Nephroureterectomy In Patients Research Articles

Comparative study of ureteral stripping versus open ureterectomy for nephroureterectomy in patients with transitional carcinoma of the renal pelvis

Objectives To evaluate the clinical outcome of nephroureterectomy with endoscopically assisted transurethral ureteral stripping for transitional cell carcinoma of the renal pelvis in a comparative study. Methods Sixty patients with localized renal pelvic cancer were enrolled in a prospective comparative nonrandomized study. Of these, 28 patients underwent nephroureterectomy with endoscopically assisted transurethral ureteral stripping and 32 underwent conventional nephroureterectomy with a bladder cuff. Both short-term and long-term results were analyzed in this series. Results The operating time for patients with ureteral stripping was significantly shorter than for those with a standard two-incision nephroureterectomy (median 183 versus 250 minutes, P = 0.0231), and the amount of blood loss was significantly less (median 150 versus 390 mL, P = 0.0002). Intravesical recurrence was detected in 10 (35.7%) of the 28 patients with ureteral stripping, and the 1-year and 3-year recurrence-free rate was 68.0% and 57.7%, respectively. Seven patients treated by the standard two-incision nephroureterectomy (21.9%) experienced intravesical recurrence, with a 1-year and 3-year recurrence-free rate of 96.8% and 75.0%, respectively. The recurrence rate was significantly greater in the group with ureteral stripping ( P = 0.0287). Conclusions Compared with conventional nephroureterectomy with a bladder cuff, nephroureterectomy with transurethral stripping is a minimally invasive procedure with a shorter operating time and less blood loss, but a statistically significantly greater intravesical recurrence rate. Greater consideration should be taken before selecting this procedure.

25: Delay in time to Nephroureterectomy for Patients Undergoing Ureteroscopic Biopsy and Laser Tumor Ablation of Upper Tract Transitional Cell Carcinoma Does not Impact Postoperative Disease Status

25: Delay in time to Nephroureterectomy for Patients Undergoing Ureteroscopic Biopsy and Laser Tumor Ablation of Upper Tract Transitional Cell Carcinoma Does not Impact Postoperative Disease Status

LAPAROSCOPIC RADICAL NEPHROURETERECTOMY FOR UPPER TRACT TRANSITIONAL CELL CARCINOMA: THE CLEVELAND CLINIC EXPERIENCE

We report our single institutional experience with retroperitoneal laparoscopic radical nephroureterectomy in patients with upper tract transitional cell carcinoma and compare results to those achieved by the open technique. A total of 77 patients underwent radical nephroureterectomy for pathologically confirmed upper tract transitional cell carcinoma. Of these patients 42 underwent laparoscopic nephroureterectomy from September 1997 through January 2000 and 35 underwent open surgery. All specimens were extracted intact. Of the laparoscopic group the juxtavesical ureter and bladder cuff were excised by our novel transvesical needlescopic technique in 27 and radical nephrectomy was performed retroperitoneoscopically in all 42. Data were compared retrospectively with 35 patients undergoing open radical nephroureterectomy from February 1991 through December 1999. Laparoscopy was superior in regard to surgical time (3.7 versus 4.7 hours, p = 0.003), blood loss (242 versus 696 cc, p <0. 0001), specimen weight (559 versus 388 gm., p = 0.04), resumption of oral intake (1.6 versus 3.2 days, p = 0.0004), narcotic analgesia requirements (26 versus 228 mg., p <0.0001), hospital stay (2.3 versus 6.6 days, p <0.0001), normal activities (4.7 versus 8.2 weeks, p = 0.002) and convalescence (8 versus 14.1 weeks, p = 0.007). Complications occurred in 5 patients (12%) in the laparoscopic group, including open conversions in 2, and in 10 (29%) in the open group (p = 0.07). Followup was shorter in the laparoscopic group (11.1 versus 34.4 months, p <0.0001). The 2 groups were similar in regard to bladder recurrence (23% versus 37%, p = 0.42), local retroperitoneal or port site recurrence (0% versus 0%) and metastatic disease (8.6% versus 13%, p = 1.00). Mortality occurred in 2 patients (6%) in the laparoscopic group and 9 (30%) in the open group. Cancer specific survival (97% versus 87%) and crude survival (97% versus 94%) were similar between both groups (p = 0.59). In patients with upper tract transitional cell carcinoma who are candidates for radical nephroureterectomy the retroperitoneal laparoscopic approach satisfactorily duplicates established technical principles of traditional open oncological surgery, while significantly decreasing morbidity from this major procedure. Short-term oncological and survival data of the laparoscopic technique are comparable to open surgery. Although long-term followup data are not yet available, it appears that laparoscopic radical nephroureterectomy may supplant open surgery as the standard of care in patients with muscle invasive or high grade upper tract transitional cell carcinoma.

Radical nephrectomy and nephroureterectomy in the octogenarian and nonagenarian: comparison of laparoscopic and open approaches

Objectives. To retrospectively compare the outcome of laparoscopic and open radical nephrectomy or nephroureterectomy in patients 80 years old or older, inasmuch as the tolerance profile of major laparoscopic renal surgery in comparison to open surgery in the elderly patient has not been previously reported. Methods. Since September 1997, 11 patients 80 years old or older underwent retroperitoneal laparoscopic radical nephrectomy or nephroureterectomy for cancer. These patients were compared with 6 consecutive patients 80 years old or older who underwent comparable open surgery at our institution since January 1994. No tumor had computed tomographic evidence of lymphatic, vascular, or perirenal extension. Results. Baseline parameters were comparable between the laparoscopic and open groups. The laparoscopic group had a similar median surgical time (210 minutes versus 175 minutes; P = 0.1) and blood loss (150 mL versus 125 mL; P = 0.8) compared with the open group. However, specimen weight was larger in the laparoscopic group (568 g versus 292 g; P = 0.04). Moreover, the laparoscopic group had a quicker resumption of oral intake (less than 1 day versus 4 days; P <0.001), decreased narcotic requirements (14 mg versus 326 mg; P = 0.004), shorter hospital stay (2 days versus 6 days; P <0.001), and faster convalescence (14 days versus 42 days; P <0.001) compared with the open group. Conclusions. Retroperitoneal laparoscopic radical nephrectomy and nephroureterectomy are well tolerated by the elderly patient. Although our sample size was small, it appears that laparoscopy is an excellent alternative to open surgery for excision of selected renal malignancies in the octogenarian and nonagenarian population.

RETROPERITONEOSCOPIC NEPHROURETERECTOMY FOR RENAL PELVIC TUMORS WITH A SINGLE ILIAC INCISION

Retroperitoneal laparoscopy, by providing direct access to the retroperitoneal cavity, is a useful approach to urological surgery. We applied this technique to nephroureterectomy in patients with tumors of the renal pelvis. Between January 1995 and March 1997 we performed 4 retroperitoneal laparoscopic nephroureterectomies in patients with tumors of the renal pelvis. The patients were placed in the lateral decubitus position. Five trocars were used. Balloon dilation was not contributory. Radical nephrectomy was performed and the kidney was left in the retroperitoneal space. Via an iliac incision ureterectomy with a bladder cuff was performed and the specimen was removed (kidney and ureter) en bloc via this incision without opening the urinary tract. One right and 3 left nephroureterectomies were performed with an average operating time of 220 minutes (range 160 to 300). Average kidney size was 110 mm. (range 100 to 120). Average hospital stay was 5.7 days (range 5 to 7). Blood loss was minimal and postoperative analgesic requirements were moderate. Conversion to open surgery was never necessary. The morbidity rate was zero. The pathological stages were pT2 G2, pT3 G2, pT3G3 and pT3 G2-G3 N+. A local recurrence was observed in a patient with a pT3 G3 tumor. Nephroureterectomy can be performed by retroperitoneal laparoscopy. The perioperative morbidity and hospital stay are reduced. Further followup is required to evaluate long-term results in terms of cancer outcome.

The significance of lymphadenectomy in transitional cell carcinoma of the upper urinary tract.

To determine the efficacy of lymphadenectomy after nephroureterectomy in patients with transitional cell carcinoma (TCC) of the upper urinary tract. Between January 1986 and December 1995, 72 patients (mean age 67 years, range 45-82) underwent nephroureterectomy for primary TCC of the upper urinary tract. In 35 patients, a lymphadenectomy was also performed. The clinicopathological data were analysed retrospectively, focusing on the significance of lymphadenectomy. Lymph vessel invasion was found in 28 patients and its incidence was closely correlated with both tumour grade and pathological stage. Of the 35 patients who underwent lymphadenectomy, lymph node metastases were found in 13 patients, all of whom had lymph vessel invasion. There was no significant difference in the survival rate between patients with and without lymphadenectomy; however, among the 44 patients with no lymph vessel invasion, the survival rate of those with lymphadenectomy was significantly higher than in those without (P<0.05). Lymphadenectomy may provide a therapeutic advantage in patients with upper urinary tract TCC and no lymph vessel invasion. However, patients with lymph vessel invasion seem to have systemic disease; therefore, aggressive systemic adjuvant therapies rather than regional lymphadenectomy should be applied in these patients.

COMPARISON OF LAPAROSCOPIC AND OPEN NEPHROURETERECTOMY FOR BENIGN DISEASE

Purpose We report our experience with laparoscopic nephroureterectomy for benign disease and compare the results to a contemporary group of patients undergoing open nephroureterectomy. Materials and Methods Between October 1994 and March 1997, 12 women and 4 men with a mean age of 50 years (range 22 to 70) underwent laparoscopic nephroureterectomy at our hospital. Indications for operation were nonfunctioning kidneys due to vesicoureteral reflux with recurrent episodes of pyelonephritis or analgesic nephropathy before a planned renal transplantation. In comparison 11 women and 4 men with a mean age of 40 years (range 18 to 64) underwent open nephroureterectomy for various benign diseases. Results Laparoscopic and open nephroureterectomy had no significant differences regarding operative times (100 versus 124 minutes) and complication rates (25 versus 20%). In the laparoscopy group conversion to open surgery was not necessary. Patients who underwent laparoscopic nephroureterectomy has significantly less consumption of morphine equivalent for postoperative pain control (12 versus 40 mg.), shorter time to achieve mobilization and oral intake (11 versus 39 hours), shorter hospital stay (6 versus 12.7 days) and faster return to normal activities (21 versus 39 days). Conclusions Laparoscopic nephroureterectomy in patients with benign disease has similar operative results but obvious postoperative advantages compared to the open approach.

The Role of Lymphadenectomy in the Treatment of Transitional Cell Carcinoma of the Upper Urinary Tract

Purpose We evaluated the efficacy of lymphadenectomy in conjunction with nephroureterectomy in patients with transitional cell carcinoma of the upper urinary tract. Materials and Methods Data were evaluated retrospectively in 21 consecutive men and 15 women (mean age 67 years) who underwent total nephroureterectomy with lymphadenectomy between January 1985 and December 1993. Results Of the 36 patients 11 (31%) had lymph node metastases. Of 20 patients with stages pT3 to 4 or pN+ tumors 12 received cisplatin based chemotherapy (11 postoperatively and 1 preoperatively). Followup ranged from 3 to 135 months (mean 55). Among 13 patients who died by May 1996 tumor was the cause of death in 8, while 5 died of unrelated causes. The probability of a cause specific survival at 5 years was 100% in patients with stages pTa to 1, 80% with stage pT2, 59% with stage pT3 and 0% with stage pT4 cancer. The probability of a cause specific survival at 5 years in patients with nodal metastasis was 21%. No patient without nodal metastasis died of tumor related causes. Conclusions Lymphadenectomy may provide therapeutic benefit in select patients with lymph node metastasis. It also may be a useful indicator of candidates for adjuvant chemotherapy if an effective regimen is established because lymph node metastasis is common in patients with carcinoma of the upper urinary tract and is critical in establishing the prognosis.