Nephroureterectomy For Transitional Cell Carcinoma Research Articles

Panurothelial recurrence in a patient after nephroureterectomy for transitional cell carcinoma. A therapeutic dilema

Panurothelial recurrence in a patient after nephroureterectomy for transitional cell carcinoma. A therapeutic dilema

S148 ENDOSCOPIC URETERECTOMY DURING NEPHROURETERECTOMY FOR UPPER URINARY TRACT TRANSITIONAL CELL CARCINOMA

Introduction: Radical nephroureterectomy with resection of a bladder cuff remains the “gold standard” in the treatment of upper urinary tract transitional cell tumors. McDonald is the first to describe a ureteral stripping technique with subsequent endoscopic resection of the bladder cuff around the ureteral orifice during nephroureterectomy, which is called transurethral endoscopic ureterectomy and is a less invasive alternative of open surgical ureterectomy in patients with transitional cell renal pelvic carcinoma. Objective: To evaluate the clinical outcome of transurethral endoscopic ureterectomy during nephroureterectomy for transitional cell carcinoma of the renal pelvis and calyces.

Prognostic factors influencing survival after nephroureterectomy for transitional cell carcinoma of the upper urinary tract.

We analyzed the prognostic factors influencing survival after surgeries for upper urinary tract urothelial carcinoma (UUT-UC) with longer follow-up periods than in previous studies. Between January 2000 and December 2004, 386 patients underwent nephroureterectomy for UUT-UC. The data for the 221 patients with UUT-UC were retrospectively reviewed. Nine variables were evaluated for association with the survival outcomes of disease-specific survival. The prognostic significance was tested univariately with the log-rank test. The simultaneous effects of multiple prognostic factors were estimated by multiple regression analysis using the Cox proportional hazards model. The median follow-up was 38.4 months. The 5-year over all survival was 62.3%. Significant prognostic factors for disease-specific survival rate on univariate analysis were pathological stage (p＜0.0001), tumor grade (p＝0.0324), and venous invasion (p＜0.0001). Multivariate analysis revealed that only venous invasion was significant for disease-specific survival rate (p＝0.0205). Venous invasion was the only independent prognostic factor in pathologically localized UUT-UC.

A COMPARISON OF LYMPH NODE DISSECTION IN LAPAROSCOPIC NEPHROURETERECTOMY AND OPEN NEPHROURETERECTOMY FOR TRANSITIONAL CELL CARCINOMA OF THE RENAL PELVIS AND URETER

You have accessJournal of Urology1 Apr 2009A COMPARISON OF LYMPH NODE DISSECTION IN LAPAROSCOPIC NEPHROURETERECTOMY AND OPEN NEPHROURETERECTOMY FOR TRANSITIONAL CELL CARCINOMA OF THE RENAL PELVIS AND URETER Tomonori Komatsu, Ryohei Hattori, Yoshihisa Matsukawa, and Momokazu Gotoh Tomonori KomatsuTomonori Komatsu More articles by this author , Ryohei HattoriRyohei Hattori More articles by this author , Yoshihisa MatsukawaYoshihisa Matsukawa More articles by this author , and Momokazu GotohMomokazu Gotoh More articles by this author View All Author Informationhttps://doi.org/10.1016/S0022-5347(09)60366-9AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail "A COMPARISON OF LYMPH NODE DISSECTION IN LAPAROSCOPIC NEPHROURETERECTOMY AND OPEN NEPHROURETERECTOMY FOR TRANSITIONAL CELL CARCINOMA OF THE RENAL PELVIS AND URETER." The Journal of Urology, 181(4S), p. 128 © 2009 by American Urological AssociationFiguresReferencesRelatedDetails Volume 181Issue 4SApril 2009Page: 128 Advertisement Copyright & Permissions© 2009 by American Urological AssociationMetricsAuthor Information Tomonori Komatsu More articles by this author Ryohei Hattori More articles by this author Yoshihisa Matsukawa More articles by this author Momokazu Gotoh More articles by this author Expand All Advertisement PDF downloadLoading ...

Hand Assisted Retroperitoneoscopic Nephroureterectomy With the Patient Spread-Eagled: An Approach Through a Completely Supine Position

We evaluated the feasibility of hand assisted retroperitoneoscopic nephroureterectomy for transitional cell carcinoma of the upper urinary tract with the patient completely supine (spread-eagled). From October 2006 to January 2008 hand assisted retroperitoneoscopic nephroureterectomy with open bladder cuff excision was performed in 32 patients with upper tract transitional cell carcinoma. The patient was placed supine with the legs extended and abducted at 45 to 60 degrees, and the arms stretched out to the sides in the spread-eagle position. The patient was secured to the operation table with 3-inch tapes to permit lateral table tilt. The operation was completed via a 7 or 8 cm Gibson incision plus 2 laparoscopic ports. All procedures were successful. The mean time needed for hand assisted retroperitoneoscopic nephroureterectomy and bladder cuff resection was 137.6 minutes. Mean estimated blood loss was 200 ml. Simultaneous transurethral endoscopic procedures were performed in 8 patients. Time to oral intake was 2.1 days and time to ambulation was 2.0 days. No specific complication was related to the position. All patients recovered to normal daily activity uneventfully. Hand assisted retroperitoneoscopic nephroureterectomy with the patient completely supine is feasible and safe. The completely supine position has several advantages, including ease of patient positioning and the ability to perform simultaneous endoscopic procedures. It not only decreases the time and cost of changing position, but also avoids potential risks associated with the lateral decubitus position. Bowel interference with the visual field and mechanical bowel injury are not a concern using this approach.

Management of the Distal Ureter and Bladder Cuff During Nephroureterectomy for Transitional Cell Carcinoma

Management of the Distal Ureter and Bladder Cuff During Nephroureterectomy for Transitional Cell Carcinoma

Initial Experience with Robot-Assisted Minimally-Invasive Nephroureterectomy

Various techniques have been described for laparoscopic nephroureterectomy. We reviewed our initial experience of laparoscopic nephroureterectomy with robot-assisted extravesical excision of the distal ureter and bladder cuff. Nine consecutive patients aged 43 to 83 years underwent laparoscopic nephroureterectomy for transitional cell carcinoma (TCC) between August 2005 and March 2007. The first five patients were repositioned after laparoscopic nephrectomy from flank to lithotomy position to dock the robot for excision of the distal ureter and bladder cuff by a single surgeon. In contrast, the last four patients remained in flank position throughout the entire procedure, with the robot docked in flank position following laparoscopic nephrectomy. A two-layer closure re-approximated the cystotomy and a urethral catheter was left in place for a mean of 5 days. Eight men and one woman with a mean age of 64.2 years and mean body mass index (BMI) of 28.4 kg/m(2) underwent flexible cystoscopy and laparoscopic nephroureterectomy for five right-sided and four left-sided tumors. Mean operative time was 303 minutes (range 210-430 minutes), estimated blood loss was 211 mL (range 50-700 mL), and mean length of hospital stay was 2.3 days. Pathologic staging revealed T(3) for five (55.6%), T(a) for two (22.2%), carcinoma in situ (CIS) for two (22.2%) patients, and high-grade disease for seven (77.8%) patients. With a mean follow-up of 16.2 months (range 4.3-24.3 months), three patients with a history of bladder cancer have experienced recurrence in the bladder, and one of the three has also developed metastatic disease. Laparoscopic nephroureterectomy with robot-assisted extravesical excision of the distal ureter and bladder cuff appears to be a feasible alternative for patients with TCC of the upper urinary tract.

Nephroureterectomy for Transitional Cell Carcinoma – The Value of Pre-Operative Histology

Nephroureterectomy with excision of a cuff of bladder remains the standard for managing upper tract transitional cell carcinoma (TCC). Increasing use of diagnostic upper tract endoscopy has underlined the importance of obtaining a pre-operative histological diagnosis in order to avoid under-treating high-grade or multifocal disease and over-treating low-grade disease, which could, in selected cases, be managed conservatively. We review nephroureterectomy at our institution over a 10-year period with particular reference to a pre-operative histological diagnosis. Nephroureterectomy was performed in 113 patients from February 1994 to February 2004. Of these cases, 58 were for upper tract TCC and 50 of these 58 had intravenous urography (IVU): 9 had only IVU, 28 had an additional CT scan, 5 had an additional ultrasonography and 8 had additional CT + ultrasonography for pre-operative work-up. Thirty-four of the 58 cases had retrograde pyelography. Nineteen (32.7%) of the 58 cases had a pre-operative ureteroscopy (URS) and biopsy; 14 of these had rigid URS for tumours in the lower (11) and middle (3) thirds of the ureter and 5 had flexible URS for pelvicalyceal tumours by an experienced endourologist. Thirty-one (53%) of the 58 tumours were within the pelvicalyceal system and 27 within the ureter (upper, 5; middle, 3; lower, 19). Forty-eight patients underwent a total nephroureterectomy: 40 had a two incision approach and 8 had an endoscopic resection of the lower ureter. Five of the 58 cases had a sub-total nephroureterectomy and 5 a laparoscopic nephroureterectomy with open excision of lower ureter. Nineteen (32.7%) of the 58 patients had a pre-operative histological diagnosis - 17 G2pTa, 1 G1pTa, and 1 G2pT1. Fourteen (74%) biopsies matched the final postoperative histology, but 1 was down-staged, 3 up-staged and 1 up-graded compared to the original histology. Five (12.8%) of 39 patients without pre-operative histology had no TCC in the final surgical specimen: 4 (10.25%) had benign pathology such as capillary haemangioma, urothelial cysts and reactive urothelial changes while one had renal cell carcinoma (RCC). This study underlines the importance of obtaining a pre-operative histological diagnosis in cases with presumed upper tract TCC. Failure to do so can result in unnecessary ablative surgery for benign disease. Such an approach can also help identify multifocality and grade of disease so that treatment of upper tract TCC can be tailored more appropriately with ablative surgery for high-grade or multifocal disease and conservative (endoscopic) therapy for low-grade disease in selected cases. Patients with suspected TCC of the upper tract should be managed at centres where facilities for the comprehensive evaluation of such tumours exist.

Laparoscopic radical nephroureterectomy for transitional cell carcinoma: where are we in 2007?

Nephroureterectomy has undergone critical changes during the past 15 years with the advent of the laparoscopic approach. New data supporting laparoscopic nephroureterectomy (LNU) continue to emerge as new techniques are developed and current approaches refined. The purpose of this study was to investigate the findings within LNU from the past 2 years as an evolving although proven modality for treatment of upper-tract transitional cell carcinoma (TCC). Intermediate outcomes continue to be published equating the oncologic efficacy and perioperative parameters (i.e. blood loss and pain medication requirements) of LNU to those of open nephroureterectomy, allaying previous arguments against the minimally invasive approach. Newer approaches to the nephrectomy segment of LNU have been described, including robot assistance in retroperitoneoscopic cases and hand-assisted laparoscopic nephrectomy without the use of a hand-port. Data supporting specific approaches to the distal ureter have been published, including implementing robotics and flexible cystoscopy. Findings over the past 2 years show both the continued progress of LNU and the need for further evolution to optimize patient morbidity and oncologic outcomes. As laparoscopic training is integrated into urologic residency programs, standardizing the variables within LNU will be paramount.

A Modified Supine Position to Speed Hand Assisted Retroperitoneoscopic Nephroureterectomy: The Johnnie Walker Position

To minimize the operative time of hand assisted retroperitoneoscopic nephroureterectomy by avoiding position change we report an especially designed surgical position. A total of 41 patients with upper tract transitional cell carcinoma who underwent hand assisted retroperitoneoscopic nephroureterectomy and bladder cuff resection were enrolled. Patients lay supine, and the flank and hip on the lesion side were elevated 30 degrees. The legs were extended and abducted in the Johnnie Walker position, allowing the operator to stand between them. Operation was completed via a 7 to 8 cm Gibson incision and 2 additional laparoscopic ports. All procedures were successful except 1 open conversion due to bleeding, in which there was no need to reposition the patient. Average patient age was 65.2 years (range 34 to 85), mean operative time was 207.6 minutes (range 130 to 345) and mean estimated blood loss was 166 ml (range 50 to 900). Simultaneous transurethral endoscopic procedures were performed in 11 patients in the same position. Time to oral intake and ambulation was 2.1 and 2.0 days, respectively. Two patients had postoperative complications, including pneumonia and wound hematoma in 1 each. No complication was related to the position. The Johnnie Walker position minimizes operative time by eliminating the delay caused by patient positioning and draping changes, allowing better coordination for the surgeon and assistant, and permitting more efficient use of the nondominant hand. The retroperitoneal approach prevents bowel interference in the visual field, making laparoscopic surgery in this modified supine position possible. Nephroureterectomy, bladder cuff resection and endoscopic procedures can be done with ease with the patient in this position.

Increased Serum Pancreatic Enzymes after Bilateral Laparoscopic Nephroureterectomy for Transitional Cell Carcinoma of Renal Pelvis

A 52-year-old female underwent transperitoneal laparoscopic bilateral nephroureterectomy with bladder cuff excision to treat transitional cell carcinoma of renal pelvis. Chronic renal insufficiency was noted before the operation. She did not have other systemic diseases or risk factors of acute pancreatitis such as biliary stone or alcoholism. Abdominal fullness with high levels of pancreatic enzymes (amylase: 687 U/L; lipase: 1342 U/L) were noted postoperatively. There were no symptoms of epigastragia or radiating back pain. The drainage fluid was clear and abdominal computed tomography did not reveal evidence of intestinal or pancreatic injuries. The clinical course was not compatible with typical acute pancreatitis. She received partial parenteral nutrition and started oral feeding 15 days after the operation. The patient no longer complained of having abdominal discomfort but high levels of pancreatic enzymes (amylase: 346 U/L, lipase: 423 U/L) were still noted five months after the operation.

1106: Preoperative Urinary Cytology Predicts Disease Progression and Overall Survival after Nephroureterectomy for Transitional Cell Carcinoma of the Upper Urinary Tract

1106: Preoperative Urinary Cytology Predicts Disease Progression and Overall Survival after Nephroureterectomy for Transitional Cell Carcinoma of the Upper Urinary Tract

Laparoscopic nephroureterectomy for transitional cell carcinoma of renal pelvis and ureter: Nagoya experience

Objectives To evaluate the efficacy of retroperitoneoscopic nephroureterectomy for transitional cell carcinoma of the renal pelvis and ureter, we analyzed the clinical outcomes and long-term cancer control of 89 patients. Methods In 36 patients, the kidney was retroperitoneoscopically dissected and the ureteral end was resected with open procedure (combined laparoscopy group). In 53 patients, the ureteral end with a bladder cuff was transected using an endoscopic stapler (pure laparoscopy group). Sixty patients underwent open nephroureterectomy (open group). The median follow-up period was 35, 31, and 17 months in the open, combined, and pure laparoscopy groups, respectively. Results The average operative time and bleeding volume was 5.4 hours and 665 mL in the open group, 5.1 hours and 580 mL in the combined laparoscopy group, and 4.3 hours and 354 mL in the pure laparoscopy group, respectively. The cause-specific patient survival rate at 3 years was 81% in the open group, 86% in the combined laparoscopy group, and 80% in the pure laparoscopy group. The bladder recurrence-free rate at 3 years was 51% in the open group, 65% in the combined laparoscopy group, and 45% in the pure laparoscopy group. The extravesical recurrence-free rate at 3 years was 71% in the open surgery group, 76% in the combined laparoscopy group, and 71% in the pure laparoscopy group. No statistically significant difference was seen in patient survival, bladder recurrence, or extravesical recurrence rates among the three groups. Conclusions Our retroperitoneal laparoscopic nephroureterectomy is less invasive than open surgery and is a safe and effective alternative.

Factors Affecting the Survival of Patients Treated by Standard Nephroureterectomy for Transitional Cell Carcinoma of the Upper Urinary Tract

In this study we tried to evaluate the predictive factors for survival in patients with upper urinary tract tumors. From 1993 to 2003, 46 patients were treated by standard nephroureterectomy for upper urinary tract tumor, but only 24 patients (52%) who had regular follow-up were included in the study. Age, sex, presenting symptoms of the patients, tumor localization, tumor stage and grade were analyzed with respect to survival. Univariate and multivariate analyses were done using Kaplan-Meier method with log-rank test and Cox proportional hazards regression model, respectively. The median of patient age was 61 years (34-74). Of the 24 patients, 9 (37.5%) were disease-free and alive at a mean time of 54 (26-97) months, 8 (33.3%) died of disease at a mean period of 23.4 months (2 because of bladder tumor, 2 had liver metastases, 1 had lung metastasis and 3 had lung and liver metastases) and 7 (29.2%) died disease-free at a mean period of 30.3 months. Metastases were detected in a mean period of 11.8 (6-24) months. Survival according to tumor stage Ta, T1-2, and invasive tumors were 87.5, 43.9, 15.7 months (p = 0.0001), respectively. Survival of the patients with low-grade tumors was significantly longer than those with high-grade tumors (77.3 and 31.4 months, respectively, p = 0.01). Patients with pelvis tumors when compared to ureter tumors (28.5 and 61.6 months, respectively, p = 0.038) and those presenting with flank pain when compared to those presenting with macroscopic hematuria and bladder cancer (17.7, 45.7, and 57.9 months, respectively, p = 0.046) had shorter survival rates. When multivariate analyses were done using Cox regression test, the only factor that affected survival was the stage of the tumor. Age and gender had no impact on survival. In univariate analysis, the stage, grade, localization of the tumor and presenting symptoms were found important predictors that affect the prognosis of the transitional carcinoma of the upper tract. However, tumor stage was the only independent predictor of survival in multivariate analysis. For high grade and high stage tumors, really effective adjuvant treatments along with aggressive surgery may be considered.

Vesicovaginal fistula: An unusual complication of laparoscopic assisted nephroureterectomy

We report a case of vesicovaginal fistula in 71-year-old lady who had previously undergone a lapascopic assisted nephroureterectomy for transitional cell carcinoma in her right ureter and kidney. The surgery was uncomplicated with no post-operative problems and was discharged on day on seven. She later presented five weeks following the initial operation with signs and symptoms suggestive of a vesicovaginal fistula, which was confirmed on cystogram and flexible cystosopy. She proceeded to have an abdominal (O'Connor's) repair of the fistula together with cystodiathermy for a few superficial bladder recurrences. The area of the fistula (within the bladder) was noted to be tumour free. She had an uneventful post-operative recovery and was discharged from hospital on day 11. At six month follow-up, there was another superficial recurrence in the bladder that was resected, with no sign of fistula.

Early Experience of Retroperitoneoscopic Nephroureterectomy for Transitional Cell Carcinoma of Renal Pelvis and Ureter

Purpose: To evaluate the results of our experience with a retroperitoneoscopic nephroureterectomy, in patients with transitional cell carcinomas of the renal pelvis and ureter, compared to those treated by open nephroureterectomy. Materials and Methods: Between August 2003 and February 2006, 17 patients with a transitional cell carcinoma of the upper urinary tract underwent retroperitoneoscopic nephroureterectomy. The distal ureter and bladder cuff was treated with a Gibson incision in 11 patients, with an endoscopic stapler employed in 6 patients. During the endoscopic stapler firing of the bladder cuff, complete removal of the ureteral orifice was confirmed using a flexible cystoscope. The patients’ operative and clinical records were retrospectively reviewed, and compared to 16 patients with a transitional cell carcinoma of the upper urinary tract treated using an open nephroureterectomy. Results: The retroperitoneoscopic nephroureterectomies were successfully performed in all patients. The mean operative time, transfusion rate and time to drain removal were not significantly different between the two groups. The initiations of the postoperative oral intake and ambulation, as well as the hospital stay were shorter in the retroperitoneoscopy than the open group. Complications were detected in 1 and 5 patients of the retroperitoneoscopy and open groups, respectively. With respect to the follow-up results, no statistical differences were seen in either bladder or extravesical recurrence between the two groups. Conclusions: A retroperitoneoscopic nephroureterectomy is a less invasive technique than an open nephroureterectomy for patients with a transitional cell carcinoma of the renal pelvis and ureter. Especially, using an endoscopic stapler for the lower ureter and bladder cuff may shorten the operative time. However, long term follow-up will be necessary to confirm the cancer control effects. (Korean J Urol 2006;47:1263-1268)

81: Patterns of Recurrence after Nephroureterectomy for Transitional Cell Carcinoma of the Upper Urinary Tract

81: Patterns of Recurrence after Nephroureterectomy for Transitional Cell Carcinoma of the Upper Urinary Tract

976: Clinical and Pathological Predictors of Pathologic Lymph Node Metastasis Identified during Nephroureterectomy for Transitional Cell Carcinoma of the Upper Urinary Tract

976: Clinical and Pathological Predictors of Pathologic Lymph Node Metastasis Identified during Nephroureterectomy for Transitional Cell Carcinoma of the Upper Urinary Tract

Oncological Safety of Laparoscopic Surgery for Urological Malignancy: Experience With More Than 1,000 Operations

Although laparoscopy is being increasingly used to treat urological malignancies, there is still concern regarding the induction of local recurrence and port site metastasis. To our knowledge no major clinical study with long-term followup has been presented in the field of urological laparoscopy. We assessed the oncological safety of laparoscopy with emphasis on incidence of local recurrence and port site metastasis, analyzing the risk factors for such events based on a 10-year experience. From June 1992 to May 2002 we performed 1,098 laparoscopic procedures for urological malignancies, including 450 radical prostatectomies, 478 pelvic and 80 retroperitoneal lymph node dissections, 45 radical nephrectomies, 22 radical nephroureterectomies, 12 partial nephrectomies and 11 adrenalectomies. In 418 cases of laparoscopic radical prostatectomy pelvic lymphadenectomy was done simultaneously. Of the procedures 917 were performed transperitoneally, including 181 via retroperitoneal or extraperitoneal access. A total of 567 procedures were performed in case of histologically proven cancer, whereas 531 represented only staging operations. Median followup was 58 months (range 4 to 127). Eight local recurrences were observed (0.73% overall, 1.41% of histologically proven cases). There were recurrences after nephroureterectomy for transitional cell carcinoma of the ureter in 1 patient, after radical nephrectomy for renal cell carcinoma in 1, growing teratoma after retroperitoneal lymph node dissection in 2, local recurrence of prostate cancer in 3 and after removal of an adrenal metastasis of melanoma in 1. Two port site metastases (0.18% overall, 0.35% of histologically proved cases) occurred, including metastasis of small cell lung carcinoma after adrenalectomy and a residual mass following 2 cycles of chemotherapy after retroperitoneal lymph node dissection. According to our experience the incidence of local recurrence and the risk of port site metastases is low and seems to be mainly related to the aggressiveness of the tumor and immunosuppression status of the patient, respectively rather than to technical aspects of the laparoscopic approach.

Retroperitoneoscopic nephroureterectomy for transitional cell carcinoma of the renal pelvis and ureter: Nagoya experience

Objectives To evaluate the efficacy of our new retroperitoneoscopic nephroureterectomy for patients with transitional cell carcinoma of the renal pelvis and ureter, we present the operative procedure and analysis of the clinical outcome of retroperitoneoscopy in 23 patients. Methods Twenty-three patients with transitional cell carcinoma of the upper urinary tract underwent retroperitoneal laparoscopic nephroureterectomy between February 2000 and February 2002. Patient age ranged from 44 to 83 years (mean 66.7). Each kidney was retroperitoneoscopically dissected en bloc, together with the perirenal fatty tissue, lymph nodes, and/or adrenal gland, without transecting the ureter. The lower ureter was resected with the bladder cuff transected using an ultrasonic scalpel and an endoscopic gastrointestinal automatic stapler. The dissected specimen was removed intact through a 6-cm-long original incision. Results The mean operating time was 4.8 hours, including 0.7 hours for complete removal of the ureteral end with the bladder cuff. The mean estimated blood loss was 304 mL. The mean time to recovery to normal activity was 18 days. In the mean follow-up period of 15 months, 2 patients died of cancer progression in the sixth postoperative month, 2 died of other causes, and 4 had recurrent transitional cell carcinoma of the bladder after surgery. Conclusions Our retroperitoneal laparoscopic nephroureterectomy using an endoscopic gastrointestinal automatic stapler is a fast, low-risk, and minimally invasive procedure and might be an alternative to other laparoscopic techniques and open nephroureterectomy. However, long-term follow-up is necessary to confirm the efficacy for patients with transitional cell carcinoma of the renal pelvis and ureter.