Name: Technical Modification of the Terminal Ureter During Total Transperitoneal Laparoscopic Nephroureterectomy for Upper Urinary Tract Urothelial Carcinoma (Video) | JoVE Journal
Uploaded: 2019-11-22T14:00:00.000+00:00
Duration: 6 min 39 s
Description: Learn a modified laparoscopic nephroureterectomy technique that precuts the umbilical ligament to expand the surgical field. This method reduces operating time and lowers complication risks in upper urinary tract cancer surgery.

ai_agent_IP

ai_agent

maintenance

instantTrialDurationMinutes

isBiopharma

enableNewMyJoveSectionDesign

educationFeatures

seoMetaApi

ai_copilot_institution_blacklist

ai_chat_institution_blacklist

freeAccessWindow

ssoRoleCapture

scheduledMaintenanceBanner

joveLabsFeatures

disable_autoplay_for_bots

extended_trial_duration

5 minutes

This study was sponsored by CAMS Innovation Fund for Medical Sciences,No. 2018-I2M-1-002.

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
<ol>
	<li>Ensure the availability of the laparoscopic imaging system, images of the pneumoperitoneum, and ultrasonic scalpel.</li>
</ol>
2. Preparation for Operation
<ol>
	<li>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.</li>
	<li>Prepare the skin around the surgical site.</li>
	<li>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.</li>
	<li>Before administering general anesthesia, lay the patient down on the operating table.</li>
	<li>After general anesthesia, place the healthy side of the patient in a 60&#176; recline at the waist, so the patient is in a V-shaped position on the operating table.</li>
</ol>
3. Procedure
<ol>
	<li>Place trocars (see Figure 1).
	<ol>
		<li>Begin the operation with the patient in the right lateral position.</li>
		<li>Establish pneumoperitoneum by inserting a pneumoperitoneal needle using the Veress method. Maintain the pneumoperitoneum pressure at 14 mmHg.</li>
		<li>Implant a trocar at the umbilical level near the outer edge of the left rectus abdominis muscle. Then, insert the laparoscope.</li>
		<li>Place the other trocars.</li>
	</ol>
	</li>
	<li>Treat the kidney and upper and middle ureters.
	<ol>
		<li>Rotate the operating bed axially so that the patient is in an ~80&#176;&#8211;90&#176; lateral position. 
		NOTE: This position allows for the intestines to fall to the side, which better exposes the renal hilum for treatment.</li>
		<li>Dissect the peritoneum on the affected side and fully release the colon downwards.</li>
		<li>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.</li>
		<li>Treat the renal artery and renal vein successively and completely free the kidney.</li>
		<li>Free the ureter to the external vascular level.</li>
	</ol>
	</li>
	<li>Treat the terminal ureter.
	<ol>
		<li>Rotate the operating bed axially so that the patient is in a 50&#176; 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.</li>
		<li>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).</li>
		<li>Cut the medial iliac crest so that the artery can reach the outside of the bladder (Figure 3).</li>
		<li>Clamp and cut the distal end of the vascular structure as is the norm. Free the bladder until the ureter enters the bladder.</li>
		<li>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 mucosa5,7.</li>
		<li>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).</li>
	</ol>
	</li>
	<li>Take out the specimen.
	<ol>
		<li>Load the surgical specimen into the specimen bag.</li>
		<li>According to the conditions, extend the incision for cannula A and take out the specimen.</li>
		<li>Layer off each incision.</li>
	</ol>
	</li>
	<li>Postoperative care.
	<ol>
		<li>Let the patient lay in bed for approximately 1 h postoperatively in the care unit until he or she completely wakes up from anesthesia.</li>
		<li>Meanwhile, monitor the patient and ensure that oxygen is available during this time.</li>
		<li>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).</li>
	</ol>
	</li>
</ol>

<ol><li>Roupret, M., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((European+guidelines+for+the+diagnosis+and+management+of+upper+urinary+tract+urothelial+cell+carcinomas%3A+2011+update%5BTitle%5D)+AND+%22European+Urology%22%5BJournal%5D)">European guidelines for the diagnosis and management of upper urinary tract urothelial cell carcinomas: 2011 update.</a> European Urology. 59 (4), 584-594 (2011).</li>
<li>Ristau, B. T., Tomaszewski, J. J., Ost, M. C. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Upper+Tract+Urothelial+Carcinoma%3A+Current+Treatment+and+Outcomes%5BTitle%5D)+AND+%22Urology%22%5BJournal%5D)">Upper Tract Urothelial Carcinoma: Current Treatment and Outcomes.</a> Urology. 79 (4), 749-756 (2012).</li>
<li>Ni, S., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Laparoscopic+Versus+Open+Nephroureterectomy+for+the+Treatment+of+Upper+Urinary+Tract+Urothelial+Carcinoma%3A+A+Systematic+Review+and+Cumulative+Analysis+of+Comparative+Studies%5BTitle%5D)+AND+%22European+Urology%22%5BJournal%5D)">Laparoscopic Versus Open Nephroureterectomy for the Treatment of Upper Urinary Tract Urothelial Carcinoma: A Systematic Review and Cumulative Analysis of Comparative Studies.</a> European Urology. 61 (6), 1142-1153 (2012).</li>
<li>Ghazi, A., Shefler, A., Gruell, M., Zimmermann, R., Janetschek, G. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((A+Novel+Approach+for+a+Complete+Laparoscopic+Nephroureterectomy+with+Bladder+Cuff+Excision%5BTitle%5D)+AND+%22Journal+of+Endourology%22%5BJournal%5D)">A Novel Approach for a Complete Laparoscopic Nephroureterectomy with Bladder Cuff Excision.</a> Journal of Endourology. 24 (3), 415(2010).</li>
<li>Hiroshi, K., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Comparison+of+Laparoscopic%2C+Hand-Assisted%2C+and+Open+Surgical+Nephroureterectomy%5BTitle%5D)+AND+%22Journal+of+the+Society+of+Laparoendoscopic+Surgeons%22%5BJournal%5D)">Comparison of Laparoscopic, Hand-Assisted, and Open Surgical Nephroureterectomy.</a> Journal of the Society of Laparoendoscopic Surgeons. 18 (2), 288-293 (2014).</li>
<li>Ni, S., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Laparoscopic+Versus+Open+Nephroureterectomy+for+the+Treatment+of+Upper+Urinary+Tract+Urothelial+Carcinoma%3A+A+Systematic+Review+and+Cumulative+Analysis+of+Comparative+Studies%5BTitle%5D)+AND+%22European+Urology%22%5BJournal%5D)">Laparoscopic Versus Open Nephroureterectomy for the Treatment of Upper Urinary Tract Urothelial Carcinoma: A Systematic Review and Cumulative Analysis of Comparative Studies.</a> European Urology. 61 (6), 1142-1153 (2012).</li>
<li>Seisen, T., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((A+Systematic+Review+and+Meta-analysis+of+Clinicopathologic+Factors+Linked+to+Intravesical+Recurrence+After+Radical+Nephroureterectomy+to+Treat+Upper+Tract+Urothelial+Carcinoma%5BTitle%5D)+AND+%22Journal+of+Urology%22%5BJournal%5D)">A Systematic Review and Meta-analysis of Clinicopathologic Factors Linked to Intravesical Recurrence After Radical Nephroureterectomy to Treat Upper Tract Urothelial Carcinoma.</a> Journal of Urology. 67 (6), 1122-1133 (2015).</li>
<li>Michael, M. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Long-term+oncologic+outcome+after+laparoscopic+radical+nephroureterectomy+for+upper+tract+transitional+cell+carcinoma%5BTitle%5D)+AND+%22European+Urology%22%5BJournal%5D)">Long-term oncologic outcome after laparoscopic radical nephroureterectomy for upper tract transitional cell carcinoma.</a> European Urology. 6 (51), (2007).</li>
<li>Terakawa, T. T. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Retroperitoneoscopic+nephroureterectomy+for+upper+urinary+tract+cancer%3A+a+comparative+study+with+conventional+open+retroperitoneal+nephroureterectomy%5BTitle%5D)+AND+%22Journal+of+Endourology%22%5BJournal%5D)">Retroperitoneoscopic nephroureterectomy for upper urinary tract cancer: a comparative study with conventional open retroperitoneal nephroureterectomy.</a> Journal of Endourology. 22 (8), 1693-1699 (2008).</li>
<li>Gkougkousis, E. G., Mellon, J. K., Griffiths, T. R. L. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Management+of+the+Distal+Ureter+during+Nephroureterectomy+for+Upper+Urinary+Tract+Transitional+Cell+Carcinoma%3A+A+Review%5BTitle%5D)+AND+%22Urologia+Internationalis%22%5BJournal%5D)">Management of the Distal Ureter during Nephroureterectomy for Upper Urinary Tract Transitional Cell Carcinoma: A Review.</a> Urologia Internationalis. 85 (3), 249-256 (2010).</li>
<li>Li, C. C., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Significant+Predictive+Factors+for+Prognosis+of+Primary+Upper+Urinary+Tract+Cancer+after+Radical+Nephroureterectomy+in+Taiwanese+Patients%5BTitle%5D)+AND+%22European+Urology%22%5BJournal%5D)">Significant Predictive Factors for Prognosis of Primary Upper Urinary Tract Cancer after Radical Nephroureterectomy in Taiwanese Patients.</a> European Urology. 54 (5), 1127-1135 (2008).</li>
<li>Cormio, L., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Simultaneous+radical+nephroureterectomy+and+transurethral+distal+ureter+balloon+occlusion+and+detachment%5BTitle%5D)+AND+%22World+Journal+of+Surgical+Oncology%22%5BJournal%5D)">Simultaneous radical nephroureterectomy and transurethral distal ureter balloon occlusion and detachment.</a> World Journal of Surgical Oncology. 12 (1), 345(2014).</li>
<li>Waldert, M., Remzi, M., Klingler, H. C., Mueller, L., Marberger, M. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((The+oncological+results+of+laparoscopic+nephroureterectomy+for+upper+urinary+tract+transitional+cell+cancer+are+equal+to+those+of+open+nephroureterectomy%5BTitle%5D)+AND+%22Bju+International%22%5BJournal%5D)">The oncological results of laparoscopic nephroureterectomy for upper urinary tract transitional cell cancer are equal to those of open nephroureterectomy.</a> Bju International. 103 (1), 66-70 (2010).</li>
<li>Liu, P., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((A+Novel+and+Simple+Modification+for+Management+of+Distal+Ureter+During+Laparoscopic+Nephroureterectomy+Without+Patient+Repositioning%3A+A+Bulldog+Clamp+Technique+and+Description+of+Modified+Port+Placement%5BTitle%5D)+AND+%22Journal+of+Endourology%22%5BJournal%5D)">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.</a> Journal of Endourology. 30 (2), 195-200 (2016).</li>
<li>Xylinas, E., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Impact+of+distal+ureter+management+on+oncologic+outcomes+following+radical+nephroureterectomy+for+upper+tract+urothelial+carcinoma%5BTitle%5D)+AND+%22European+Urology%22%5BJournal%5D)">Impact of distal ureter management on oncologic outcomes following radical nephroureterectomy for upper tract urothelial carcinoma.</a> European Urology. 65 (1), 210-217 (2014).</li>
</ol>

The authors have nothing to disclose.

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 ...

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 possible4,5.
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.

<table><tbody><tr><td>Laparoscopic imaging system</td><td>STORZ</td><td></td><td></td></tr><tr><td>Pneumoperitoneum</td><td>STORZ</td><td></td><td></td></tr><tr><td>Ultrasonic scalpel</td><td>Johnson</td><td></td><td></td></tr><tr><td>Vascular closure clip</td><td>Hem-o-Lock</td><td></td><td></td></tr></tbody></table>

technical modification of the terminal ureter during total transperitoneal laparoscopic nephroureterectomy for upper urinary tract urothelial carcinoma

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

Upper tract urothelial carcinoma (UTUC) accounts for 5%&ndash;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.

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 ± ...

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.

Upper tract urothelial carcinoma (UTUC) accounts for 5%&ndash;10% of all urothelial tumors. Radical nephroureterectomy is the standard treatment ...

technical-modification-terminal-ureter-during-total-transperitoneal

Research

JoVE Journal

Medicine

The murine model of irreversible unilateral ureteric obstruction (UUO) is presented together with the model of reversible UUO in which the ureteric obstruction is relieved by anastomosis of the severed ureter into the bladder. These models enable the study of renal inflammation and scarring as well as tissue remodeling.

A Murine Model of Irreversible and Reversible Unilateral Ureteric Obstruction

This protocol presents a new surgical technique of mouse kidney transplantation focusing on a modified arterial anastomosis strategy. A vascular suture technique including a simple and safer ureter-bladder anastomosis method is also presented. These modifications shorten the operation time and improve the success rate of the mouse kidney transplantation procedure.

A Modified Surgical Technique for Kidney Transplantation in Mice

In this report, we present a case of intraperitoneal laparoscopic surgery in the Trendelenburg position (ILSTP) for trans mesenteric pyeloplasty in a horseshoe kidney with hydronephrosis. We provide a detailed protocol and practical tips for surgeons interested in adopting this approach.

Transmesenteric Laparoscopic Pyeloplasty in Trendelenburg Position for Horseshoe Kidney with Hydronephrosis

This paper provides detailed instructions to enable investigators to perform reversible unilateral ureteric obstruction in mice using a standardized model that allows analysis of the long-term structural and functional outcomes after the reversal of prolonged ureteric obstruction.

A Mouse Model to Evaluate the Long-Term Structural and Functional Outcomes after the Reversal of Prolonged Unilateral Ureteric Obstruction

Probe-based confocal laser endomicroscopy enables real-time microscopy of the human urinary tract during cystoscopy, providing dynamic, intravital imaging of pathological states such as bladder cancer with cellular resolution.  Endomicroscopy may augment the diagnostic accuracy of standard white light endoscopy and provide intraoperative image guidance to improve surgical resection.

Probe-based Confocal Laser Endomicroscopy of the Urinary Tract: The Technique

The goal is to produce an arteriovenous fistula that is simple and reproducible. This method does not use sutures or glue adhesive. Therefore the samples can be used with the least amount of foreign materials for analysis.

Technical Aspects of the Mouse Aortocaval Fistula

Dual-phase cone-beam computed tomography (DP-CBCT) is a useful intraprocedural imaging technique for transarterial chemo-embolization treatment with drug-eluting beads of hepatocellular carcinoma. DP-CBCT has been used to perform three major steps in oncologic interventional radiology: tumor localization (see), navigation and intraprocedural catheter guidance (reach), and intraprocedural evaluation of treatment success (treat).

Dual-phase Cone-beam Computed Tomography to See, Reach, and Treat Hepatocellular Carcinoma during Drug-eluting Beads Transarterial Chemo-embolization

This manuscript presents a simple, yet powerful, in vitro method for evaluating smooth muscle contractility in response to pharmacological agents or nerve stimulation. Main applications are drug screening and understanding tissue physiology, pharmacology, and pathology.

Bladder Smooth Muscle Strip Contractility as a Method to Evaluate Lower Urinary Tract Pharmacology

We describe the use of high frequency ultrasound with contrast imaging as a method to measure bladder volume, bladder wall thickness, urine velocity, void volume, void duration, and urethral diameter. This strategy can be used to assess voiding dysfunction and treatment efficacy in various mouse models of lower urinary tract dysfunction (LUTD).

Ultrasonography of the Adult Male Urinary Tract for Urinary Functional Testing

The following manuscript details a stepwise approach to the robot-assisted pancreaticoduodenectomy performed at the University of Pittsburgh Medical Center.

Technical Detail for Robot Assisted Pancreaticoduodenectomy

Learn a modified laparoscopic nephroureterectomy technique that precuts the umbilical ligament to expand the surgical field. This method reduces operating time and lowers complication risks in upper urinary tract cancer surgery.

Technical Modification of the Terminal Ureter During Total Transperitoneal Laparoscopic Nephroureterectomy for Upper Urinary Tract Urothelial Carcinoma (Video) | JoVE Journal

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

Explore More Videos