Laparoscopic Transvesical Resection of an En Bloc Bladder Cuff and Distal Ureter during Nephroureterectomy

Abstract

Objective. The most appropriate technique for excising the distal ureter and bladder cuff during laparoscopic nephroureterectomy is still debated. We report our experience with a pure laparoscopic transvesical method that duplicates the long-standing open transvesical approach. Materials and Methods. Seven men and three women diagnosed with upper tract transitional cell carcinoma were treated with this procedure. Three intravesical ports were inserted, and pneumovesicum was established at 12 mmHg. Transvesical laparoscopic circumferential detachment of the bladder cuff and en bloc mobilization of the last centimeters of the distal ureter were performed, followed by the closure of the bladder defect. Subsequently, a nephrectomy was performed either laparoscopically or using an open flank approach. Results. The median age was 68.5 years. The procedure was completed uneventfully in all cases. The median operating time for distal ureter excision was 82.5 minutes (range 55–120). No complications directly related to the pneumovesicum method were recorded. The median follow-up period was 31 months (range 12–55). During the follow-up period, two patients (20%) died from the disease, and a bladder tumor developed in three cases (30%). Conclusion. The laparoscopic transvesical resection of the en bloc bladder cuff and distal ureter is a reliable, effective, and oncologically safe technique, at least in the midterm.

A Novel and Simple Modification for Management of Distal Ureter During Laparoscopic Nephroureterectomy Without Patient Repositioning: A Bulldog Clamp Technique and Description of Modified Port Placement

“…The main disadvantage of this approach is the possibility of port-site metastases, which may be caused by urine extravasation with tumor cells through the bladder wall defect. In addition, this method is technically difficult with a steep learning curve 23,24 . In summary, none of these four techniques are purely laparoscopic, resulting in the requirement of patient repositioning or the risk of urethral complication due to the use This article has been peer-reviewed and accepted for publication, but has yet to undergo copyediting and proof correction.…”

Long‐term oncological outcomes of the Agarwal loop‐ligation technique for management of the distal ureter during laparoscopic radical nephroureterectomy

“…Pure laparoscopic approaches aim to replicate an open approach by maintaining an intact ureter during RNU. This requires advanced technical skills to isolate the ureter down to the detrusor hiatus and suture the bladder defect close [12,19]. Inadequate dissection of ureter can result in leaving the distal ureteric stump behind.…”

“…Some of these methods do not involve UO occlusion and run the risk of tumour spillage and increase the risk of local recurrence [3,10,11]. Complete laparoscopic or robot‐assisted approaches to the management of the distal ureter have been described [12–14], but these may be technically demanding and long‐term oncological safety is not yet established [1,15].…”

Distal ureterectomy techniques in laparoscopic and robot-assisted nephroureterectomy: Updated review

“…[ 24 ] “According to this procedure, the laparoscopic method was used firstly for the nephrectomy and afterward and intravesical incision of the ureteric orifice was performed robotically to manage the bladder cuff.” Similar techniques have been also described in pure LNU. [ 28 35 ]…”