Laparoscopic Nephroureterectomy for Upper Tract Transitional Cell Cancer

Abstract

Standard therapy for most patients with upper-tract transitional cell carcinoma (TCC) is total nephroureterectomy with excision of an ipsilateral cuff of bladder, performed through two separate incisions or one long abdominal incision. Laparoscopic nephrectomy is a recognized form of ablative therapy for patients with benign renal disease; recently it has been extended to the management of renal cell carcinoma and upper-tract TCC. In May 1991, the first clinical laparoscopic nephroureterectomy (LNU) was performed at Washington University in St. Louis. Since then, a total of 20 patients with upper-tract TCC have undergone LNU at our institution. The technique begins with a transurethral unroofing and electrocoagulation of the ureteral orifice with placement of an external ureteral catheter. Next, a transperitoneal laparoscopic total or radical nephrectomy dissection is performed. Then, another 12-mm port is inserted infraumbilically and the ureter is dissected distally to the ureterovesical junction; a 12-mm laparoscopic GIA tissue stapler is fired across the bladder cuff. The specimen is placed into an entrapment sack and removed intact by enlarging one of the trocar sites to 7–10 cm. In our experience, LNU has had a short-term efficacy similar to that of open nephroureterectomy. However, LNU required an average of 3.6h longer operative time. In favor of LNU were a 74% reduction in analgesia requirements, a brief hospital stay (average, 4 days), and a rapid convalescence (average, 2.4 weeks).