Case characteristics – “disaster is not the only thing that happens” Patient male, 63 years old, hematuria found left renal pelvis tumor admitted for preoperative. He was diagnosed with cT2bN0M0 prostate cancer after a transrectal prostate puncture 4/13 with PCa, 3+4. A full-length ureterectomy + radical prostatectomy was required. The procedure is discussed – “face it bravely” The simultaneous appearance of two malignant tumors is a big blow to the patient, and removing them in one surgery and one anesthetic is the best option. The two tumors require completely different surgeries: renal pelvic tumors require a full-length ureterectomy, which mostly requires two positions: lateral and then horizontal; prostate cancer requires a radical prostatectomy, which requires a horizontal head-down position; both surgeries are also extraperitoneal/transabdominal/open/laparoscopic. The combination of the two, if not carefully designed, may not only result in cumbersome and lengthy surgical steps, but also increase the trauma to the patient. The good thing is that the full-length ureterectomy in the unchanged position is now largely mature. On this basis, after careful consideration, the team under the leadership of Director Han Wenke chose to narrow down to two options: total extraperitoneal and total transabdominal. The advantage of the former is that total extraperitoneal surgery causes less damage to the intraperitoneal gastrointestinal tract and quicker postoperative recovery, but the removal of the specimen will encounter the obstacle of space inaccessibility, while the latter happens to be more suitable for taking the specimen. Finally, it was decided to choose the total extraperitoneal route, leaving more benefits to the patient and the difficulties to be fought by us! After satisfactory anesthesia, the retroperitoneal cavity (very adequately dilated to the level below the iliac fossa) was established in the right lateral position, and a retroperitoneoscopic left nephrectomy was performed, followed by freeing the ureter down to the transiliac vessels. A further channel is created at the antimaxillary point, the laparoscope is moved to the anterior axillary line trocar, and the operator stands ventrally and continues to free the ureter downward. The superior cystic artery is dissected to the end of the ureter. The end is sutured and the ureter is clamped and clipped over it. The specimen is placed into the iliac fossa. The drainage tube is left in place, the cannula is removed, and each wound is sutured. A small subumbilical incision is made in a flat-lying head-down position, and the anterior abdominal cavity is again dilated by the balloon method, and a trocar is placed for radical prostatectomy by the three-hole extraperitoneal route. After the main steps of the procedure are completed, the procedure of taking the specimen is more creative. Although both procedures are retroperitoneal routes, one is the upper and one is the lower urinary tract, and the spaces are not directly connected. We captured a clever key point “wormhole” to open up the two worlds – the iliac vessels. The external iliac artery and the external iliac vein were found in the pelvic extraperitoneal field, and wasn’t the connective tissue on its surface the landmark for the final step of the upper urinary tract surgery! Opening this layer of connective tissue and seeing the dilated space of the full length of the renal ureter after surgery was an immediate revelation. The ureteral specimen was moved intact to the pelvis, placed in a specimen bag, and removed along with the prostate specimen through a small incision in the lower abdomen. The drainage tube was left in place and the wound was sutured. The operation was completed. Summary and Discussion This surgery was long on creativity, combining both extensive resection and reconstruction, which are both time-consuming and labor-intensive procedures, making full use of the dexterity and bravery of the urologist. The key point – to maintain the integrity of the peritoneum at all times, any small detail of error causing a peritoneal leak would destroy the entire surgical design. Difficulty – In addition to several difficult steps in the prostate surgery part, the treatment of the end of the ureter – freeing + suturing – is also a more difficult step. This is where the innovation of this surgery lies. The most classic way is to use Hem-o-lok clamp, which is easy and fast, but there are many complications of bladder erosion due to pressure clamp; using a lumpectomy cutter and suture to solve the problem of clamp The problem of “swallowing” is solved, but it is difficult and expensive to operate in the narrow retrobulbar space; the currently recommended trans-laparoscopic clip-and-suture method is in line with the routine steps of open surgery and can be achieved with skilled microscopic suturing techniques. However, the operation of suturing the end of the ureter in the retroperitoneum is less commonly seen, and the standing position and view of the surgeon during suturing are completely incompatible with the axis of operation, making it much more difficult and requiring a very large technical reserve to complete. This operation was also applied after this step was performed many times before without any problems. The highlight – the “wormhole” that opens up the “two worlds”. (As mentioned above) Some doctors suggested during the discussion that the patient’s pelvic cancer was large, invaded the kidney parenchyma, and had a late stage, resulting in a poor prognosis, while the prostate cancer had an early stage, was still low risk, and there were many treatment options, so it was not necessary to complete both surgeries, but only to remove the pelvic cancer and add endocrine therapy and radiotherapy for prostate cancer after surgery. This view has a scientific basis and can also reduce the surgical trauma of the patient to a certain extent. I considered that the patient was not yet old enough to tolerate surgery well and recovered quickly from total extraperitoneal surgery; after interacting with the patient, I learned that his economic condition was poor and his fear of tumor was serious, so I was afraid that there were obvious difficulties in maintaining endocrine therapy or radiotherapy after surgery; moreover, the effect of surgical treatment for early prostate cancer was better than that of endocrine therapy and radiotherapy. In the end, he decided to face the difficulties bravely and completed this rather creative surgery. May the patient recover soon after surgery!