Clinical application of one-position complete retroperitoneal laparoscopic radical resection of renal pelvis and ureteral carcinoma

Background: To explore the surgical technique and the clinical efficacy of complete retroperitoneal laparoscopic radical resection in patients with upper tract urothelial carcinoma (UTUC). Methods: A total of 11 patients (6 males and 5 females) newly diagnosed with UTUC with T1/T2 were enrolled in this study who underwent one-position complete retroperitoneal laparoscopic radical resection in our hospital from March 2016 to December 2018. Among them, 8 cases were of renal pelvis carcinoma and 3 cases were of ureteral carcinoma. The average age was 57.5 years (range, 44-78 years). All patients were presented with painless gross hematuria. CTU and ureteroscopy were used to diagnose. Results All the 11 patients had successful operations without open transition. The mean operating time was 85 min (range 60 to 115 min). The mean amount of intraoperative bleeding was below 90 ml. The postoperative hospital stay was 3-7 days, with an average of 5 days. There was no obvious complication after operation. No local tumor recurrence or new bladder implantation metastasis has already been observed with the postoperative follow-up time in 8 to 40 months. change,


Background
Upper tract urothelial carcinoma (UTUC) is a relatively rare urological malignant tumor, 3 accounting for 5%-6% of upper urinary tract tumors [1]. In recent years, retroperitoneal laparoscopy nephroureterectomy has been used progressively as a minimally invasive treatment substituted for open surgery in China [2], the standard resection limitation of which generally includes the total nephroureterectomy with excision of bladder cuff [3].
However, prevalently, patient's posture should be changed from side-lying position to horizontal position during this surgery after kidney and upper ureter dissociated, in order for the resection of distal ureter and bladder near ureteral orifice. Although transperitoneal approach could also accomplish this laparoscopic procedure without posture changes in western countries, pneumoperitoneum interferences on abdominal organs reflecting in abdominal pain, abdominal distension, bacterial translocation and abdominal cavity implantation metastasis has been paid more great attentions in recent study. In this study, we attempt to suggest the complete retroperitoneal laparoscopic

General data
This group is of 11 patients, consisting of 6 male patients and 5 female patients, with a mean age of 57.5 years (range, 44-78 years). Among them, 8 cases had renal pelvic carcinoma, 3 cases had primary ureter carcinoma (7 of them had right-sided lesions, and the remaining 4 had left-sided). The irritative symptoms of all patients were gross hematuria with or without affected side waist abdomen ache. CTU and intraoperative ureteroscopy were used to diagnose with the staging of clinical pathology from cT1 to cT2.
All patients did not receive chemotherapy, radiotherapy or biological immunotherapy before surgery, and there was no serious underlying disease and history of upper urinary tract surgery. Informed consent was signed for all patients and the study was approved by the Medical Ethics Committee of our hospital.

Operative technique
All patients received the operation under general anesthesia. The patients were placed on the lateral side. The waist bridge was heightened adequately so as to ensure the patient's waist fully extended. A 10-12 mm skin incision was made at the intersection of the vertical line perpendicular to the anterior superior iliac spine to the dorsal side and the lower edge of the costal margin to indicate blunt dissection of the lumbar fascia, and the peritoneal dilator was fully expanded and the retroperitoneal space was established to insert a 12mm sleeve. A 10mm skin incision was made at the intersection of the horizontal and the anterior line of the anterior superior iliac spine, and a 10mm cannula was used to place the lens. The pneumoperitoneum was established and the pressure was 12-15 mmHg (1 mmHg = 0.133 kPa). The third and fourth cannulas were laparoscopically placed, forming a parallelogram with the first two cannulas (Figure 1). The extraperitoneal fat was removed using an ultrasonic scalpel. The boundary between the peritoneal reflex and the perirenal fascia was exposed; the anatomical landmarks such as the psoas muscle, the perirenal fascia and the peritoneal regurgitation were identified. The perirenal fascia was dissected from the dorsal side of the kidney with an ultrasonic knife and separated. The lateral fascia was cut along the anterior edge of the psoas muscle into the anterior space of the psoas muscle and the lumbar muscle; the dorsal side of the perirenal fascia was 5 isolated. The ureter was found along the surface of the psoas muscle and clamped with Hem-o-lok in the upper ureter ( Figure 2). From the level of the diaphragm, down to the level of the iliac vessels, efforts were made to try to push the kidney to the ventral side.
The renal hilum was bluntly separated from the posterior kidney by an aspirator, and the renal artery was revealed and separated, and the cutting was made with Hem-o-lok.
Efforts continued to detach from the distal end of the ureter. The lens was reinserted from a 12 mm cannula towards the pelvic cavity, and the ureter was continued to the inner segment of the bladder wall with an ultrasonic knife, and part of the bladder wall muscle layer was cut to reveal a large portion of the swelling. The ureter and part of the bladder wall were lifted, multiple Hem-o-lok clips were used for bladder sleeve resection, and the incision in the bladder was sutured with absorbable sutures (Figure 3). The intact gross specimen of the renal ureter ( Figure 4) was removed from the 12 mm cannula under the enlarged costal margin and the end of the ureter and the cystic resection of the bladder were examined for completeness. After the bleeding was stopped and the retroperitoneal drainage tube was placed, the incision was sutured.

Results
Complete retroperitoneal laparoscopic radical resection in all these patients was carrying UTUC accounts for about 5% of urothelial carcinoma [4], with the characteristics of high recurrence and multi-center occurrence. With the advancement of laparoscopic techniques and the accumulation of operative experience, laparoscopic total nephroureterectomy with excision of bladder cuff have been applicable to a growing number of pelvic ureteral cancer patients in many centers since it was successfully performed by Clayman et al in 1991 [5,6]. Recently, laparoscopic nephroureterectomy has replaced open surgery as standard surgical treatment for upper urinary tract epithelial carcinoma bacause of the less intraoperative bleeding, minimal invasion, quicker recovery and shorter postoperative hospital stay [7][8][9][10][11].
At present there are many surgical approaches for laparoscopic nephroureterectomy. The most common method was the Bishoff method [12], that is, laparoscopic renal and upper ureter resection in the upper abdomen, and lower ureter and partial bladder incision in the lower abdomen. But this procedure is not completely done under the laparoscopy. In 1999, Gill et al [13,14]

Conclusions
In summary, completing retroperitoneal laparoscopic nephroureterectomy for the treatment of UTUC has its advantage in no posture change, less bleeding during operation, minimally invasive, quicker recovery and shorter postoperative hospital stay without any postoperative complications such as bladder calculi, higher local recurrence and vesical 9 implantation metastasis probability of cancer.
As the limited number of specimen available and insignificant follow-up time, further follow-up observation is required to confirm the long-term efficacy of the treatment.

Availability of data and materials
Not applicable.

Ethics Approval and Consent to Participate
Affiliated Hospital of Xuzhou Medical University ethics committee. The study had the consent of the participants and was documented in a medical document with surgical informed consent.

Consent for publication
Not applicable.

Conflict of interest
The authors declare that they have no conflict of interest. The third and fourth cannulas were laparoscopically placed, forming a parallelogram with the first two cannulas.
13 Figure 2 The ureter was found along the surface of the psoas muscle and clamped with Hem-o-lok in the upper ureter.
14 Figure 3 The ureter and part of the bladder wall were lifted, multiple Hem-o-lok clips were used for bladder sleeve resection, and the incision in the bladder was sutured with absorbable sutures.
15 Figure 4 The intact gross specimen of the renal ureter was removed from the 12 mm cannula under the enlarged costal margin