Abstract
Surgical management of the lower end of the ureter during laparoscopic nephroureterectomy remains a matter of debate. The commonest method during laparoscopic nephroureterectomy-endoscopic incision-has been shown to have a higher recurrence rate compared with open surgical excision with a cuff of bladder. In addition, the literature still lacks comparative studies between different approaches to support and guide the current clinical practice. Three consecutive series of patients undergoing laparoscopic radical nephrectomy for transitional cell carcinoma located in the lower one-third of the ureter with different methods (laparoscopic en bloc resection of ureter with a cuff of bladder, open surgical excision, and endoscopic incision) of dealing with the lower end were compared in their short-term surgical and oncological outcomes. The primary outcome was recurrence at 12 months of follow-up. The secondary outcomes were hospital stay, positive surgical margins, and duration of catheterization. Analysis of perioperative and postoperative outcomes revealed laparoscopic en bloc resection of the lower end of the ureter with a cuff of bladder is a safe and feasible approach with the advantages of the laparoscopic approach such as less hospital stay compared with the open approach. The analysis of oncological outcomes in this feasibility study showed a higher rate of recurrences in the endoscopic approach. Laparoscopic en bloc resection of the lower end of the ureter with a cuff of bladder during nephroureterectomy for tumors located in the lower one-third of ureters is safe and feasible in terms of perioperative outcomes and early oncological results. We acknowledge that the small sample size and the nonrandomized design are a limit of the study. Thus, prospective randomized controlled trials are recommended to prove the superiority of one approach over the others.
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