Urothelial carcinoma can arise from any part of the urothelium: bladder, renal collecting system, or ureter. The nomenclature of upper tract urothelial carcinoma (UTUC) is reserved for tumors that are localized to the renal calyces or ureter. UTUC is a relatively rare disease, representing only 5% to 10% of all urothelial cancers with an incidence of about 3,500 cases in the United States annually.
Reports from multiple comparative studies and one randomized study describe similar oncologic outcomes for laparoscopic and open extirpative surgery, with reduced perioperative morbidity favoring a laparoscopic approach. Because most upper tract urothelial tumors are not large or bulky, laparoscopic surgery is ideal for most patients, at least for the renal portion of a radical nephroureterectomy when the tumor warrants removal of the entire renal unit. There has been a recent shift in the paradigm for treatment of low-grade and low-stage tumors, for which consideration of endoscopic treatment or segmental ureterectomy may be given, but this discussion is beyond the scope of the chapter.
Once the extirpative management has been chosen, the surgical approach should be planned in a way that does not compromise oncologic control because UTUC is rarely able to be salvaged by adjuvant modalities. Accordingly, the removal of an intact specimen is desirable to minimize the risk of tumor seeding from both the ureter and bladder. While open radical nephroureterectomy has been considered the gold standard for extirpative management of UTUC, systematic reviews and meta-analyses have supported similar oncologic outcomes. Laparoscopic nephroureterectomy can be performed by transperitoneal, retroperitoneal, hand-assisted, and robotic-assisted approaches as dictated by the surgeon’s experience. In this chapter, we describe the more widely used transperitoneal technique.
Indications and contraindications
Radical nephroureterectomy with removal of the bladder cuff is the gold standard for large, high-grade, and invasive urothelial tumors of the renal pelvis and proximal ureter. It is also the choice for large, multifocal, or rapidly recurring low-grade or noninvasive tumors.
Large bulky tumors with involvement of adjacent viscera or those cases requiring extended lymph node dissection in the hands of a less-experienced laparoscopic surgeon may be better suited for the open approach. Other patient factors, such as a prior history of ipsilateral or extensive abdominal surgery or the presence of a perinephric inflammatory process, should prompt the consideration of a retroperitoneal or an open approach.
Patient preoperative evaluation and preparation
The preoperative evaluation of a patient with a suspected upper tract tumor should include a complete history and physical examination and laboratory studies to include complete blood count, chemistry profile, and urine cytology. The upper tract collecting system should be evaluated by computed tomography (CT) urography, but if the patient is unable to undergo contrast administration owing to poor renal function or allergies, it may be replaced with a magnetic resonance imaging (MRI) urogram. If MRI is contraindicated or unavailable, CT without contrast or ultrasound of the kidneys supplemented with retrograde pyelography is an acceptable alternative. If a suspicious lesion is identified, a normal saline washing of the area is performed, followed by ureteroscopic biopsy of the tumor. Cystoscopy should always be performed to exclude bladder tumors.
In the setting of positive cytologic test results without an identifiable lesion, one should consider the bladder and prostatic urethra, in addition to the upper tracts, as possible sites harboring cancer. If the results of the bladder evaluation were negative or if cytologic test results remain positive after successful treatment of the bladder, then one should proceed with evaluation of extravesical sites to include selective cytologic samples from each upper urinary tract as well as resection of a representative specimen of the prostatic urethra in men. Selective cytologic tests should preferably be performed along with ureteroscopy to allow for direct visualization of the upper urinary tracts. However, cytologic testing alone has limitations including false-positive results and the high risk for bilateral disease in the future; if the selective cytologic test results are persistently positive in the absence of any ureteroscopic or radiographic findings, or if the treatment is not well established, radical nephroureterectomy is not recommended.
Consideration of nuclear renal scan to evaluate the function of the contralateral kidney may help with the decision regarding an extirpative versus organ-sparing approach. Staging should include chest radiography or tomography and bone scan only in the presence of symptoms or elevated alkaline phosphatase or calcium. No bowel preparation is necessary, but the patient should be on a clear liquid diet the day before surgery. We administer a prophylactic dose of subcutaneous heparin preoperatively.
The use of neoadjuvant chemotherapy has been extrapolated from the bladder literature. The rationale is the high number of patients with chronic renal disease following nephrectomy, which may limit dosing in the adjuvant setting. The intergroup trial EA8141 showed the efficacy of the neoadjuvant approach. The benefits are theoretically administering chemotherapy in those patients likely to need it prior to the loss of a renal unit, which may compromise dosing.
Operating room configuration and patient positioning
The operating room configuration for laparoscopic or robotic-assisted surgery is illustrated in Fig. 16.1 . The surgical team stands on the contralateral side of the patient, and the scrub technician stands at the foot of the patient’s bed to facilitate access to the instrument table. Two towers with monitors are positioned, one on each side of the patient, to maximize visualization of the surgical progress by all members of the operating room care team.
If a transurethral approach is desired for bladder cuff removal, the patient is initially placed in the dorsal lithotomy position. The patient is then moved to the supine position with the ipsilateral hip and shoulder rotated approximately 20 degrees for open distal ureterectomy and total laparoscopic or robotic-assisted technique or after the completion of the cystoscopic portion ( Fig. 16.2 ). The patient is secured to the table and can be easily moved from the flank position (nephrectomy portion) to the supine position (open portion) without repreparing the operative field. The table can be flexed to widen the distance between the costal margin and iliac crest, but we do not find this necessary in most cases. Once the patient is secured to the table, we test the stability of the position by rotating the table left and right. Finally, the ipsilateral flank and urethra are prepared and draped, and a Foley catheter is placed in the sterile field before insufflation of the abdomen.
The abdomen is insufflated, and three or four trocars are placed as outlined in Fig. 16.3 A–B, with the first usually being the lateral trocar. Subsequent trocars are placed under direct vision. With this configuration, the camera is kept at the umbilicus for the entire procedure. The upper midline and lateral trocars are used by the surgeon for the dissection of the kidney and the proximal half of the ureter. The lower midline and lateral trocars are used for the dissection of the distal ureter. On the left side, dissection of the distal ureter may require placement of the fourth trocar. A 3-mm trocar just below the xiphoid process can be helpful in retracting the spleen and liver for left- and right-sided nephrectomy, respectively. In obese patients, shifting of the trocars may be necessary to achieve optimal visualization ( Fig. 16.3 C). If a hand-assisted approach is chosen, the hand port site should be placed so that it can be used for the dissection of the distal ureter and open bladder cuff as indicated ( Fig. 16.3 D).
For robotic-assisted surgery, proper port positioning is paramount to success ( Fig. 16.4 ). When docking the robot, the surgeon places the left arm in port 1 and the right arm in port 2; the fourth arm is placed in port 3 and used for retraction. Once the nephrectomy portion has been completed, the retraction instrument is moved to port 1 and the left arm to port 3 for distal ureter and bladder cuff dissection.
Procedure (see )
Nephrectomy with mobilization of the ureter
The peritoneum is incised along the white line of Toldt from the level of the iliac vessels to the hepatic flexure on the right and to the splenic flexure on the left ( Fig. 16.5 ). The colon is mobilized medially by releasing the renocolic ligaments while leaving the lateral attachments of the Gerota fascia in place to prevent the kidney from “flopping” medially. The colon mesentery should be mobilized medial to the great vessels to facilitate dissection of the ureter, renal hilum, and local lymph nodes as needed ( Fig. 16.6 ). On the right side, a Kocher maneuver to deflect the duodenum medially is necessary to expose the hilum ( Fig. 16.7 A); on the left side, the pancreatic tail needs to be mobilized. Division of the splenorenal ligament is imperative to avoid injury to the spleen and achieve mobility of the upper pole of the kidney ( Fig. 16.7 B). The proximal ureter is identified, just medial to the lower pole of the kidney, and dissected toward the renal pelvis, avoiding skeletonization and maintaining copious periureteral fat if any tumor is located in this area ( Fig. 16.8 ). If an invasive ureteral lesion is suspected, the dissection should include a wide margin of tissue. The renal hilum is identified, and its vessels are exposed with a combination of blunt and sharp dissection. The artery is ligated and divided through the use of a stapling device with a vascular load or multiple clips. The renal vein is then divided in a similar fashion ( Fig. 16.9 ). With vascular control ensured, most prefer to ligate the ureter with a clip, and the kidney is dissected free outside the Gerota fascia. As described for nephrectomy, the adrenal gland does not need to be removed routinely. Adrenal gland removal should be considered for high-grade and invasive lesions in the vicinity of the adrenal gland. The ureteral dissection is continued distally as far as is technically feasible, keeping in mind that the ureteral blood supply is generally anteromedial in the proximal third, medial in the middle third, and lateral in the distal third. If distal limits of the dissection are below the level of the iliac vessels ( Fig. 16.10 ), the remainder of the procedure can easily be completed through a lower abdominal incision. The specimen is placed in the pelvis, and the renal bed is inspected meticulously for bleeding.