Laparoscopic surgery is increasingly being used worldwide for the treatment of upper urinary tract uroepithelial carcinoma. Currently, laparoscopic total length nephroureterectomy performed within foreign countries mostly involves laparoscopic removal of the kidney, followed by the application of open small incisions or electrodesiccation for ureteral and bladder sleeve resection. There are no clinical reports of transabdominal complete laparoscopic total length ureterectomy in China. In this article, the authors performed transabdominal access complete laparoscopic total-length nephroureterectomy from May 2010 to April 2011 to treat 25 patients with urothelial carcinoma of the upper urinary tract with satisfactory results, and report the preliminary results as follows. The article was later published in the Medical Journal of Peking University.
1 Data and methods
1.1 Clinical data The 25 patients in this group, 10 males and 15 females, aged 41 to 88 years, average 55.5 years. There were 14 cases of renal pelvis cancer, 11 cases of ureteral cancer, 14 cases on the right side and 11 cases on the left side. 22 cases were seen for painless carnal hematuria, and 3 cases were found to have upper urinary tract tumor after bladder cancer surgery.
1.2 Surgical method
No gastrointestinal decompression was required before surgery, and only a urinary catheter was left in place. General anesthesia was used, and patients were placed in 45° oblique position on the healthy side. A small incision of 1 cm below the costal margin in the midclavicular line was made on the affected side, and a pneumoperitoneal needle was inserted by the Veress method, the pneumatic pressure was injected to 14 mmHg, a 10-mm trocar was punctured, and a 0° or 30° laparoscope was placed. The pneumoperitoneum was inspected for any abdominal organ damage during the establishment of the pneumoperitoneum. The 10-mm, 10-mm and 5-mm trocars were placed 3 cm above the umbilicus, 3 cm below the umbilicus and 3 cm above the anterior superior iliac spine, respectively, and the corresponding intracavitary instruments were placed under surveillance (Figure 1).
Renal resection: the lateral peritoneum of the paracolic sulcus of the ascending (descending) colon was incised with an electric hook or ultrasonic knife as far down as possible to the iliac vessels and the pelvic peritoneum. On the right side, the paracolic sulcus of the ascending colon was freed upward to the hepatic colonic ligament to reveal the perirenal fascia behind it, and the duodenum and colon were retracted medially by Kocher’s maneuver to reveal the inferior vena cava and genital vein. The left lateral peritoneal incision was made on the lateral aspect of the descending colon, up to the upper part of the spleen, and the spleen, colonic splenic flexure and descending colon were pushed medially. The perirenal fascia is revealed posteriorly and freed to the level of the renal hilum. At the level of the inferior pole of the kidney, the ureter is revealed on the right side just outside the inferior vena cava and on the left side just outside the abdominal aorta by freeing the ureter and the inferior pole of the kidney and freeing it along the inferior vena cava or the aorta toward the renal hilum. The renal vein can be found along the gonadal vein on the left side and along the inferior vena cava on the right side. The renal arteries are exposed while keeping the fat and lymphatic tissue around the renal hilum on the renal side. The renal artery is fully freed and treated with Hem-o-lock, or lumpectively with a cutting suture, and the renal artery is dissected separately or simultaneously (Figure 2). The ipsilateral adrenal gland is preserved when the upper pole of the kidney is freed. The dorsal aspect of the kidney is freed outside the perirenal fascia. Complete resection of the kidney, perirenal fat, Gerota’s fascia and perinephric lymph nodes is performed.
Ureterectomy: A separate 10 mm trocar is placed in the middle of the lower abdomen, and the assistant goes to the patient’s head side to hold the scope and disconnects the gonadal vessels at the level of the iliac fossa with hem-o-lock clamping. The peritoneum at the level of the iliac vessels is dissected down to the lateral pelvic wall to the lateral aspect of the bladder, and the ureter is dissected along the periureter to the opening of the ureteral bladder. In women, attention is paid to freeing, titanium-clamping and dissecting the uterine artery. The periureteral forceps are freed, part of the bladder forceps is incised, the ureter is drawn cephalad to pull the ureteral opening and part of the bladder mucosa out of the bladder wall, and it is cut off after clamping part of the bladder wall and bladder mucosa with a 12 mm Hem-o-lock (Figure 3). The urinary system was in a completely closed state during the whole procedure, with no urine extravasation.
The kidney was loaded into a 130 mm diameter specimen bag, the surgical area was flushed with sterile saline, the pneumoperitoneum pressure was adjusted down to 4 cm H2O, the trauma was observed to be free of active bleeding, the median incision in the lower abdomen was enlarged by an average of 5.5 cm (3.5-7 cm), and the specimen was removed. An F20 porous silicone tube was left in the abdomen for drainage. The abdominal wall incision was sutured, stapled or glued (Figure 4).
Figure 1 Location of the trocar and corresponding intracavitary instruments
Figure 2 Lumpectomy of the renal artery with a cutting suture
Figure 3 12 mm Hem-o-lock clamping of part of the bladder wall
Figure 4 Various incisions in the abdominal wall
2. Results
All 25 surgeries were completed under complete laparoscopy without intermediate opening. The operative time ranged from 120 to 180 min, with an average operative time of 150 min. The intraoperative bleeding volume ranged from 20 to 100 ml, with an average of 40 ml, and none of them had blood transfusion. No complications of abdominal organ injury occurred. Patients drank water 6 hours after surgery, and left bed on the first postoperative day to eat a clear liquid diet. The abdominal drainage tube was removed 2 to 4 days after surgery. There were no complications of intestinal obstruction or intestinal adhesions. The average postoperative hospital stay was 5.5 (4-6) days. All postoperative pathologies were uroepithelial carcinoma.
3. Discussion
Radical total nephroureteral resection and bladder sleeve resection is the gold standard for the treatment of uroepithelial carcinoma of the upper urinary tract, and its classical surgical approach is open total resection of the kidney and ureter including the inner bladder wall segment. However, this procedure generally uses two incisions, a lumbar incision for the kidney and an incision for the ureter in the lower abdomen, which is more traumatic. clayman et al [1] performed the first laparoscopic total ureterectomy in 1991, and since then several clinical studies have compared open surgery with laparoscopic surgery and confirmed the safety, therapeutic effects and advantages of laparoscopic nephroureterectomy [2-4]. Although laparoscopic techniques have been widely applied to manage uroepithelial carcinoma of the upper urinary tract in China and abroad, the specific ways of surgical access, ureteral end treatment, specimen removal and other steps still differ.
At present, the kidney is mostly removed laparoscopically at home and abroad, followed by the application of various open or endoscopic methods for ureteral and bladder sleeve resection. For example, the first applied transurethral ureteral dissection was created by Mcdonald et al. in 1952, which could reduce the surgical incision in the lower abdomen [5]. Shalhav et al [6] first described a cystoscopic “debulking” method combined with EndoGIA to complete a sleeve resection. The advantages of this approach are that it reduces the risk of tumor cell extravasation and implantation, but the disadvantages are that the metal anastomotic staples may lead to stone formation and that the tissue between the staples is alive and may become a focal point for tumor recurrence [7], and the positive margin rate and postoperative recurrence rate of this procedure have been reported to be higher than those of open surgery [8].
Gill et al [9] reported a transcystic laparoscopic resection of the terminal ureter. Prior to nephrectomy, the patient was placed in an amputated position with an indwelling ureteral catheter, two 2-mm cannulae were placed from the pubic bone to the bladder, the ureteral opening was retracted, the ureteral orifice and ureteral catheter were ligated with a ligature to form a closed system, and a Collins knife was used to cut a circle around the ureteral orifice and retract the ureteral orifice to facilitate removal of the wall segment ureter up to the external bladder space.Gill and his colleagues concluded that this method is clinically effective, with a low rate of positive incision margins and recurrence; however, it is technically difficult, has a difficult learning curve, and is even less applicable to patients who are obese and have more difficult pelvic anatomy [10].
Transurethral ureteral orifice resection was originally described by McNeill [11] et al. In China, some scholars [12,13] also used this method in combination with posterior laparoscopic techniques to perform a certain number of procedures and achieved better results, but this method requires repositioning and is time-consuming. Moreover, intraoperative extravasation of irrigation fluid increases the risk of tumor implantation.
Alexander Tsivian et al [14] reported a completely laparoscopic surgical approach, where they used LigaSure to dissociate the full length of the ureter and part of the bladder wall, avoiding the possibility of harboring live tumor cells between the EndoGIA anastomotic staples. Recently Agarwal et al [15] created another modified approach to deal with the distal ureter, they applied a special capsule to ligate the distal ureter directly under the cystoscope in a satisfactory procedure.
In the present study, the ureter was separated along the ureter up to the opening of the ureteral bladder. In this study, the ureter was detached along the ureter up to the ureteral bladder opening, and the periureteral muscles were freed and part of the bladder muscles were cut, and the ureter was pulled cephalad to pull the ureteral opening and part of the bladder mucosa out of the bladder wall, and part of the bladder wall and bladder mucosa were closed with a 12 mm Hem-o-lock and then cut, In 1970, HOWERTON [16] was the first to report that the same results could be achieved by removing only the bladder mucosa around the ureteral opening as by removing the entire bladder wall around the ureteral opening when dealing with the bladder wall around the ureteral opening.
This procedure also has some features: ① complete laparoscopic resection of the kidney and ureter and cuff resection of the bladder in a completely transabdominal approach without changing the patient’s position; ② large space for transabdominal operation and clear anatomical landmarks; ③ complete laparoscopic surgery in a closed state for removal of the kidney and ureter in a transabdominal approach, avoiding tumor implantation; ④ complete laparoscopic surgery is performed in a closed abdominal cavity, The operation of complete laparoscopy is performed in a closed abdominal cavity, and only the abdominal cavity is opened when the kidney is removed, so that the internal organs are exposed for a short time and the internal environment is less disturbed, and the stomach and intestines are not exposed outside the body, so that the gastrointestinal function recovers quickly after the operation and the hospital stay is short; 5.
In conclusion, our preliminary experience of 25 cases of complete laparoscopic nephroureterectomy with transabdominal approach showed that the intraoperative and short-term postoperative results of this procedure are satisfactory and it is a safe and effective minimally invasive method. Long-term follow-up is needed to obtain oncologic results in the future.