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

Our center has adopted a new technique to treat the distal ureter. Comparing with the previous one, our new technique increase the operating space and reduce the difficulty of the procedure. Disconnecting the umbilical artery allows the visual field to be opened, increasing access to the surgical space and helping reduce the risk of injury to the surrounding tissues.

In addition, this technique can reduce the overall operating and anesthesia time, reduce the risk of tumor implantation, and also the difficulty of the procedure. The best application of this skill is for you to see, but we can also use this skill to do other laparoscopic surgery to increase the working space. Before beginning the procedure, administer an intravenous antibiotic.

After administering general anesthesia, position the healthy side of the patient in a 60-degree recline at the waist so that the patient is in a V-shaped position on the operating table. Place the second trocar near the lateral edge of the rectus abdominis along the umbilical level of the affected side. In third trocar, under the affected part of the midline of the clavicle.

With the patient in the left lateral position, use the trocar to establish pneumoperitoneum and maintain the pneumoperitoneum pressure at 14 millimeters of mercury at the midline of the clavicle, and the midpoint of the inguinal ligament, and under the xiphoid process. To treat the kidney in upper and middle ureters, dissect the peritoneum on the affected side to fully release the colon. Use a vascular closure clip to free and clamp the ureter at the distal end of the tumor and dislodge the tissue upward along the ureter until the renal hilum is reached.

Sequentially treat the renal artery and the renal vein to completely free the kidney. Then free the ureter to the external vascular level. To treat the terminal ureter, use an ultrasonic scalpel to open the anterior peritoneum of the ureter.

After crossing the iliac vessels, identify the umbilical medial iliac crest at which the umbilical artery is located. Then cut the medial iliac crest so that the artery can reach the outside of the bladder. It is critical to cut the medial iliac crest before the terminal ureter treatment.

Clamp and cut the distal end of the vascular structure according to standard protocols. Free the bladder until the point at which the ureter enters the bladder. Cut the entire layer of the bladder wall at the upper side of the uretal junction and suture the full layer of the bladder with 3-0 absorbable thread to provide traction and to allow visualization of the normal bladder mucosa.

Then use a scalpel to remove the ureteral bladder wall segment and part of the bladder mucosa before completely suturing the bladder wall with absorbable lines. When the specimen has been located, extend the incision for cannula A and remove the specimen. Then load the surgical specimen into the specimen bag and layer off each incision.

At the end of the procedure allow the patient to lay in bed in the postoperative care unit for approximately one hour with monitoring. When the patient is completely awake, return the patient to the ward. In this representative analysis of 87 patients who underwent the surgery as demonstrated, the average patient age was 67.25 plus or minus 9.9 years, with 47 cases of renal pelvic cancer, 10 cases of pelvic cancer with ureteral cancer, 10 cases of upper ureteral cancer, 9 cases of middle ureteral cancer, and 11 cases of lower ureteral cancer.

49 cancers were on the left side of the patient, and 38 were on the right side. The average tumor diameter was 3.24 plus or minus 1.47 centimeters, and the average operation time was 162.5 plus or minus 45.64 minutes. The volume of intraoperative blood loss was 113.33 plus or minus 59.74 millileters, and no patients required perioperative blood transfusion.

On average, the drainage tubes were in place for 4.56 plus or minus 1.12 days, and the catheters were in place for 5.63 plus or minus 2.17 days. The postoperative pathological stages ranged from T-1, N-0, N-0 to T-4, N-0, N-0. No complications occurred during the operations, although two patients had complications after the surgery.

The follow-up time was one to 44 months with the median follow-up time of 13 months. Eight patients had postoperative tumor recurrence, all of which were bladder recurrence. Excision of the umbilical medial iliac crest can significantly increase the surgical field of vision and improve the success of the procedure.

Maybe cutting the medial iliac crest can be a performed right here with scissors. But it has not been often reported in the literature to present.