UTUC accounts for about 5% of urothelial carcinoma , 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 because of the less intraoperative bleeding, minimal invasion, quicker recovery and shorter postoperative hospital stay[7–11].
At present there are many surgical approaches for laparoscopic nephroureterectomy. The most common method was the Bishoff method, 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] reported a complicated laparoscopic radical resection of renal pelvic ureteral cancer. The ureteral bladder wall was firstly treated with lithotomy position, and then supine position was performed through the renal and abdominal ureteral resection surgery. In this operation, two 5 mm cannulas were inserted into the bladder by puncturing the lower abdomen into the bladder, and another surgeon completed ureteral intubation by transurethral insertion of cystoscope. Under the help of grasping forceps of bladder, the inner segment of ureteral bladder wall was cut about 3–4 cm. Then the lasso was placed at the distal end of the free ureteral wall and tightened. Then the electrotomy was continued to remove the entire ureteral wall from the bladder. Ligation of the lasso effectively prevents the leakage of urine in the upper urinary tract, but it could not prevent the leakage of urine containing tumor cells in the bladder, so it still remains the risk of tumor spread. In response to the problem of leaking urine in the bladder and ureteral stump, McDougall et al. proposed a solution: using a linear cutting occluder to perform a sleeve-like resection of the bladder tissue around the ureteral opening. At the same time, the stump was sealed to avoid the urine leakage and prevent the spread of tumor as possible. This report examined the effects of 10 patients and found no tumor spread after surgery. Chandhoke et al followed up for 3–9 months in patients undergoing bladder-sleeve resection with a straight-lined closure. No resection of bladder staples and formation of stones were found after cystoscopy.
A total of 43 patients (35 males and 8 females) with TRNU were enrolled in this study. Forty patients (31 males and 9 females) received CRNU. The CRNU group had significantly shorter average operation time (105.83 ± 5.80 min versus 147.28 ± 17.58 min) and visual pain score (P = 0.024). No significant difference was found in age, BMI, T stage, complication, change of albumin and hemoglobin, postoperative hospital stays and tumor recurrence (P > 0.05). Surgical trauma will put the patient in a state of emergency, and elevated glucocorticoids will cause protein breakdown. The change of serum albumin before and after the operation reflects the trauma of the patient to a certain extent. There was no significant difference in the impact of surgical trauma between the two groups. In addition, we cannot accurately estimate the amount of intraoperative bleeding, so we used the change between preoperative hemoglobin and the first day of postoperative hemoglobin to estimate the amount of bleeding, which was more accurate. Similarly, there was no significant difference was found between TRNU group and CRNU group.
Accordingly, in this study, based on the traditional retroperitoneal laparoscopic radical nephrectomy, a modified four-hole method complete retroperitoneal laparoscopic radical nephrectomy for pelvic and ureteral cancer was performed. After radical nephrectomy and upper ureter dissection, we added the fourth Trocar in the ventral of the sight Trocar which had been located over the iliac crest at the same level. Then, the lens was relocated from the dorsal subcostal Trocar towards the pelvic cavity, and the distal ureter was continued dissociating downward to the bladder wall. Afterwards, multiple Hem-o-lock clips were used for the bladder sleeve resection and absorbable titanium clips were used for clipping the distal bladder incision.
At present, there rarely have reports of the application about complete retroperitoneal laparoscopic radical resection of renal pelvis and ureteral carcinoma. The technique we introduced has the following advantages: 1) Through the establishment of retroperitoneal approach, the anatomical landmark is easy to identify with clear visual field; 2) The application of absorbable clips of the bladder incision reduces the possibility of postoperative bladder calculus; 3) Four-hole operation is beneficial to adjust the operating field to the best; 4) The entire surgical procedure without the need of posture changes, shortening the time of operation and reducing potential safety risks during the movement of patients; 5) On the basis of the retroperitoneal laparoscopic nephrectomy, no additional surgical instrument or special equipment should be added so that there has not been a rise in cost.
Through this study, we have some enlightenments as follows: 1) After finding the upper part of the ureter, Hem-o-lock should be used to clamp the distal ureter in order for blocking the implantation metastasis caused by the influx of proximal urine containing cancer cells; 2) Specimen bag should be used for removing the excision to decrease the occurrence of implantation metastasis to abdominal incision after complete resection; 3) Operation area should be washed repeatedly with warm sterilized water at about 42℃ to destroy the potential escaped cancer cells; 4) Although we do not recommend this new surgical technique in lower ureteral cancer because of the relatively difficult exposure of distal ureter, we are trying to resect the lower ureter and partial bladder first before the dissociate of kidney and upper ureter. The feasibility and the effect on prognosis are still in observation.
In summary, one-position complete retroperitoneoscopic nephroureterectomy for the treatment of UTUC has its advantage in no posture change, less postoperative pain score, minimally invasive and shorter operation time without any postoperative complications such as bladder calculi, higher local recurrence and vesical implantation metastasis probability of cancer.