Abstract
BackgroundDistal ureter bladder cuff (DUBC) excision is an essential part of radical nephroureterectomy (RNU) but there is no agreement on the ideal surgical technique to achieve it. We describe a novel technique for endoscopic DUBC excision during RNU that complies with the oncological principle of preventing spillage of tumor cells, by occluding the distal ureter before its excision, while shortening surgical time, and by avoiding repositioning the patient.MethodsBetween June 2010 and May 2012, 10 patients underwent simultaneous open RNU and transurethral distal ureter balloon occlusion and detachment using a flexible cystoscope (f-TUDUBOD) in lumbotomy position. After having ruled out the presence of a concomitant bladder tumor, one surgeon used a flexible cystoscope to occlude the affected ureter with a 5Fr Fogarty catheter and circumferentially incised the orifice until detaching it from the bladder with a boogie electrode or a Holmium laser; meanwhile, two other surgeons performed open RNU through a lumbotomic approach. Data were compared with those of patients who had previously undergone open RNU after TUDUBOD.ResultsMean surgical time for simultaneous open RNU and f-TUDUBOD was 113.4 ± 29.2 minutes, significantly shorter (P <0.01) than that for open RNU after TUDUBOD (154.2 ± 26.4 minutes). There were no complications. Surgical margins were always negative; at mean follow-up of 31.1 months, there was no recurrence in the perivesical space and a 20% (2/10) bladder recurrence rate comparing favorably with that (23.1%) observed at 30-month follow-up in patients who had undergone open RNU after TUDUBOD.ConclusionsSimultaneous open RNU and f-TUDUBOD proved to be feasible and to represent a safe and effective means of shortening surgical time, with obvious clinical and economical benefits.
Highlights
Distal ureter bladder cuff (DUBC) excision is an essential part of radical nephroureterectomy (RNU) but there is no agreement on the ideal surgical technique to achieve it
Radical nephroureterectomy (RNU) with distal ureter bladder cuff (DUBC) excision is the standard treatment for high-risk non-invasive and invasive upper tract transitional cell carcinoma (UT-TCC), but there is no agreement on the ideal technique for DUBC excision [1,2,3]
To comply with the oncological principle of preventing spillage of tumor cells, we recently described a technique for transurethral distal ureter balloon occlusion before detachment called TUDUBOD [4]
Summary
Distal ureter bladder cuff (DUBC) excision is an essential part of radical nephroureterectomy (RNU) but there is no agreement on the ideal surgical technique to achieve it. We describe a novel technique for endoscopic DUBC excision during RNU that complies with the oncological principle of preventing spillage of tumor cells, by occluding the distal ureter before its excision, while shortening surgical time, and by avoiding repositioning the patient. The patient is placed in the dorsal lithotomy position and the distal ureter occluded with a balloon catheter to prevent spillage of tumor cells outside the bladder while excising the DUBC with a resectoscope; after having completed this phase, the patient is turned to the lumbotomy position for open RNU. The present study describes the technique for simultaneous open RNU and f-TUDUBOD and evaluates its efficacy in shortening surgical time
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