Technical Modification of the Terminal Ureter During Total Transperitoneal Laparoscopic Nephroureterectomy for Upper Urinary Tract Urothelial Carcinoma

Summary

Here, we present a protocol to increase the surgical field of view and reduce the difficulty of total transperitoneal laparoscopic nephroureterectomy surgery by precutting the umbilical ligament before treating the terminal ureter.

Abstract

Upper tract urothelial carcinoma (UTUC) accounts for 5%–10% of all urothelial tumors. Radical nephroureterectomy is the standard treatment procedure. At present, different choices still exist for treating the ureteral end during laparoscopic ureteral bladder sleeve resection. Our center has adopted a new method for treating the ureteral end. This new method can increase the operating space and reduce the difficulty of the surgery compared with current methods.

Introduction

Radical nephroureterectomy is a standard procedure for treating upper tract urothelial carcinoma (UTUC)¹. Traditional open surgery requires two large incisions in the lower abdomen, which is associated with a large amount of trauma and many complications². With the rapid development of minimally invasive techniques in urology, laparoscopic surgery has been gradually applied in many research studies. Laparoscopic surgery is identical to open surgery in treating the tumors, so the traditional surgical methods have gradually been replaced by laparoscopic surgery³.

In laparoscopic surgery, treatment of the terminal ureter has been an area of focus and a known difficulty of the surgery. At present, different choices exist for treating the ureteral end in laparoscopic nephroureterectomy. However, reductions in the difficulty of the surgery and the amount of trauma has not been possible^4,5.

After years of exploration, our center has improved and adopted a new method for the treatment of the terminal ureter: precutting the medial umbilical fold not only increases the operating space but also reduces the difficulty of the surgery and minimizes extra trauma to the patient.

Protocol

All methods described here have been approved by the ethics committee of the Beijing Hospital. Indications and contraindications for surgery are according to the European Association of Urology guidelines for upper urinary tract urothelial cell carcinoma.

1. Instruments for Operation

1. Ensure the availability of the laparoscopic imaging system, images of the pneumoperitoneum, and ultrasonic scalpel.

2. Preparation for Operation

1. Prepare the patient with a bowel cleansing before the operation. Have the anesthesiologist perform an anesthesia risk assessment of the patient prior to surgery. Have patients taking aspirin before surgery stop taking it.
2. Prepare the skin around the surgical site.
3. Preoperatively administer an intravenous antibiotic 30 min before the operation to all patients. Use cefuroxime sodium 1.5 g with 100 mL of 0.9% sodium chloride solution.
4. Before administering general anesthesia, lay the patient down on the operating table.
5. After general anesthesia, place the healthy side of the patient in a 60° recline at the waist, so the patient is in a V-shaped position on the operating table.

3. Procedure

1. Place trocars (see Figure 1).
   1. Begin the operation with the patient in the right lateral position.
   2. Establish pneumoperitoneum by inserting a pneumoperitoneal needle using the Veress method. Maintain the pneumoperitoneum pressure at 14 mmHg.
   3. Implant a trocar at the umbilical level near the outer edge of the left rectus abdominis muscle. Then, insert the laparoscope.
   4. Place the other trocars.
2. Treat the kidney and upper and middle ureters.
   1. Rotate the operating bed axially so that the patient is in an ~80°–90° lateral position.
      NOTE: This position allows for the intestines to fall to the side, which better exposes the renal hilum for treatment.
   2. Dissect the peritoneum on the affected side and fully release the colon downwards.
   3. Free and clamp the ureter at the distal end of the tumor with a vascular closure clip and then dislodge upwards along the ureter until reaching the renal hilum level.
   4. Treat the renal artery and renal vein successively and completely free the kidney.
   5. Free the ureter to the external vascular level.
3. Treat the terminal ureter.
   1. Rotate the operating bed axially so that the patient is in a 50° lateral position.
      NOTE: This position is optimal for surgery inside the pelvic area and avoids having the surgeon operate in a position that is too low.
   2. Open the anterior peritoneum of the ureter with an ultrasonic scalpel and after crossing the iliac vessels, identify the umbilical medial iliac crest, where the umbilical artery is located⁶ (Figure 2).
   3. Cut the medial iliac crest so that the artery can reach the outside of the bladder (Figure 3).
   4. Clamp and cut the distal end of the vascular structure as is the norm. Free the bladder until the ureter enters the bladder.
   5. Cut the entire layer of the bladder wall at the upper side of the ureteral junction. Suture the full layer of the bladder with 3-0 absorbable thread to indicate and provide traction to see the normal bladder mucosa^5,7.
   6. Remove the ureteral bladder wall segment and part of the bladder mucosa with a scalpel. While making the incision, completely suture the bladder wall with absorbable lines (Figure 4).
4. Take out the specimen.
   1. Load the surgical specimen into the specimen bag.
   2. According to the conditions, extend the incision for cannula A and take out the specimen.
   3. Layer off each incision.
5. Postoperative care.
   1. Let the patient lay in bed for approximately 1 h postoperatively in the care unit until he or she completely wakes up from anesthesia.
   2. Meanwhile, monitor the patient and ensure that oxygen is available during this time.
   3. When the patient completely wakes up, return the patient to the ward. Pay attention to the color and volume of the urine and abdominal drainage. Pay attention to the presence of any abdominal signs and symptoms (e.g., stomachache and peritoneal irritation).

Results

In total, 87 patients underwent surgery without difficulties, and there were no open surgeries. The average age of the patients was 67.25 ± 9.90 years. Within this group, there were 47 cases of renal pelvic cancer, 10 cases of pelvic cancer with ureteral cancer, and 30 cases of ureteral cancer (10 cases of upper ureteral cancer, 9 cases of middle ureteral cancer, and 11 cases of lower ureteral cancer). In total, 49 cancers were on the left side and 38 cancers were on the right side. The average tumor diameter was 3.24 ± ...

Discussion

A traditional open renal ureter resection and bladder cuff-like resection mostly involve upper and lower incisions, which require changing positions and disinfecting the surgical towels twice. The operation time is long, and the amount of trauma is large. Laparoscopic renal ureter and bladder sleeve resection have been gradually adopted by urologists since minimally invasive surgery techniques have been widely used in urology⁸. The methods for laparoscopic nephroureterectomy and radical resection ...

Materials

List of materials used in this article

Name	Company	Catalog Number	Comments
Laparoscopic imaging system	STORZ
Pneumoperitoneum	STORZ
Ultrasonic scalpel	Johnson
Vascular closure clip	Hem-o-Lock