Management of the Distal Ureter during Nephroureterectomy for Upper Urinary Tract Transitional Cell Carcinoma: A Review

Abstract

Introduction: The standard treatment for upper urinary tract transitional cell carcinoma (UUT-TCC) is open radical nephroureterectomy with excision of a bladder cuff. We assess the successful endoscopic completion and oncological efficacy of the various minimally invasive transurethral techniques devised for the management of the intramural ureter during nephroureterectomy. Materials and Methods: A comprehensive review of the English literature until February 2009 using the PubMed database returned 42 relevant papers. Five methods of endoscopic management of the distal ureter were identified and compared to the open technique. Results: There are no randomised studies. Successful completion of the endoscopic procedure was less (91%) for the ureteric stripping technique than for the other endoscopic modalities (99.8–100%). Recurrences were highest for laparoscopic extravesical ureteric stapling in conjunction with cystoscopic detachment of the ureter, although the numbers analysed were small. For the other endoscopic modalities, bladder recurrence, positive margins and retroperitoneal recurrence (20–37, 0–4 and 1–3%, respectively) in case series were similar compared with the open method (36, 5 and 3%, respectively). Conclusions: Current non-randomised evidence is open to selection bias and is insufficient to support or refute endoscopic management of the distal ureter as an alternative to open bladder cuff excision. We highlight the reported inefficiency of the ureteric stripping technique.

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

“…11 become a feasible and safe mini-invasive procedure for the treatment of UTUC in many centers with increasing frequency [11][12][13] This article has been peer-reviewed and accepted for publication, but has yet to undergo copyediting and proof correction. The final published version may differ from this proof.…”

“…The final published version may differ from this proof. 12 Additionally, this open approach may be difficult to perform in obese patients or those with a history of pelvic surgery. Transurethral resection of the ureteric orifice and intramural ureter followed by "plucking" of the entire distal ureter out of the bladder wall is considered an alternative method that avoid the need for an extra incision and is associated with a shorter operative time compared to open excision 18 .…”

Common iliac artery thrombosis as a possible complication of the pluck technique in nephroureterectomy

“…In a review of distal ureter management, Gkougkousis et al reported that 8 of 508 patients (2%) developed complications related to cystoscopic detachment of the distal ureter, including haematuria, retroperitoneal extravasation requiring prolonged drainage, urinary retention and urinary tract infection 4. We could find only two reports of CIA dissection or thrombosis in nephroureterectomy but not in nephrectomy, which is a similar surgery without lower ureteral dissection 5 6.…”

Transurethral Electric Coagulation Combined With Retroperitoneal Laparoscopic Nephroureterectomy for Upper Urinary Urothelial Carcinoma

“…4,[7][8][9] There are 2 approaches for the LNU procedure, transperitoneal and retroperitoneal route. The retroperitoneal approach is featured by less interference to abdomen organs and quicker recovery of intestinal function, and it is widely appreciated by urologists and patients.…”

“…Since tumor cells in renal pelvis and ureter could exfoliate easily, the damage to renal pelvis, ureter, and bladder may result in tumor planting during operation. There are several techniques of distal ureteric excision: 8,13 (1) cystoscopic detachment of ureter without ligation or stapling; 14 (2) cystoscopic detachment of ureter with ureteric stripping technique; 15 (3) extravesical laparoscopic stapling of ureter; (4) cystoscopic detachment of the ureter with endoscopic ligation or stapling; 16 and (5) open excision of bladder cuff. 17 The technique of distal ureteric excision is still debatable, and the data reporting is also inconsistent.…”