Editing Nephroureterectomy (section)

== 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]