95 Wayland J. Wu & Jessica E. Kreshover The Arthur Smith Institute for Urology, Zucker School of Medicine at Hofstra/Northwell, Lake Success, NY, USA Laparoscopic approaches to renal surgery have gained popularity as a result of decreased morbidity for patients and equivalent oncologic outcomes. Since it was first described in 1991, laparoscopic nephroureterectomy (LNU) has also gained popularity [1]. This surgery presents a new set of difficulties over renal procedures, with the surgical field spanning the hemi‐abdomen down into the ipsilateral pelvis. Arguably, the approach to resection of the distal ureter is the most difficult part of this case and certainly is highly variable and surgeon dependent. With the laparoscopic approach to nephrectomy described in Chapter 92, this chapter focuses on the means of managing the distal ureter for completion of a nephroureterectomy. There is no approach that has been shown to be clearly superior to another in either oncological or perioperative outcomes and so surgeon preference remains the mainstay of the decision for management of the distal ureter. LNU is used for patients with upper tract urothelial tumors, which accounts for about 5% of all urothelial tumors [2]. The surgery involves the removal of the kidney and the entirety of the ureter, including the ureteral orifice with a cuff of bladder urothelium. This remains the gold standard approach for management of renal pelvis and ureteral tumors. With many tumors being lower grade and stage and with increasing goals to maintain renal function, less invasive means can be used, including endoscopic management (ureteroscopic and percutaneous) and segmental ureterectomy [3–5]. Nephroureterectomy with en bloc excision of the ureteral orifice with bladder cuff, however, remains the optimal choice for bulky, high‐grade, and/or invasive tumors. Open nephroureterectomy (ONU) uses two incisions and with this comes significant morbidity. LNU decreases this morbidity at a minimum for the nephrectomy portion of the procedure. The indications for laparoscopic approach remain the same as those for open. The principles of oncologic control should apply regardless of approach – open versus laparoscopic. There are copious data comparing laparoscopic and open approaches. A large multicentered retrospective study out of France found no difference in 5‐year cancer‐specific survival between laparoscopic and open nephroureterectomy [6]. In addition to their main outcome, there was also no difference in 5‐year recurrence‐free survival, metastasis‐free survival, or complications between surgical techniques, including when stratified by pathological stage. Despite suffering from inherent flaws with retrospective study design, this study offered a highly powered comparison between surgical approaches. Similar findings were obtained by Fairey et al. in their multi‐institutional study [7]. They had a total of 849 patients, approximately half in the laparoscopic cohort, who had a median follow‐up of 2.2 years without significant differences in disease‐specific survival between laparoscopic and open groups. Multivariate analysis did not find that surgical approach influenced survival, but the authors did express some concern as there was a slight trend towards worse recurrence‐free survival in the laparoscopic group (hazard ratio = 1.01, P = 0.08). Again, limitations exist because the study is retrospective. A prospective study by Simone examined 80 patients randomized to LNU or ONU [8]. Subjects who underwent a laparoscopic approach had lower average blood loss and length of stay but 5‐year cancer‐specific survival and metastasis‐free survival were also lower; however, this difference was not statistically significant. When stratified by tumor stage, subjects with stage pT3 had statistically significant lower cancer‐specific survival and metastasis‐free survival, suggesting laparoscopic may be inferior to open approach in patients with locally advanced disease. Despite having a small sample size owing to the relative rarity of upper tract urothelial carcinoma, the data provided are supportive of LNU as being an oncologically sound operation at least of low‐stage disease. Given the size of the surgical field spanning the hemi‐abdomen, there is significant morbidity associated with an open approach, predominantly with two sizeable incisions. Hospital length of stay may serve as a surrogate marker of patient convalescence after surgery. A retrospective analysis of a major British national registry found minimally invasive (pure or robot‐assisted laparoscopic) nephroureterectomy afforded a significantly decreased hospital stay compared to open (5 vs. 8 days) [9]. The superiority of minimally invasive nephroureterectomy in reducing length of stay is echoed in several other studies [6, 8, 10]. The American College of Surgeons National Surgical Quality Improvement Program (NSQIP) is a multi‐institutional database providing perioperative outcomes of various operations. Hanske et al. queried this database and compared outcomes between patients who underwent open or minimally invasive nephroureterectomy [11]. They found no statistically significant difference in 30‐day postoperative complications, readmission rate, and perioperative mortality. Minimally invasive approach was superior to open with regard to transfusion rate (9.2% vs. 21.5%, P < 0.05) and need for repeat surgical intervention (odds ratio = 0.24 95% confidence interval (CI) 0.07–0.83, P < 0.05). Although all these series seem to indicate comparable oncologic and perioperative outcomes, there remain multiple approaches for excision of the distal ureter during a laparoscopic approach. Patient positioning is similar to that for laparoscopic nephrectomy as described in Chapter 92 with modified lateral decubitus positioning. The hips should be more externally rotated to open the pelvis and expose the lower quadrant. It is often advantageous to mark the midline prior to positioning to aid in appropriate trocar and incision alignment before the skin shifts when the patient is positioned on their side. This positioning allows for access for nephrectomy as well as the distal ureterectomy portion for purely laparoscopic and for open excision approaches. This also prevents patient repositioning. There are various ways to manage the distal ureter. The entire ureter, including the intramural portion, ureteral orifice, and bladder cuff, should be removed. Approach used is generally based on surgeon preference. There are minor variations among techniques for distal ureteral management but most fall into four main categories: purely laparoscopic, open, endoscopic “pluck,” and endoscopic “intussusception.” The endoscopic approaches require patient repositioning into the dorsal lithotomy position for that portion of the case. The modified lateral decubitus positioning is still used for the nephrectomy portion. For a purely laparoscopic approach, trocars should be placed to allow for dissection in the hemi‐abdomen as well as the pelvis (Figure 95.1). Just as in renal surgery, trocars are shifted laterally in obese patients. Upper abdominal trocars are placed and used just as that described for a nephrectomy (umbilical camera port and upper midline and lateral ports for right and left hands). A laparoscopic nephrectomy takes place (as described in Chapter 92) without transection of the ureter. Clips should be placed across the ureter as early as possible below the level of the primary tumor to prevent tumor spillage. Once the kidney is freed, the ureter is traced down into the pelvis. It is about at the level of the iliac vessels where a lower abdominal approach must be taken. It is at this point that the trocar configuration is transitioned into the pelvis (Figure 95.2). The camera port remains at the umbilicus and right and left hands are shifted to the trocars within the pelvis (lateral and lower midline trocars). The surgical bed can be adjusted into a Trendelenburg position to help in visualization by shifting the colon cephalad.
Laparoscopic Radical Nephroureterectomy
Introduction
Indications
Oncological outcomes
Perioperative outcomes
Operative technique
Patient positioning
Procedure
Pure laparoscopy
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