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OTHER GU ONCOLOGY: NEPHROURETERECTOMY

Approach

Options: open, laparoscopic, or robotic
- Most UTUC are not large or bulky. Thus, minimally-invasive approach is ideal, at least for the renal portion of radical nephroureterectomy when the tumor warrants removal of the entire renal unit.

Pre-operative Preparation

Hold/bridge anticoagulation medications prior to surgery

Open Nephroureterectomy with Bladder Cuff Excision

Position:
- Supine or in modified flank position.
- In male patients the genitalia are included in the surgical field so that the bladder catheter may be accessed during the procedure.
Incision:
- Midline approach gives the most optimal exposure to the retroperitoneal lymph nodes and bladder, however, may limit exposure of the upper pole of the left kidney, especially in obese patients
- Other incisions are flank, subcostal, and thoracoabdominal. The choice of these incisions necessitates using an additional Gibson, midline, or Pfannenstiel incision for bladder cuff removal
Summary of steps:
- Mobilize ipsilateral colon: after incision of the white line of Toldt, the ipsilateral colon is mobilized to expose the Gerota fascia.
- Control hilum: ideally, the hilum is controlled before excessive manipulation of the kidney and ureter. The renal hilum is exposed, reflecting duodenum medially on the right side. For left-sided tumors, care should be taken to avoid injury to the pancreatic tail and spleen. The renal artery and vein are secured and divided in a standard manner. The ureter is typically ligated at this time to prevent migration of tumor fragments into the bladder.
- Mobilize kidney: the entire kidney is mobilized, taking care to stay outside of the Gerota fascia (Fig. 58-7). On the right side, attachments between the liver and kidney, and on the left side the splenorenal ligament, are incised, allowing mobility of the kidney. Traditionally, the ipsilateral adrenal gland has been removed with the specimen, although adrenalectomy does not aid the oncologic control of UTUC, unless its direct involvement is suspected based on preoperative imaging or intraoperative examination. Thus, routine adrenalectomy is unnecessary.
- Management of distal ureter and bladder cuff
  - Complete removal of the distal ureter and bladder cuff is associated with improved oncologic outcomes compared to incomplete resection
    - The risk of tumor recurrence in a remaining ureteral stump is 30-75%. Therefore, the entire distal ureter, including the intramural portion and the ureteral orifice, has to be removed.
      - Techniques such as simple extravesical dissection and tenting up of the ureter will result in an incomplete removal of the distal ureter.
      - The kidney and proximal ureter may be kept in continuity with the distal segment though this technique is not necessary as long as the distal ureter is divided in a controlled manner between ties or clips at a location that is free of gross tumor.
  - Open distal ureterectomy
    - Bladder cuff removal is performed using a transvesical, extravesical, or combined approach.
    - Extravesical approach: the distal ureter is freed toward the bladder to the point of intramural ureter. Gentle traction on the ureter and full bladder may aid in this step; however, for adequate access to the entire intramural ureter, the lateral pedicle of the bladder (obliterated artery; superior, middle, and inferior vesical arteries) must be ligated and divided. Care must be taken to avoid uncontrolled entry to the urinary tract. A cuff of bladder is removed en bloc with ureter by applying a clamp to bladder wall and excising the full intramural portion of the ureter, taking care to stay away from the contralateral ureteral orifice.
    - Transvesical approach: an anterior cystotomy is made and intravesical dissection of the ureter is performed, including a traditional 1 cm mucosal area around the orifice. A wider margin can be taken if a gross tumor is seen protruding from the orifice; and if invasive intramural tumor is suspected, an en bloc partial cystectomy may be required to ensure negative margins. Cystotomy defects are closed in two layers with interrupted or running absorbable sutures: The first layer should incorporate mucosa, and the second layer should include detrusor muscle and adventitia. A Foley catheter is placed and maintained for 5 to 7 days, and a suction drain is left in the perivesical space
  - Transvesical ligation
    - Before the nephrectomy portion, the patient is placed in the low lithotomy position, a cystoscope is passed into the bladder and kept in place, and the bladder is filled.
    - With a Collins knife the bladder cuff is incised, and this incision is carried into the extravesical space
  - Transurethral resection of ureteral orifice
    - Also referred to as a “pluck” technique
    - Can be used in patients with proximal tumors and absence of bladder disease.
    - With the patient in the lithotomy position, the resectoscope is inserted into the bladder and aggressive resection of the ureteral orifice and intramural ureter is performed down to the perivesical fat. This facilitates the plucking of the distal ureter during the nephrectomy portion of the procedure.
    - Even though equivalent oncologic outcomes have been reported in limited studies, concerns about tumor seeding of the extravesical space and the potential for leaving incompletely resected ureter have caused this technique to be largely abandoned
  - Intusseption technique
    - Contraindicated in the presence of ureteral tumors
    - At the beginning of the procedure, a ureteral catheter is placed in the ureter, and nephrectomy is carried out as usual. The distal ureter is isolated extravesically, and a tie is placed around it, securing the catheter to the ureter. After the nephrectomy portion has been completed, the ureter is transected between ties and the bladder cuff is incised cystoscopically with a Collins knife. By pulling on the ureteral catheter, the distal ureter is everted inside the bladder. The intussuscepted ureter is then removed by traction out of the urethra. The edges of the bladder mucosa can be fulgurated.
    - Concerns with this technique include exposure of bladder urothelium to ureteral mucosa with extensive manipulation of the ureter and the potential for incomplete intramural ureter excision
  - Total laparoscopic technique
    - Contraindication: presence of distal ureteral tumors
    - Initially, cystoscopy is performed and the ureteral orifice is cauterized, which may be preceded by placement of a ureteral catheter and incision of an intramural tunnel at the 12 o’clock position. The nephrectomy portion is performed as usual, and the distal ureter is traced to detrusor muscle. The ureteral dissection is carried down to the bladder. The detrusor muscle is split and the ureter retracted in antegrade direction. The endovascular stapler is then used to place a staple line as distally as possible. A fulguration mark helps serve as an identifier of the bladder cuff
    - The concerns with this technique include the potential for leaving ureter mucosa within the staple line and the inability of the pathologist to evaluate the distal margin because of the presence of staples. Laparoscopic stapling has been associated with a higher risk of positive margins, which in this disease is associated with significantly reduced survival

Laparoscopic Radical Nephroureterectomy

Transperitoneal laparoscopic nephroureterectomy
- Laparoscopic Removal of Kidney Down to Mid-Ureter
  - Position: supine with ipsilateral hip and shoulder rotated ≈20°. Patient is secured to the table and can be easily moved from the flank position (nephrectomy portion) to the modified supine position (open portion) by rotating the operative table. The ipsilateral flank and urethra are prepared and draped, and a Foley catheter is placed before insufflation of the abdomen
  - Summary of steps:
    - The abdomen is insufflated, and 3 or 4 trocars are placed as outlined in Figure 58-16, with the first usually being the lateral trocar. Subsequent trocars are placed under direct vision. With this configuration, the camera is kept at the umbilicus for the entire procedure. The upper midline and lateral trocars are used by the surgeon for the dissection of the kidney and the proximal half of the ureter. The lower midline and lateral trocars are used for the dissection of the distal ureter. A 3-mm trocar just below the xiphoid can be helpful in retracting the spleen and liver for left- and right-sided lesions, respectively.
    - The exception is with obese patients, in whom shifting of the trocars may be necessary to provide optimal visualization (Fig. 58-17). If a hand-assist approach is chosen, the hand port site should be placed so that it can be used for the dissection of the distal ureter and open bladder cuff as indicated.
    - The table is rotated so that the patient is in the flank position. The peritoneum is incised along the white line of Toldt from the level of the iliac vessels to the hepatic flexure on the right and to the splenic flexure on the left. The colon is moved medially by releasing the renocolic ligaments while leaving the lateral attachments of the Gerota fascia in place to prevent the kidney from “flopping” medially. The colon mesentery should be mobilized medial to the great vessels to facilitate dissection of the ureter, renal hilum, and local lymph nodes as needed.
    - Proximal Ureteronephrectomy. The proximal ureter is identified, just medial to the lower pole of the kidney, and dissected toward the renal pelvis, avoiding skeletonization and maintaining copious periureteral fat if any tumor is located in this area. If an invasive ureteral lesion is suspected, the dissection should include a wide margin of tissue. The renal hilum is identified, and its vessels are exposed with a combination of blunt and sharp dissection. The artery is ligated and divided by use of a stapling device with a vascular load or multiple clips. The renal vein is then divided in a similar fashion. With vascular control ensured, most prefer to ligate the ureter with a clip as previously described, and the kidney is dissected free outside the Gerota fascia. Similar to the procedure described for open nephroureterectomy, the adrenal gland does not need to be removed routinely. The ureteral dissection is continued distally, keeping in mind that the ureteral blood supply is generally anteromedially located in the proximal third, medially located in the middle third, and laterally located in the distal third. Dissection of the lower half may require placement of the fourth trocar. In the area of primary disease, surrounding tissue should be left to provide an adequate tumor margin. The ureteral dissection is continued as far as is technically feasible. If the distal limits of the dissection are below the level of the iliac vessels, the remainder of the procedure can easily be completed through a lower abdominal incision. The specimen is placed in the pelvis, and the renal bed is inspected meticulously for bleeding. At this time, the 10-mm port sites are closed before proceeding to the open portion of the case.
    - Open Distal Ureterectomy with Excision of Bladder Cuff. [Further details in Campbell’s]

Robotic-Assisted Laparoscopic Nephroureterectomy

Contraindications
1. Contraindications to laparoscopic surgery
2. History of extensive abdominal or pelvic surgery
3. Morbid obesity
4. Extremely large tumor
Advantages to robotic approach
- Reduced blood loss, less pain, and shorter hospital stays
Steps of procedure
- Position: 60° ipsilateral (tumor side up) flank with 15° Trendelenburg (head down) tilt.
- Venous thromboembolism prophylaxis
  - Compression stockings
  - Heparin
  Antibiotics
  - 2g cefazolin (900 mg clindamycin, if penicillin allergic)
- Surgical plan:
  - Number of ports: 5 (6 if right-sided) (variations possible, depending on institution equipment and surgeon preference)
  - Location of ports:
    - Camera (12 mm): level of the tip of the 11th rib
    - Robotiic Arm 1 (8 mm): 2 fingerbreadths below the costal margin
    - Robotic Arm 2 (8 mm): level of ASIS
    - Assistant 1 (12 mm): between camera trocar and Arm 2.
    - Assistant 2 (5 mm): between camera trocar and Arm 1.
    - All ports are placed in a straight line at the lateral border of the ipsilateral rectus abdominus muscle.
      - Port placement medial to the rectus border risks injury to the epigastric vessels.
      If right-sided, an additional liver retraction trocar is placed just in the midline, inferior to xiphoid process. Use Allis clamp to hold on abdominal wall.
  - Step by step:
    - Patient positioning, antiseptic preparation, draping. Pressure points should be padded. Axillary roll should be placed to prevent neuropraxia. Arm boards for arms.
    - Veress needle access. Commonly where camera port will be. Palmer's point (3 cm below the left costal margin and in the midclavicular line) is another option. Confirm appropriate placement with saline test.
    - Achieve pneumoperitoneum. Have gas on low flow and determine opening pressure. If pressures are low (< 10 mmg Hg), increase to high flow. As the pressure slowly rises to 20, the port sites are prepared.
    - Insert ports. Once at 20mm Hg, the first port, the camera port is placed through a 12 mm transverse incision followed by the remaining five ports all under direct vision. Once all ports are positioned, AirSeal is installed and activated and the pneumoperitoneum is reduced to 12-15 mm Hg for the procedure.
    - Dock robot
      - If Xi
        
        Attach camera port to robot. Insert and attach camera. Target camera in pelvis. Hold camera port steady and allow robot to adjust. Attach remaining ports to robot.
    - Medialize bowel to expose retroperitoneum. Incise peritoneum at line of Toldt down to sigmoid. Use blunt and sharp dissection to develop plane anterior to Gerota fascia and posterior to the mesocolon. Release attachments to the spleen and liver as needed.
      - On the right side there is no need for extensive mobilization of the bowel to expose the renal hilum.
      - During the mobilization of the duodenum medially, the use of cautery is minimized.
    - Identify ureter. The mid-ureter is identified along the anterior aspect of the psoas. Once identified, dissection proceeds along the psoas muscle with anterior elevation of the ureter and/or gonadal vein to identify the renal hilum
      - The gonadal vein is an important anatomic landmark when proceeding toward the renal hilum; the renal vein can be identified by tracing the gonadal vein proximally to its insertion in the renal vein on the left side or to its insertion in the inferior vena cava just caudal to the hilum on the right side.
      - On the right side, the gonadal vein is kept medially toward the vena cava, whereas on the left side, the gonadal vein is lifted along with the left ureter to expose the lower margin of the left renal hilum.
    - Dissect hilum. Dissect the renal hilum meticulously to clearly delineate the vascular structures prior to their ligation. Apply vessel clips or vascular staples to ligate first the artery, and then the vein. The vessels are then transected.
    - Complete kidney dissection. The kidney along with Gerota's fascia are dissected free of the renal fossa with a combination of cautery and blunt dissection. Adernal sparing surgery is recommended, when feasible.
    - Distal ureter and bladder cuff. While leaving the ureter attached to the kidney, continue distal dissection of the ureter towards the pelvis. The superior vescial artery is ligated and transected to reach the distal ureter. The intramural ureter is then dissected by incising the surrounding detrusoer muscle until tenting of the bladder urothelial mucosa is seen. Two absorbable stay sutures are placed laterally and medially, prior to excision of the bladder urothelial mucosa. Then by incising the bladder mucosa circumferentially around the ureteric orifice the entire distal ureter with surrounding bladder cuff is release and the specimen, kidney ureter and bladder cuff, should be free from all surrounding structures.
    - Closure of cystotomy. The previously placed absorbable stay sutures are used to close the cystotomy. The closure is then tested by instillation of sterile saline through the urethral catheter.
    - Delver specimen. A laparoscopic entrapment sac is introduced by the assistant through the 12 mm assistant trocar; the specimen is placed in the sac and removed from an incision extended medially (to avoid injury to the inferior epigastric vessels) from the lower quadrant port site to form either a Gibson or Pfannensteil incision (more cosmetic).
      - Gibson: 3 cm above and parallel to the inguinal ligament.§
      - Pfannenstiel: transverse lower abdominal incision, superior to the pubic ridge. Dissection is made through the skin and subcutaneous fat; the anterior rectus sheath is divided transversely. The rectus muscle is open vertically in the midline sparing the muscle fibers from being divided. The peritoneum is then entered through a vertical incision. Be careful of branches from the inferior epigastric branches as well as the superficial epigastric.§
      - Care must be taken to make a large enough incision to prevent disruption of the specimen; this enables proper histopathological examination.
    - Undock robot.
    - Closure. All 12-mm incisions are closed with 0-Vicryl suture by using the Carter-Thomason device (Inlet Medical Inc., Eden Prairie, MN, USA).

Complications

Intra-operative
- Bleeding
- Injury to adjacent organ (bowel, diaphragm, liver, spleen, pancreas)
Early post-operative
- Infection
- Urine leak
- Re-operation due to
  - Bleeding
  - Wound dehiscence
Late post-operative
- Incisional hernia

References

Caputo, Peter A., et al. "Robotic‐assisted laparoscopic nephrectomy." Journal of surgical oncology 112.7 (2015): 723-727.
Wein AJ, Kavoussi LR, Partin AW, Peters CA (eds): CAMPBELL-WALSH UROLOGY, ed 11. Philadelphia, Elsevier, 2015, chap 58