Bladder Cuff Excision Research Articles

The impact of method of distal ureter management during radical nephroureterectomy on tumour recurrence.

Radical nephroureterectomy for upper tract urothelial carcinoma (UTUC) must include some form of distal ureter management to avoid high rates of tumour recurrence. It is uncertain which distal ureter management technique has the best oncologic outcomes. To determine which distal ureter management technique resulted in the lowest tumour recurrence rate, we analyzed a multi-institutional Canadian radical nephroureterectomy database. We retrospectively analyzed patients who underwent radical nephroureterectomy with distal ureter management for UTUC between January 1990 and June 2010 at 10 Canadian tertiary hospitals. Distal ureter management approaches were divided into 3 categories: (1) extravesical tenting for ureteric excision without cystotomy (EXTRAVESICAL); (2) open cystotomy with intravesical bladder cuff excision (INTRAVESICAL); and (3) extravesical excision with endoscopic management of ureteric orifice (ENDOSCOPIC). Data available for each patient included demographic details, distal ureter management approach, pathology and operative details, as well as the presence and location of local or distant recurrence. Clinical outcomes included overall recurrence-free survival and intravesical recurrence-free survival. Survival analysis was performed with the Kaplan-Meier method. Multivariable Cox regression analysis was also performed. A total of 820 patients underwent radical nephroureterectomy with a specified distal ureter management approach at 10 Canadian academic institutions. The mean patient age was 69.6 years and the median follow-up was 24.6 months. Of the 820 patients, 406 (49.5%) underwent INTRAVESICAL, 316 (38.5%) underwent EXTRAVESICAL, and 98 (11.9%) underwent ENDOSOPIC distal ureter management. Groups differed significantly in their proportion of females, proportion of laparoscopic cases, presence of carcinoma in situ and pathological tumour stage (p < 0.05). Recurrence-free survival at 5 years was 46.3%, 35.6%, and 30.1% for INTRAVESICAL, EXTRAVESICAL and ENDOSCOPIC, respectively (p < 0.05). Multivariable Cox regression analysis confirmed that INTRAVESICAL resulted in a lower hazard of recurrence compared to EXTRAVESICAL and ENDOSCOPIC. When looking only at intravesical recurrence-free survival (iRFS), a similar trend held up with INTRAVESICAL having the highest iRFS, followed by ENDOSCOPIC and then EXTRAVESICAL management (p < 0.05). At last follow-up, 406 (49.5%) patients were alive and free of disease. Open intravesical excision of the distal ureter (INTRAVESICAL) during radical nephroureterectomy was associated with improved overall and intravesical recurrence-free survival compared with extravesical and endoscopic approaches. These findings suggest that INTRAVESICAL should be considered the gold standard oncologic approach to distal ureter management during radical nephroureterectomy. Limitations of this study include its retrospective design, heterogeneous cohort, and limited follow-up.

Robot-assisted nephroureterectomy and bladder cuff excision without patient or robot repositioning: description of modified port placement and technique.

Nephroureterectomy (NUx) with full bladder cuff excision is the gold-standard treatment for upper urinary tract urothelial cancer. Although minimally invasive techniques for NUx have demonstrated comparable outcomes to those of the open technique, the robotic technique is limited by the need for intraoperative patient repositioning and robot redocking to manage the distal ureter and bladder cuff. We describe our novel technique of robotic NUx that allows for complete access to the kidney and full bladder cuff excision. This modified technique was performed on a consecutive series of patients undergoing robotic NUx for upper urinary tract urothelial cancer from August 2012 to January 2014. Operative parameters and pathologic data were recorded, and patients were followed up for surveillance. After insufflation, the robotic trocars are placed in a standardized fashion, allowing for a one-time switch of instruments to facilitate distal ureteral dissection and a wide bladder cuff excision without patient repositioning or robot redocking. Twenty-six patients have undergone NUx using our modified technique. Mean blood loss and operative time were 66 mL and 230 minutes, respectively. There were no intraoperative complications or open conversions, and there were no positive surgical margins. The average follow-up time was 7.8 months (range, 2-17 months), and 4 cases of cancer recurrence in the bladder were identified. This novel technique for robotic NUx offers a standardized and easy-to-implement approach for NUx that requires a minimal learning curve for an experienced robotic surgeon, while affording a comparable oncologic control without the need for patient repositioning or additional port placement.

Traitement chirurgical des tumeurs de la voie excrétrice supérieure par néphro-urétérectomie totale : état-de-l’art pour le rapport annuel de l’Association française d’urologie

To review current knowledge about techniques of radical nephroureterectomy (RNU) for the treatment of the upper urinary tract cancer (UTUC). A systematic review of the literature search was performed from the database Medline (NLM, Pubmed), focused on the following key-words; nephroureterectomy; renal pelvis; ureter; bladder-cuff excision; urothelial carcinoma; surgery; lymph-node dissection; laparoscopy. The removal of a bladder-cuff during RNU is mandatory. After the surgical procedure, intravesical instillation of ametycine reduces significantly the risk of recurrence into the bladder. Ureteral stripping should not be practiced and continuity of the bladder wall must be restored to avoid compromising the post-operative instillation. Lymphadenectomy during RNU is of prognostic and therapeutic interests. However, the anatomic sites of lymphadenectomy and the number of nodes to be analyzed are not consensual. The oncological results of laparoscopic approach are similar to those of open surgery. The RNU must include a lymphadenectomy and an excision of a bladder-cuff and restore the sealing of the bladder to allow practicing of a EPOI. Laparoscopic or open surgery may be used equally, and must respect these rules to avoid compromising the oncological outcome.

Conditional Survival After Radical Nephroureterectomy for Upper Tract Carcinoma

BackgroundConditional survival (CS) provides better estimates of the survival probability at each follow-up time, and its usefulness has been proven in several solid malignancies. ObjectiveTo assess the changes in 5-yr CS rates after radical nephroureterectomy (RNU) for upper tract urothelial carcinoma (UTUC) and to determine how well-established prognostic factors evolve over time. Design, setting, and participantsWe analysed data from 3544 patients treated with RNU at 15 international academic centres between 1989 and 2012. InterventionRNU. Outcomes measurements and statistical analysisConditional intravesical recurrence-free (IVRFS), cancer-specific survival (CSS), and overall survival (OS) estimates were calculated using the Kaplan-Meier method. A multivariable Cox regression model was used to calculate proportional hazard ratios for the prediction of mortality. Results and limitationsThe 5-yr bladder cancer recurrence-free survival, CSS, and OS rates were 54.9%, 72.2%, and 62.6%, respectively. Given a 1-, 2-, 3-, and 4-yr survivorship, the 5-yr conditional OS rates improved to 65.2%, 69.3%, 71.5%, and 73.0%, respectively. The 5-yr CS improvement was primarily noted among surviving patients with advanced-stage disease. The impact of pathologic parameters on CS estimates decreased over time for both CSS and OS, whereas the impact of age and gender increased with survivorship. No survival benefit was noted regarding the adjuvant chemotherapy status. Findings were confirmed upon multivariable analyses. Tumour location, the presence of carcinoma in situ, and the type of bladder cuff excision were continuously predictive for IVRFS whatever the survivorship. A limitation is the retrospective design. ConclusionsCS analysis demonstrates that the patient risk profile evolves during the post-RNU follow-up. The probability of survival markedly increases over time in patients having high-stage disease. The impact of prognostic pathologic features decreases over time and can disappear for long-term CS. Patient summaryIn this study, we found that the risk of intravesical recurrence, cancer-specific survival, and overall mortality evolves over the follow-up after surgery. Taking into account the survivorship provides better estimates of the survival probability at each follow-up time.

Sarcomatoid carcinoma of the renal pelvis: A case report.

Sarcomatoid carcinoma is a high-grade malignant neoplasm which exhibits morphological and/or immunohistochemical evidence of bidirectional epithelial and mesenchymal differentiation. Sarcomatoid carcinoma occurring in the upper urinary tract is rare. The present study reports a case of primary sarcomatoid carcinoma of the renal pelvis. A 49-year-old female patient was admitted to Beijing Chao-Yang Hospital for experiencing two weeks of intermittent hematuria. A computed tomography scan revealed a mass of 2 cm in diameter in the left renal pelvis. A retroperitoneoscopic nephroureterectomy combined with a bladder cuff excision was performed, and the final pathological diagnosis was sarcomatoid carcinoma of the renal pelvis. The patient did not receive systemic chemotherapy and radiotherapy. Regular follow-up was performed for 30 months, and there was no evidence of tumor local recurrence or distant metastasis.

Laparoendoscopic Single-Site Plus One Port Nephroureterectomy: Single Center Initial Experience

Nephroureterectomy (NU) with bladder cuff excision is the gold standard treatment for patients with upper urinary tract urothelial cancer. We report our initial experience with laparoendoscopic single-site plus one port (LESS POP) technique for NU and bladder cuff excision. We retrospectively reviewed the records of consecutive patients undergoing LESS POP NU between 2011 and 2012. We describe in detail our surgical technique and summarized the outcomes in this initial series. Ten patients (7 male, 3 female) aged 55 to 84 years underwent LESS POP NU. There were no conversions to open technique or additions of conventional laparoscopic ports. Median (range) operative time was 217 minutes. Specimens were extracted through the umbilical incision in five patients and through an extension of the lower quadrant port in five. One patient experienced urine leak followed by umbilical wound dehiscence (Clavien grade IIIb complication). In this series, LESS POP NU was feasible with encouraging outcomes. We believe that it is possible to extend the benefits of LESS to patients with upper tract tumors while adhering to strict oncologic principles.

IgG4 Related Disease of the Ureter (Inflammatory Pseudotumor)

A 49-year-old male presented with right flank pain without gross hematuria. Computerized tomography revealed a 2 cm soft tissue mass of the right distal ureter with moderate right hydroureteronephrosis. On ureteroscopy the mass obstructed the ureter but ureteral brushing was nondiagnostic. The patient underwent robotic assisted laparoscopic distal ureterectomy including bladder cuff excision and reconstruction with a psoas hitch and ureteral reimplantation. Gross examination revealed a 3.0 cm mass involving the distal ureter. Margins were uninvolved. Microscopic examination showed a fibroinflammatory process in a storiform pattern with marked inflammatory infiltrates consisting primarily of plasma cells admixed with eosinophils and macrophages (fig. 1). Approximately 60 plasma cells per high power field stained positive for IgG4 immunostain consistent with IgG4 related disease (RD), also known as IgG4 inflammatory pseudotumor (fig. 2). IgG4-RD is a newly recognized clinical condition initially described in 2003 as the etiology of type 1 autoimmune pancreatitis. The classic

Carcinosarcoma of the ureter with a small cell component: report of a rare pathologic entity and potential for diagnostic error on biopsy.

Carcinosarcomas of the ureter are rare biphasic neoplasms, composed of both malignant epithelial (carcinomatous) and malignant mesenchymal (sarcomatous) components. Carcinosarcomas of the urinary tract are exceedingly rare. We report a unique case of a carcinosarcoma of the ureter with a chondrosarcoma and small cell tumor component arising in a 68-year-old male who presented with microscopic hematuria. CT intravenous pyelogram revealed right-sided hydroureter and hydronephrosis with thickening and narrowing of the right ureter. The patient underwent robot-assisted ureterectomy with bladder cuff excision and subsequent adjuvant chemotherapy. The patient is disease-free at 32 months after treatment. We provide a brief synoptic review of carcinosarcoma of the ureter and bladder with utilization of immunohistochemical (IHC) stains and potential diagnostic pitfalls.

Simultaneous radical nephroureterectomy and transurethral distal ureter balloon occlusion and detachment.

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.

Chronic Kidney Disease and Upper Tract Urothelial Carcinomas

Upper tract urothelial carcinomas (UTUC) have high prevalence rates in patients with chronic kidney disease (CKD), including dialysis patients and kidney transplant recipients. Analgesic nephropathy, Balkan endemic nephropathy, and aristolochic acid (AA) nephropathy share the common association with the development of CKD and UTUC. Genome studies allow identification of patients with genetic predisposition to Balkan endemic nephropathy and AA nephropathy. Furthermore, the identification of aristolactam deoxyribonucleic acid (DNA) adducts now provides robust evidence for AA exposure in UTUC patients, even in the absence of recallable exposure history. Diagnosis and treatment of UTUC in CKD patients are challenging. Clinical diagnosis of UTUCs in CKD patients with the available urological and imaging methods is much more difficult than in patients with normal renal function due to atrophic kidneys and poor excretory functions in these patients. High prevalence rates of contralateral upper tract and urinary bladder involvements of UC in CKD, either at presentation or recurrence, raise concerns of the necessity and techniques as well as perioperative risk of complete urinary tract exenteration. The standard treatment of radical nephroureterectomy with bladder cuff excision for UTUC patients may result in deterioration of renal function, rendering adjuvant chemotherapy unsuitable. This special issue collectively addresses these important topics regarding UTUC in CKD patients. The authors in one paper nominate three mutant genes (CELA1, HSPG2, and KCNK5) in Balkan endemic nephropathy patients, which are associated with angiogenesis. This finding suggests that angiogenesis might play an important role in the development of Balkan endemic nephropathy. Another paper shows an elevated risk of urothelial carcinomas (UC) in ESRD patients with the analysis of a national wide cohort in Taiwan. Female patients have 9–18 folds of increased risk of UC as compared to 4–14 folds in male ESRD patients, which may reflect female predominance in AA consumption. One paper discusses the challenges of UTUC diagnosis in CKD patients. It reviews the detection rate of UTUCs in dialysis patients and kidney transplant recipients with the use of a variety of imaging and urological methods in the literature. Combination use of urological and imaging methods has been suggested for diagnosing UTUCs in symptomatic dialysis patients and kidney transplant recipients. Another paper develops a predictive model for postoperative renal insufficiency in UTUC patients undergoing radical nephroureterectomy, which help in selecting eligible patients for cisplatin based adjuvant chemotherapy. Older age, lower estimated glomerular filtration rate before surgery, smaller tumor size, renal pelvis tumor, and absence of hydronephrosis or multifocal tumors are predictors for ineligibility for adjuvant chemotherapy. One paper describes modified incision complete urinary tract exenteration for UC in dialysis patients, providing short operative time, early oral feeding, and no major perioperative complications of this modified surgical procedure. Another paper reviews epidemiological evidence of AA exposure associated with occurrence of nephropathy and UC, including AA exposure scenarios in Belgium, Taiwan, and the Danube River as well as occupational exposure in Chinese herbalists. The identification of aristolactam DNA adducts in these patients further corroborates biological plausibility of AA exposure contributing to the occurrence of UTUC. Li-Jen Wang Joelle L. Nortier Bin Tean Teh Cheng-Keng Chuang Shen-Yang Lee

Nephron-sparing surgery with autotransplantation for high-grade upper urinary tract urothelial carcinoma in a patient with solitary kidney

Instead of nephroureterectomy with bladder cuff excision, nephron-sparing surgery can be considered in selected patients with non-muscle invasive upper urinary tract urothelial carcinoma. The role of kidney-sparing surgery has been established for the management of low-grade urothelial carcinoma. We report a solitary kidney patient with high-grade renal pelvis urothelial carcinoma treated with nephron-sparing surgery by ex vivo tumor excision and autotransplantation. The results of the surgery were excellent.

Oncological impact of endoscopic bladder cuff management during nephroureterectomy varies according to upper urinary tract tumor location

To compare the oncological outcome between extravesical excision and transurethral excision for bladder cuff management in patients undergoing nephroureterectomy with upper urinary tract urothelial cancer. From January 2005 to December 2010, 396 patients were enrolled in the present retrospective study. Nephroureterectomy was carried out either by endoscopic or extravesical bladder cuff excision. The oncological outcome between these two procedures was analyzed in patients with different tumor locations. The average age of the patients was 66.41 ± 10.52 years, and the median follow-up duration was 40.65 ± 23.84 months. For upper urinary tract urothelial cancer management, extravesical bladder cuff excision was carried out in 240 patients, whereas the endoscopic method was carried out in 156 patients. Previous bladder cancer is still the most independent predictor for bladder recurrence (P < 0.001). In addition, endoscopic bladder cuff management for low ureteral tumor was also independently associated with more bladder tumor recurrence (P = 0.017). Non-organ confined pathological stage still independently predicted metastasis (P < 0.001) and cancer-specific death (P < 0.001). There are similar oncological outcomes after nephroureterectomy combined with extravesical or endoscopic bladder cuff management for patients with upper urinary tract urothelial cancer above the low ureter. However, there is a higher incidence of bladder tumor recurrence for the low ureteral tumor after nephroureterectomy with endoscopic bladder cuff excision.

Prediction of Intravesical Recurrence After Radical Nephroureterectomy: Development of a Clinical Decision-making Tool

BackgroundIntravesical recurrence after radical nephroureterectomy (RNU) is a frequent event requiring intense cystoscopic surveillance. Recently, a prospective randomized clinical trial has shown that a single intravesical postoperative dose of mitomycin C (MMC) reduces the absolute risk of intravesical recurrence after RNU. ObjectiveThe aim of the current study was to identify predictors of intravesical recurrence and to develop a tool to allow a risk-stratified approach supporting patient counseling for cystoscopic surveillance and postoperative intravesical MMC administration. Design, setting, and participantsWe performed a retrospective analysis of 1839 patients with upper tract urothelial carcinoma (UTUC). The data set was split into a development cohort of 1261 patients from North America and a validation cohort of 578 patients from Europe. InterventionsRNU with bladder cuff excision was performed. The surgical approach was open in 1424 patients (77.4%) and laparoscopic in 415 patients (22.6%). Outcome measurements and statistical analysesUnivariable and multivariable Cox regression models addressed time to intravesical recurrence after RNU. We developed a nomogram for prediction of the probability of intravesical recurrence at 3, 6, 9, 12, 18, 24, and 36 mo. Predictive accuracy was quantified using the concordance index. Decision curve analysis was performed to evaluate the clinical benefit associated with the use of our nomograms. Results and limitationsWith a median follow-up of 45 mo, intravesical recurrence occurred in 577 patients (31%). The probability of intravesical recurrence-free survival at 6, 12, 24, and 36 mo was 85%±1%, 78%±1%, 68%±1%, and 47%±2%, respectively. In multivariable Cox regression analysis, advanced age, male gender, ureteral tumor location, laparoscopic surgical technique, endoscopic distal ureteral management, previous bladder cancer, higher tumor stage, concomitant carcinoma in situ, and lymph node involvement were all significantly associated with intravesical recurrence (p values ≤0.04). The nomograms were highly accurate for predicting intravesical recurrence in the external validation cohort (concordance index of 67.8% and 69.0% for the reduced model and the full model, respectively), and calibration plots revealed only minor overestimation beyond 24 mo. If one decided to perform postoperative instillation based on the risk of intravesical recurrence of 15% at 24 mo, one would spare 23% of the patients while not preventing only 0.3% of intravesical recurrences. The lack of information on the stage and grade of the intravesical recurrences is the main limitation of the study. ConclusionsIntravesical recurrence after RNU is a common event in patients with UTUC. We developed nomograms that predict intravesical recurrence after RNU with reasonable accuracy. Such nomograms could improve the clinical decision-making process with regard to cystoscopic surveillance scheduling and postoperative intravesical instillations of MMC after RNU.

Upper tract urothelial carcinoma

Upper tract urothelial carcinoma (UTUC) accounts for approximately 5% of all urothelial carcinoma. There are many risk factors for UTUC, including environmental and genetic risk factors, some of which are in common with bladder cancer. The gold standard surgical management of UTUC is radical nephroureterectomy (RNU) with excision of bladder cuff, which is increasingly being performed laparoscopically or robotically with various methods used for the distal ureter. There are increasing numbers of patients being treated endoscopically, with excellent oncological outcomes in low-grade disease. The use of topical BCG and chemotherapy agents has been extrapolated from bladder cancer and may be an adjunct to endoscopic management in those patients in whom it is imperative to avoid RNU.

Two-micron thulium laser resection of the distal ureter and bladder cuff during nephroureterectomy for upper urinary tract urothelial carcinoma

The thulium laser (Tm-laser) technique has been used in the management of many urologic conditions. The present study aimed to evaluate the use of this technique for distal ureter and bladder cuff (DUBC) excision during nephroureterectomy for upper urinary tract urothelial carcinoma (UUT-UC). Fifty-eight patients with UUT-UC who underwent radical nephroureterectomy were included in this retrospective study. DUBC was managed by open excision in 24 cases, by transurethral electrosurgery in 17 cases, and by transurethral Tm-laser in 17 cases. Perioperative measures and oncologic outcomes were compared among the three groups. Furthermore, 11 human ureteral segments were collected to measure the burst pressure and show physical pressure tolerance, and six ureteral segments were assessed histologically to investigate the sealing effect. Operative time and hospital stay were significantly longer, and intraoperative blood loss was significantly greater in the open excision group than in the electrosurgery and Tm-laser groups (P < 0.05 for all). There were no significant differences in these parameters between the electrosurgery and Tm-laser groups. In addition, there were no significant differences in the incidences of bladder tumors and retroperitoneal recurrence of urothelial carcinoma among the three groups. The coagulation time and resection time were significantly shorter in the Tm-laser group than in the electrosurgery group. The mean burst pressure did not differ significantly between the tissues sealed by electrosurgery and by Tm-laser. Histopathological analyses showed that distal ureters were completely sealed by both electrosurgery and Tm-laser. The Tm-laser technique is superior to open excision and comparable to transurethral electrosurgery in the management of DUBC during nephroureterectomy for UUT-UC, offering an alternative treatment option for this condition.

Preoperative hydronephrosis and diabetes mellitus predict poor prognosis in upper urinary tract urothelial carcinoma

Introduction: We assess the impact of traditional prognostic factors, tumour location, degree of hydronephrosis and diabetes mellitus (DM) on the survival of patients treated for upper urinary tracturothelial carcinoma (UUTUC).Methods: From January 2004 to March 2010, we analyzed data from 114 patients with UUTUC who underwent nephroureterectomy with a bladder cuff excision. Median patient age was 71 years and median follow-up was 26.5 months. The influence of traditional prognostic factors, including DM, tumour stage, grade, location and degree of hydronephrosis, on recurrence-free survival (RFS) rates were analyzed using Kaplan-Meier analysis and Cox proportional hazards regression model.Results: Among 61 renal pelvis and 53 ureteral tumour cases, recurrence was identified in 71 cases (62.3%). Kaplan-Meier analysis showed that degree of hydronephrosis was associated with RFS (p = 0.001). DM and degree of hydronephrosis were independent factors for RFS in Cox proportional regression analysis (HR=1.8 CI:1.01-3.55, p = 0.04), (HR=3.7, CI: 2.0-6.5, p = 0.001). All patients with ureteral tumour had no worse prognosis than those with renal pelvis tumour, but the pT2 patients with ureteral tumour had a worse prognosis than those with renal pelvis tumour with a median RFS of 9 months (range: 2.6-15.3 months) and 29 months (range:8.0-13.2 months), respectively (p = 0.028).Conclusions: Tumour location is not a factor influencing RFS, except in the pT2 stage. However, severe hydronephrosis is associated with a higher recurrence in UUTUC. Also, DM is related to disease recurrence. Further prospective studies are needed to establish the prognostic significance of DM in large populations.

Laparoendoscopic single-site nephroureterectomy for upper urinary tract urothelial carcinoma: outcomes of an international multi-institutional study of 101 patients

To report a large multi-institutional series of laparoendoscopic single-site (LESS) nephroureterectomy (NU). Data on all cases of LESS-NU performed between 2008 and 2012 at 15 institutions were retrospectively gathered. The main demographic data and perioperative outcomes were analysed. The study included 101 patients whose mean (SD) age was 66.4 (9.9) years and mean (SD) body mass index was 24.8 (4) kg/m², and of whom 29.7% had undergone previous abdominal/pelvic surgery. The mean (SD) operating time was 221.4 (73.7) min, estimated blood loss 231.7 (348.0) mL. A robot-assisted LESS technique was applied in 25.7% of cases. An extra trocar was inserted in 28.7% of cases to complete the procedure. Conversion to open surgery was necessary in three cases (3.0%). There was no bladder cuff excision in 20.8% of cases, and excision was carried out using a variety of techniques in the remaining cases. Six intra-operative complications occurred (5.9%). The mean (SD) length of hospital stay was 6.3 (3.5) days. The overall postoperative complication rate was 10.0%, and most of the complications were low grade (Clavien grades 1 and 2). The mean tumour size was 3.1 (1.9) cm. Pathological staging was pTis in two patients, pTa in 12 patients, pT1 in 42 patients, pT2 in 20 patients, pT3 in 23 patients and pT4 in two patients. Pathological grade was high in 71 and low in 30 patients. At a mean follow-up of 14 months, six patients (5.9%) had died. Disease recurrence (including distant and bladder recurrence) was detected in 22.8% of patients, with a mean time to recurrence of 11.5 months. This study reports the largest multi-institutional experience of LESS-NU to date. Peri-operative outcomes mirror those of published standard laparoscopy series. Despite encouraging early findings, longer follow-up is needed to determine the oncological efficacy of the procedure.

V7 Umbilical radical nephroureterectomy, bladder cuff excision and lymphadenectomy with KeyPort system in a case of upper urinary tract urothelial cancer

V7 Umbilical radical nephroureterectomy, bladder cuff excision and lymphadenectomy with KeyPort system in a case of upper urinary tract urothelial cancer

A Comparative Study of Laparoendoscopic Single-Site Surgery Versus Conventional Laparoscopy for Upper Urinary Tract Malignancies

PurposeThe proper indication for laparoendoscopic single-site surgery (LESS) in urology is still under debate, especially for malignant diseases. We compared the perioperative outcomes between LESS and conventional laparoscopy (CL) for upper urinary tract malignancies.Materials and MethodsWe reviewed the records of 75 patients who underwent radical nephrectomy, nephroureterectomy with bladder cuff excision, or partial nephrectomy with the LESS or CL approach between December 2008 and December 2010. We compared characteristics and perioperative outcomes between patients who underwent LESS or CL. All operations were performed by three surgeons using the transperitoneal approach.ResultsFor all three surgery types, no differences in patient characteristics, estimated blood losses, transfusion rates, or durations of hospital stay were found between the two groups. No complications were found between the two groups in those who underwent nephroureterectomy with bladder cuff excision; however, significantly more complications were found in the LESS group than in the CL group in those who underwent radical nephrectomy or partial nephrectomy. Most of the complications with LESS radical nephrectomy occurred in the early introduction period of the technique.ConclusionsNo significant differences in perioperative outcomes were found between the LESS and CL groups in those who underwent radical nephrectomy or nephroureterectomy with bladder cuff excision. Therefore, the use of LESS in these cases is expected to expand as surgeons gain more experience with this technique and as other technical advances in laparoscopic instruments occur. However, partial nephrectomy with LESS should be performed restrictively considering the current level of surgical skill.

Endoscopic Management of Upper Urinary Tract Urothelial Carcinoma

Upper urinary tract urothelial carcinoma (UTUC) is relatively uncommon. Radical nephroureterectomy with an ipsilateral bladder cuff excision has been the gold standard treatment for UTUC. However, recent advances in technology have made possible the increased use of endoscopic management for the treatment of UTUC. The definitive goal of endoscopic management of UTUC is cancer control while maintaining renal function and the integrity of the urinary tract. Endoscopic management includes both the retrograde ureteroscopic and antegrade percutaneous approaches. The endoscopic management of UTUC is a reasonable alternative for patients with renal insufficiency or a solitary functional kidney, bilateral disease, or a significant comorbidity that precludes radical surgery. Select patients with a functional contralateral kidney who have low-grade, low-stage tumors may also be candidates for endoscopic management. The careful selection of patients is the most important point for the successful endoscopic management of UTUC. It is crucial that patients are compliant and motivated, because a lifetime protocol of strict surveillance is necessary. Adjuvant topical therapy with Bacillus Calmette-Guerin or mitomycin C can be used after endoscopic management of UTUC in an attempt to reduce recurrence. In this article, we review current endoscopic techniques, indications for endoscopic treatment, clinical outcomes of endoscopic management, adjuvant topical therapy, and surveillance in patients with UTUC.