Nephroureterectomy entails en bloc excision of the kidney, ureter, and an ipsilateral cuff of the urinary bladder around the ureteral orifice. This operation is a primary treatment option for upper tract transitional cell carcinoma (UTTCC), particularly for patients with large-volume or high-grade disease. On rare occasion, benign conditions such as infectious processes or severe reflux disease can destroy the kidney and may warrant nephroureterectomy in an attempt to reduce the risk of persistence or recurrence of infection. Because such scenarios are rare and do not result in changes to operative technique, this chapter focuses on nephroureterectomy for malignancy.
Nephron-sparing techniques such as endoscopic resection and segmental ureterectomy may be considered in patients with special circumstances such as low-grade, low-volume disease; isolated distal ureteral malignancy; solitary kidney; or bilateral disease. However, these approaches are not discussed in this chapter.
Preoperative Considerations
Diagnosing Upper Tract Malignancy
Hematuria, either gross or microscopic, is the most common sentinel finding in patients with upper tract malignancy. During the hematuria workup, computed tomography (CT) urography is the preferred radiologic study. Identification of a filling defect in the urinary collecting system or ureter in the delayed phase of the CT urogram is a common radiologic sign of UTTCC, but clinicians should also be alert for ureteral thickening and lumen narrowing. Cystoscopy, retrograde pyelography, and ureteroscopy with biopsy and cytology are indicated in patients when there is concern for malignancy. Filling defects account for detection of 50% to 75% of upper tract malignancies, but combining ureteroscopy improves the diagnostic yield to 90%. Urine cytology is positive in about 20% of low-grade malignancies and up to 75% of high-grade malignancies. Ureteroscopy and biopsy (brush, basket, or cold cup) should be considered when the diagnosis is not clear. Percutaneous approaches can also be used to confirm the presence of tumor, but these approaches are more invasive than ureteroscopy and carry the rare but reported risk of nephrostomy tract seeding.
Staging of Malignancy
Staging for UTTCC is comparable to that for bladder urothelial carcinoma and usually includes cystoscopy to rule out a synchronous bladder tumor as well as chest radiography and triple-phase CT of the abdomen and pelvis to evaluate lymphadenopathy and metastatic disease. Laboratory studies may include urine cytology; a complete blood count; and a comprehensive metabolic panel, including liver function tests. Positive urine cultures should be treated with appropriate antibiotics preoperatively.
Role of Neoadjuvant Chemotherapy
Because of the rarity of upper tract malignancy, neoadjuvant chemotherapy lacks robust evidence. However, retrospective studies have a suggested potential survival benefit, particularly for patients with high-volume and invasive disease. Because nephroureterectomy is indicated in high-volume and invasive disease, we advise consideration of neoadjuvant chemotherapy for patients undergoing nephroureterectomy for malignancy. Chemotherapy regimens often rely on adequate renal function because they are cisplatin based. Because nephroureterectomy results in decline of renal function, neoadjuvant is often preferred to adjuvant chemotherapy.
Lymphadenectomy
Regional lymphadenectomy (LAD) facilitates accurate disease staging. A potential survival benefit has been demonstrated in retrospective studies for patients with pT2-T4 disease who undergo LAD. Because clinical staging of UTTCC is difficult and often inaccurate because of sampling issues, some recommend LAD in all patients undergoing radical nephroureterectomy. For right-sided masses located in the upper two thirds of the collecting system, nodes are removed from the level of the renal hilum to the aortic bifurcation and can include the hilar, paracaval, interaortocaval, and retrocaval lymph nodes. For left-sided masses located in the upper two-thirds of the collecting system, nodes are removed from the level of the renal hilum to the aortic bifurcation and include the paraaortic and hilar nodes. If the malignancy is in the distal third of the ureter and nephroureterectomy is performed, the recommended LAD includes the ipsilateral pelvic lymph nodes along the common iliac, external iliac, internal iliac, and obturator vessels ( Fig. 10.1 ).
Use of Intraoperative Intravesical Chemotherapy
Although not commonly used in our practice, one may consider instillation of sterile water or cytotoxic agents such as mitomycin C or Adriamycin into the bladder before proceeding to the distal ureterectomy portion of the case. Advocates of this technique believe that by allowing roughly 15 to 30 minutes of dwell time with a cytotoxic or hypotonic solution before incising the urinary bladder, free-floating urothelial carcinoma cells capable of seeding the operative site may be lysed, reducing the risk of a local recurrence. The bladder should be drained before the cystotomy is performed to prevent spillage of chemotherapy agents into the operative field. Use of such techniques is surgeon dependent.
Overview of Techniques for Nephroureterectomy
Nephroureterectomy can be accomplished using a variety of techniques and arguably has more diversity in its potential approaches than any other operation for urologic malignancy. The optimal technique is open for debate. We generally favor the less morbid laparoscopic nephroureterectomy (LNU) over the open approach. However, in cases with large invasive tumors, marked lymphadenopathy, or contraindication to laparoscopic approaches, open nephroureterectomy (ONU) remains an excellent operation. Retrospective review articles have suggested that the laparoscopic approach for nephroureterectomy offers comparable oncologic efficacy compared with the open approach. Robot-assisted laparoscopic nephroureterectomy (RANU) has recently become an attractive and accepted option because it allows for more widespread use of minimally invasive techniques and eases the task of suturing. Although multiple series confirm the short-term safety and efficacy of RANU, longer term outcome data regarding disease recurrence and survival are lacking but should be no different than for LNU. Oncologic control has seemingly improved with advances in operative technique with particular focus on the bladder cuff and extraction steps. Despite the variations available for managing the distal ureter, complete resection of the entire ipsilateral ureter with a cuff of bladder remains the underlying principal. Because of the multiple variations of the operative technique, we will divide the operation into two components: (1) nephrectomy and (2) distal ureterectomy using a bladder cuff. These approaches may be mixed and matched to maximize oncologic control and are based on patient factors, available technology, surgeon experience, and comfort. Because the nephrectomy and proximal ureter portion of the case is already covered in the nephrectomy chapter, more detail is given here to the distal ureterectomy and bladder cuff portion.
Nephrectomy
Techniques of Open Nephroureterectomy Nephrectomy
Table 10.1 highlights some of the possible variations in technique that can be used to remove the kidney, ureter, and bladder cuff in an open manner. A popular open approach remains the two-incision technique and complete extravesical cuff resection.
| Advantages | Disadvantages | |
|---|---|---|
| Thoracoabdominal | Excellent access for large masses | Long incision; slower recovery Transect large muscles Limited contralateral access Increased pulmonary complications |
| Midline laparotomy | Bilateral renal access Excellent access to aorta and vena cava | Long incision; slower recovery Suboptimal upper pole access |
| Paramedian laparotomy | Excellent access to aorta and vena cava No muscle transection Lower incidence of hernia | Long incision; slower recovery Limited contralateral access Suboptimal upper pole access Transection of deep inferior epigastrics |
| UPPER INCISION | ||
| Flank | Extraperitoneal Excellent parenchymal visualization Pedicle approached anteriorly or posteriorly | Rib resection and flank bulge Ventilation issues and pneumothorax Difficult interaortocaval node dissection |
| Subcostal | Excellent vascular control | Postoperative ileus Intestinal injury |
| LOWER INCISION | ||
| Paramedian or Gibson | Excellent distal ureter access | Transection of deep inferior epigastrics Ilioinguinal or iliohypogastric nerve injury |
| Midline or Pfannenstiel | No muscle transection Rare herniation (Pfannenstiel) | Limited exposure (Pfannenstiel) |
| Endoscopic pluck | Avoids second incision No cystotomy | Increased bladder recurrences Local tumor seeding and recurrences Defect not closed |
| Endoscopic intussusception | Avoids second incision No cystotomy | Increased bladder recurrences Local tumor seeding and recurrences Defect not closed |
| Transvesical cuff | Ensures complete upper tract excision | Prolonged need for urethral catheterization Potential urine leaks |
| Extravesical cuff | Quick No cystotomy | Complete removal of intramural ureter can be difficult |
| Extravesical transection | Quickest No cystotomy | Intramural tunnel remains; increased risk of recurrence |
Two-Incision Approach
- 1.
Position the patient in flank position with the pelvis rotated posteriorly until it is nearly supine in position. Perform a mini-flank incision and proceed with adrenal-sparing radical nephrectomy (see Chapter 8 ). Do not divide the ureter at the inferior pole of the kidney.
- 2.
Dissect the ureter as far distally as possible, usually to the level of the common iliac artery, clipping or sealing its medial vascular and lymphatic attachments ( Fig. 10.2 ). Be careful not to pull too hard on the ureter, which can result in its avulsion and seeding of the wound with urine that contains tumor cells. For upper ureteral and collecting system tumors, place a clip on the ureter distal to the tumor to prevent distal flow of tumor cells during manipulation.
FIGURE 10.2
Identify the distal ureter around the level of the iliac artery.
(From the Department of Urology, University of Patras. Robotic nephroureterectomy. http://www.laparoscopy-endourology.com/main/clinical-expertise/robotic-surgery/robotic-nephroureterectomy .)
- 3.
If indicated, perform a regional retroperitoneal LAD.
- 4.
Control the distal ureter using one of two options:
Option 1 : Doubly clip the ureter as distal as possible and transect it with electrocautery to kill any tumor cells at this surgical margin between the clips. Remove the kidney and proximal ureter and close the flank.
Option 2 : Clip the ureter as distally as possible but do not divide it; the clip will serve a landmark for the pelvic portion of the case. Place the kidney and proximal ureter in a laparoscopic specimen bag and gently place this bag as caudal as possible in the wound. Close the flank leaving the kidney and ureter in the body.
- 5.
At the conclusion of dissecting out the kidney and proximal ureter, place the patient in the supine position. Next, make a Gibson incision to split the rectus fascia and develop the space of Retzius. Some surgeons may prefer a low midline incision for the access. Proceed to the Distal Ureterectomy: Open Approach section of this chapter to complete the two-incision approach.
Single-Incision Approach
A single-incision approach may also be used to perform nephroureterectomy ( Fig. 10.3 ). A thoracoabdominal incision is rarely used nowadays; a single midline approach has been successful while being associated with less morbidity. However, when compared with the more favorable two-incision approach, the single-incision approach is often perceived as being associated with more morbidity without gaining significantly improved exposure. Because the distal ureterectomy is the primary difference between nephroureterectomy and radical nephrectomy, please review the steps of the open radical nephrectomy to guide your nephrectomy and proximal ureteral dissection, taking care to preserve the ureter while dissecting it distally. Then proceed to the Distal Ureterectomy section of this chapter.
Techniques of Laparoscopic Nephroureterectomy
Laparoscopic nephroureterectomy clearly delineates the two stages of the operation: (1) laparoscopic dissection and isolation of the kidney and ureter to the level of the pelvis and (2) complete dissection of the distal ureter and bladder cuff. For this reason, the procedure requires careful planning when positioning the patient and thoughtful port placement. Proper positioning allows the completion of both stages and intact specimen removal without the need for repositioning.
Pure Laparoscopic Technique
- 1.
With the patient under general anesthesia, ensure that an orogastric tube is in place to decompress the stomach. Depending on the operative plan for the distal ureterectomy, you may or may not start with the patient in the lithotomy position and may or may not place a catheter at the start. We will first focus on positioning for the nephrectomy portion of the case.
- 2.
The patient is placed in a modified flank position ( Fig. 10.4 ) with the operative side up and propped to about 75 to 90 degrees off the bed. The patient is strategically positioned where the kidney rest falls just cranial to the iliac crest so that elevating the kidney rest creates more space between the costal margin and the anterior superior iliac spine (ASIS). The table is then flexed about 10 to 15 degrees and leveled out. An axillary roll is the first support placed after the patient is properly situated on the flexed table followed by a shoulder and lower back support versus a “beanbag” conforming positioner. The ipsilateral arm is brought across the torso and supported either with pillows or preferably an elevated padded arm rest. The contralateral arm is placed on the usual arm board perpendicular or slightly cranial to the operating table . Pillows are placed between the legs. The downside leg is flexed at the knee, and all pressure points are adequately padded. The patient is then carefully secured to the table with padded 3-inch tape at the level of the shoulders, hips, and legs just above the knees. This position is then checked for stability because table repositioning is often necessary during the case.
FIGURE 10.4
Patient is in modified flank position for nephrectomy portion of the case. Patient is secured for possible need to rotate table supine for distal ureterectomy portion.
(From Bishoff JT, Kavoussi LR. Atlas of laparoscopic urologic surgery . Philadelphia: Elsevier; 2007.)
- 3.
The sterile skin prep is carried wide enough to accommodate conversion to an open procedure through an incision placed over the flank or pelvis if needed.
- 4.
Techniques for gaining access and insufflating are surgeon dependent and may be reviewed in Chapter 6 . We generally use a transperitoneal four-trocar approach with a visual obturator and a zero-degree lens. The trocar position depends mainly on the patient’s body habitus ( Fig. 10.5 ) because port placements are laterally adjusted for obese patients. A 10- to 12-mm trocar with a visual obturator is placed under direct vision in the midline 2 fingerbreadths cranial to the umbilicus. For a right-handed surgeon operating on a left kidney, a second 10- to 12-mm trocar is placed at the level of umbilicus but lateral to the rectus at approximately the midclavicular line or about a hand’s width lateral from the camera port. Many times we will place the off-midline trocar first so that we can visualize the anterior and posterior rectus sheath using the visual obturator. A 5-mm trocar is placed in the midline between the umbilicus and the xiphoid process, and a fourth trocar, usually 10 to 12 mm, is placed between the umbilicus and the pubis, avoiding the decompressed bladder.
