomplete ureteral excision. Laparoscopic stapling of the bladder cuff provides a fast and easily learned approach; however, recent retrospective studies have suggested it could result in a greater rate of positive surgical margins. The Cleveland Clinic UROLOGY 72 (5), 2008
UROLOGY 72 (5), 2008
Table 1. Outcomes of different approaches to distal ureter
Investigator 13
Technique
Patients (n)
Mean follow-up (mon)
PSMs (%)
McDougal Hattori54 Hsueh14
Open Open Open
6 60 77
16 35 53.6
NA NA NA
Shalhav2 McNeill30 Kawauchi4 Stifelman5 Klingler8 Goel9 Tsujihata11 Saika28 Laparoscopic Hattori54 Hsueh14
Open Open Open Open Open Open Open Open Bladder cuff technique Open Open
17 42 34 11 15 5 24 32
43 42.3 48.8 17 23.1 19 22.1 NA
NA NA NA 9.1 0 0
36 66
17 37.6
NA NA
Open Open LS LS LS LS CDL MTURUO MTURUO Open and TURUO En bloc NS NS NS
19 3 8 53 12 7 36 16 25 25 29 11 9 25
22.1 NA 25 31 19 NA 22 NA 24 32.9 NA 13 15 22.4
0 0 NA NA 25 29 2.8 0 NA NA 10 0 0 NA
Klingler6 Brown45 McDougal13 Hattori54 Matin37 Brown45 Matin37 Brown45 Shalhav2 McNeill30 Brown45 Stifelman5 Goel9 Tsujihata11
0
Recurrence (%) Retroperitoneal
Survival
Bladder
LN
66.7% NED at follow-up 81% DSS at 3 y 5-y DSS: 88.1% for T1, 64.7% for T2, 54.5% for T3 77% DSS at follow-up 79% DDS at follow-up Recurrence rate 47% at follow-up 63% NED at follow-up NA No deaths at follow-up 2 Deaths at follow-up 75% DSS at 3 y, 82.6% OS at 3 y
33 40 24.7
NA 10 LN and RP NA
54 NA 38 36.3 6.7 0 33.3 21.9
NA NA 0 0 0 0 0 NA
86% DSS at 3 y 5-y DSS 92% for T1, 80% for T2, 80% for T3 NA NA 50% NED at follow-up 80% DSS at 3 y 80% OS at 3 y NA 50% OS at 3 y NA 77% DSS at follow-up 84% DSS at follow-up NA 63% NED at follow-up 1 Death at follow-up No deaths at follow-up
33 20
11 LN and RP NA
NA NA 50 38 41.7 NA 13.9 NA 23 NA NA 27.3 22.2 28
NA NA NA 6 LN and RP 0 NA 11.1 NA 0 NA NA 0 0 0
Distant
0 — 2.6
0 16.7 0
0 NA 9 0 0 11.1 8.3 18.8
23.5 NA NA NA 0 NA NA NA
— 3
16.7 0
NA 0 12.5 — 8.3 0 5.6 0 8 NA 3 9.1 22.2 0
NA 0 0 9.4 25 0 8.3 19 12 NA 7 NA NA NA
PSMs ⫽ positive surgical margins; LN ⫽ lymph node; RP ⫽ retroperitoneum; NED ⫽ no evidence of disease; NA ⫽ not applicable; DSS ⫽ disease-specific survival; OS ⫽ overall survival; LS ⫽ laparoscopic stapling; NS ⫽ not specified.
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cystoscopic detachment and ligation technique appears to have favorable oncologic efficacy, but it has a limited patient selection and is more technically challenging. The possibility of tumor seeding using the TURUO or “pluck” technique at the beginning of the procedure has raised concerns with this approach. The modified TURUO, in which the proximal ureter is clipped and TURUO then performed after complete mobilization of the kidney and proximal ureter, might lower the risk of tumor spillage; however, long-term follow-up is necessary. Finally, robotic-assisted dissection of the distal ureter has been described, but it remains unclear whether this offers a safe and costeffective modification. Additional follow-up data are needed to better evaluate which strategy offers the best overall outcomes.
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