Impact of Earlier Ureteral Ligation on Intravesical Recurrence during Hand-Assisted Retroperitoneoscopic Nephroureterectomy

Abstract

Objective: To determine the impact of earlier ureteral ligation (EUL) during hand-assisted retroperitoneoscopic nephroureterectomy (HARN) for primary renal pelvis urothelial cancer. Methods: We retrospectively reviewed 240 patients with upper urinary tract urothelial cancer who underwent HARN. Only patients with primary renal pelvis urothelial cancer and complete follow-up with a minimum of 1 year after HARN were enrolled into our study. We defined EUL as ligating the ureter prior to pneumoretroperitoneum and mobilizing the kidney during the surgery. Of these 61 patients, 31 (who composed the study group) underwent EUL, while 30 serving as controls were without ureteral ligation during the surgery. We analyzed intravesical recurrence utilizing log rank testing to assess the significance between the two groups. Results: Clinical parameters were similar between the two groups. The median follow-up after HARN was 39.7 months (range 12-96). There was no significant difference in the rate of intravesical recurrence and cancer-specific survival. However, patients without ligation of the ureter had shorter time to first bladder tumor recurrence (11.7 ± 9.1 months vs. 26.4 ± 19.1 months, p = 0.03). Conclusion: EUL during HARN for primary renal urothelial cancer did not affect intravesical recurrence rate or cancer-specific survival.

Significance of the timing of ureteral ligation on prognosis during radical nephroureterectomy for upper urinary tract urothelial cancer

“…In contrast, Ou et al . carried out a retrospective study to determine the impact of earlier UL during hand‐assisted retroperitoneoscopic nephroureterectomy for renal pelvis urothelial cancer 7 . The authors defined earlier UL as ligating the ureter before pneumoretroperitoneum and mobilizing the kidney, and concluded that earlier UL during hand‐assisted retroperitoneoscopic nephroureterectomy did not affect intravesical recurrence 7 .…”

“…carried out a retrospective study to determine the impact of earlier UL during hand‐assisted retroperitoneoscopic nephroureterectomy for renal pelvis urothelial cancer 7 . The authors defined earlier UL as ligating the ureter before pneumoretroperitoneum and mobilizing the kidney, and concluded that earlier UL during hand‐assisted retroperitoneoscopic nephroureterectomy did not affect intravesical recurrence 7 . Although all of these studies examined the utility of UL before renovascular ligation with some difference in timing, which included the early UL group in our criteria, there is no study that examined the utility of UL after renovascular ligation, defined as late UL in the present study.…”

“…suggested that intravesical recurrence was the result of both intraluminal monoclonal tumor cell seeding and the development of distinct tumor clones as a result of field cancerization 5 . Therefore, to avoid intraluminal tumor cell seeding from UTUC, UL during RNU was introduced 6,7 . Although previous retrospective and prospective studies reported conflicting results regarding the efficacy of UL for reducing intravesical recurrence, 7,8 the randomized study showed that UL at the beginning of RNU significantly reduced intravesical recurrence after RNU 6…”

“…Therefore, to avoid intraluminal tumor cell seeding from UTUC, UL during RNU was introduced 6,7 . Although previous retrospective and prospective studies reported conflicting results regarding the efficacy of UL for reducing intravesical recurrence, 7,8 the randomized study showed that UL at the beginning of RNU significantly reduced intravesical recurrence after RNU 6…”

Prevention of Recurrent Bladder Tumors after Nephroureterectomy for Primary Upper Urinary Tract Urothelial Carcinoma: An Individualized Selection Strategy Based on Patient Risk Stratification Is Needed

“…Some studies have found that patients who are treated with a laparoscopic approach are at increased risk of intravesical recurrence [9,23] due to the high gas pressure or longer operating time, which may result in a longer tumor exposure time. Furthermore, earlier ligation of the ureter during the laparoscopic nephroureterectomy could shorten the time to first bladder tumor recurrence [24] . Concordant with previous studies, however, our study showed no difference between open and laparoscopic operations regarding intravesical recurrence [14,25] .…”