Editing Nephroureterectomy (section)

== 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'''