Comparative analysis of transurethral Holmium laser, electric resection and open surgery for the distal ureter and bladder cuff in the procedure of nephroureterectomy

Abstract

Objective To present the innovative transurethral resection of the distal ureter and bladder cuff by Holmium laser and to compare the perioperative and oncological outcomes following nephroureterectomy using three different methods of managing the distal ureter and bladder cuff. Methods From January 2000 to December 2010,162 patients underwent excision of the distal ureter and bladder cuff by transurethral Holmium laser (32 cases,Group A),transurethral electric resection (51 cases,Group B) or open procedure (79 cases,Group C) combined with open or retroperitoneal laparoscopic nephroureterectomy.5 French ureteral balloon catheter was inserted into the targeted ureter to prevent possible microscopic tumor seeding.The therapeutic effectiveness,perioperative complications,postoperative recovery and oncologic outcomes were compared among groups.The follow-up time was 3 -96 months. Results Group A and B showed statistically significant better results on the operative time (203.6 ± 31.5 min and 207.2 ±24.3 min),blood loss ( 127.4 ± 63.2 ml and 135.0 ± 82.7 ml) and postoperative hospital stay (5.8 ± 1.3d and 5.6 ±1.2 d) than those of Group C (248.0 ±42.9 min,484.5 ±217.7 ml,8.7 ±3.5 d),respectively ( P ＜ 0.01 ).Six cases of obturator nervous reflex occurred in Group B,with 3 cases of bladder peroration and 2 conversions to open procedure.There were no difference in bladder tumor occurrence,retroperitoneal recurrence,tumor cell seeding and cancer-specific survival among the 3 groups. Conclusions Our data have validated the superiority of transurethral approach over conventional open procedure including perioperative index,recovery and comparable oncologic outcomes with open group.Holmium laser demonstrated better results including fewer complication,cleaner surgical vision and operating accuracy than that of electric resection.Transurethral Holmium laser resection of the distal ureter and bladder cuff has been proved to be a technically innovative minimally invasive and oncological safe method. Key words: Urothelial carcinoma; Nephroureterectomy; Holmium; Laser surgery