Full text of DOI:10.1016/S0022-5347(05)67701-4

0022-5347/00/1634-1100/0
®
THE JOURNAL OF UROLOGY
Vol. 163, 1100–1104, April 2000
Copyright © 2000 by AMERICAN UROLOGICAL ASSOCIATION, INC.®
Printed in U.S.A.
LAPAROSCOPIC NEPHROURETERECTOMY FOR UPPER TRACT
TRANSITIONAL CELL CANCER: THE WASHINGTON UNIVERSITY
EXPERIENCE
ARIEH L. SHALHAV, MATTHEW D. DUNN, ANDREW J. PORTIS, ABDELHAMID M. ELBAHNASY,
ELSPETH M. MCDOUGALL* AND RALPH V. CLAYMAN†
From the Division of Urology and Department of Radiology, Mallinckrodt Institute, Washington University School of Medicine, St Louis,
Missouri, and Department of Urology, University of Tanta, Tanta, Egypt
ABSTRACT
Purpose: Laparoscopic nephroureterectomy has only recently been done to treat patients with
upper tract transitional cell carcinoma. We retrospectively evaluated our experience with and
long-term followup of laparoscopic nephroureterectomy, compared our results to those of con-
temporary series of open nephroureterectomy and reviewed the literature.
Materials and Methods: We reviewed the charts of and followed up by telephone 25 patients
who underwent laparoscopic nephroureterectomy between May 1991 and June 1998, and 17
who underwent open nephroureterectomy between March 1990 and January 1997. Demographic,
perioperative and followup data were compared. We performed a MEDLINE search and reviewed
the literature on laparoscopic nephroureterectomy for upper tract transitional cell carcinoma.
Results: Laparoscopic nephroureterectomy required twice the operating time of open
nephroureterectomy (7.7 versus 3.9 hours). However, patients who underwent the laparoscopic
procedure had a 74% decrease in analgesia requirements (37 versus 144 mg. morphine sulfate
equivalent), a 63% shorter hospital stay (3.6 versus 9.6 days) and a 72% more rapid convalescence
(2.8 versus 10 weeks). Subsequent bladder transitional cell carcinoma and overall cancer specific
survival were similar at a mean followup of 2 years. There was no sign of trocar site or peritoneal
seeding after laparoscopic nephroureterectomy.
Conclusions: Although laparoscopic nephroureterectomy is a longer operation, it has the same
efficacy and is better tolerated by patients than open nephroureterectomy for upper tract
transitional cell carcinoma. As operating time decreases due to surgeon experience and the recent
development of hand assisted laparoscopy, laparoscopic nephroureterectomy may soon become
the procedure of choice for the ablative management of upper tract transitional cell carcinoma.
KEY WORDS: carcinoma, transitional cell; kidney; nephrectomy; laparoscopic surgical procedure
Open complete nephroureterectomy with excision of the noma the initial clinical laparoscopic nephroureterectomy
ipsilateral ureteral orifice and a periureteral cuff of bladder was performed at our institution in May 1991, followed by a
is accepted standard operative therapy for most patients series of 10 cases completed in July 1994.6, 7 To date 25
with upper tract transitional cell carcinoma.1 This major patients with upper tract transitional cell carcinoma have
operation involves 1 or 2 long abdominal incisions that cause been treated with laparoscopic nephroureterectomy at our
significant postoperative discomfort and a lengthy convales- institution. We describe our current method of laparoscopic
cence. In recent years minimally invasive, antegrade or ret- nephroureterectomy, retrospectively review our experience
rograde endoscopic management has become an acceptable with and long-term followup of this procedure, compare our
option under highly select circumstances, such as solitary results to those of contemporary series of open nephroureter-
kidney, renal insufficiency, bilateral tumors or when there is ectomy and review the literature on laparoscopic nephroure-
a high anesthetic risk.2 However, minimally invasive man- terectomy for upper tract transitional cell carcinoma.
agement of upper tract tumors remains controversial in pa-
tients with 2 functional intact kidneys even when the tumor
is of low stage and grade.3 In the majority of these patients
PATIENTS AND METHODS
open radical nephroureterectomy remains the standard of
care.
We retrospectively reviewed the charts and followed up
by telephone 25 patients who underwent laparoscopic
nephroureterectomy for upper tract transitional cell carci-
noma between May 1991 and June 1998, and 17 consecutive
patients of a contemporary series who underwent open
nephroureterectomy between March 1990 and January 1997.
Patients underwent laparoscopic or open nephroureterec-
tomy based on surgeon preference at a single institution
where 1 group of surgeons exclusively performed laparo-
Laparoscopic nephrectomy is a recognized form of therapy
for patients with benign renal disease.4 Recently the laparo-
scopic approach has been extended to include the manage-
ment of renal cell cancer by radical or complete nephrecto-
my.5 In an attempt to minimize patient morbidity from open
nephroureterectomy for upper tract transitional cell carci-
Accepted for publication October 7, 1999.
* Financial interest and/or other relationship with Cook Urological scopic and open procedures, respectively. Demographic, peri-
Inc., Applied Medical Resources, Boston Scientific Microvasive, Storz
operative and followup data were recorded and compared.
America Inc. and Ethicon Endo-Surgery Inc.
Statistical analysis was done using Student’s t test and a
commercially available statistical program. We performed a
MEDLINE search using the key words, surgical procedures-
† Financial interest and/or other relationship with Cook Urological
Inc., Applied Medical Resources, Boston Scientific Microvasive, Storz
America Inc., Greenwald, OSI and Ethicon Endo-Surgery Inc.
1100

LAPAROSCOPIC NEPHROURETERECTOMY FOR UPPER TRACT TRANSITIONAL CELL CANCER
1101
laparoscopic, carcinoma-transitional cell, kidney neoplasms drome developed but after it resolved the patient had a fatal
and nephrectomy. Reports on laparoscopic nephroureterec- cardiac arrhythmia on postoperative day 66.
tomy for upper tract transitional cell carcinoma were re-
viewed and summarized.
Radiation cystitis developed in a 68-year-old man (ASA 4)
with a history of prostate carcinoma treated with external
Disease staging, indications and preoperative preparation beam radiation therapy
1
year before laparoscopic
are largely similar for laparoscopic and open nephroureter- nephroureterectomy. Postoperatively the patient had hema-
ectomy. The only exception is that 24 hours before the lapa- turia, clot retention and urine leakage from the bladder sta-
roscopic procedure the patient is placed on a clear liquid diet ple line secondary to clot retention. Cystoscopy and electro-
for 24 hours and given a laxative suppository on the morning coagulation of several bleeding sites failed, necessitating
of surgery to empty the bowel. The details of our 5 to 6-port alum and formalin instillation. Deep venous thrombosis with
transperitoneal technique have been previously reported.8 bilateral lower limb edema then developed, which was
However, it is important to emphasize a few points. In all treated with anticoagulants. Eventually the bladder leak and
cases a pure laparoscopic approach was used with intact lower extremity edema resolved with conservative manage-
removal via an 8 cm. lower midline or subcostal incision at ment, and the patient was discharged home on postoperative
the end of the procedure. Except for 1 patient in whom a day 65.
pluck procedure was performed the distal ureter was man-
Of the open nephroureterectomy group 5 patients had ma-
aged by transurethral ureteral unroofing and electrocoagu- jor complications postoperatively (table 2). Pneumonia and
lation without penetrating the bladder wall just before the acute renal failure in a 73-year-old man (ASA 3) were man-
laparoscopic procedure. The Foley catheter was maintained aged conservatively. The patient was discharged home on
in the bladder 2 to 3 days after laparoscopic nephroureterec- postoperative day 23. In a 64-year-old man (ASA 2) intraop-
tomy, at which time a cystogram was performed to test blad- erative injury to the spleen necessitated transfusion of 3
der cuff closure. When there was no extravasation, the Foley units of blood, although splenectomy was not required. Sub-
catheter was removed.
sequently myocardial infarction was managed conservatively
The postoperative followup protocol included cystoscopy and the patient was discharged home on postoperative day
and urine sampling for cytology every 3 months for 2 years, 13. A 28-year-old woman (ASA 2) with a pleural injury that
every 6 months for 2 years and then annually if no bladder required a chest tube was discharged home on postoperative
tumor recurred. Baseline abdominal computerized tomogra- day 6. Pneumonia and atrial fibrillation in an 83-year-old
phy was done 2 to 3 months postoperatively. Chest x-ray, man (ASA 4) were treated medically, and he was discharged
abdominal computerized tomography and excretory urogra- home on postoperative day 10. A 38-year-old man (ASA 2)
phy were recommended yearly.
received antibiotic treatment for pneumonia and was dis-
charged home on postoperative day 8.
In a patient with a preoperative diagnosis of transitional
cell carcinoma on ureteroscopy the final pathological evalu-
ation revealed multifocal granulomatous inflammation. At
23 months a small bladder lesion was fulgurated but not
biopsied. At 38 months of followup he has no evidence of
disease.
RESULTS
Data were obtained on 25 and 17 patients who underwent
laparoscopic and open nephroureterectomy, respectively.
Body mass index and American Society of Anesthesiologists
(ASA) risk grade were similar in both groups, although lapa-
roscopy group patients tended to be older (table 1). Laparo-
scopic excision of the kidney with the ureter and a bladder
cuff was successful in all except our initial patient, in whom
a 1 cm. ureteral stump remained postoperatively. Patholog-
ical evaluation showed no positive margins or lymph node
metastasis but the final pathology report revealed renal cell
cancer in 1 laparoscopy case.
Total operating time for laparoscopic nephroureterectomy,
including ureteral unroofing and repositioning the patient
from supine to lateral decubitus, was nearly double that of
the open procedure (table 2). On the other hand, estimated
blood loss and hospital stay were more than 50% less, and
postoperative analgesia requirement (morphine sulfate
equivalent), time to oral intake and return to normal activity
were less then a third that of open nephroureterectomy (table
2). When determining average hospital stay, we excluded 2
complicated cases in each group for which stay was more
than 21 days.
At surgery 2 patients had urothelial atypia. One patient
underwent percutaneous resection of the primary tumor be-
fore laparoscopic nephroureterectomy. At 6-month followup
there was bladder recurrence and transurethral bladder tu-
mor resection was done. Pathological evaluation showed a
grade 1, T1 lesion. He subsequently received a course of
bacillus Calmette-Guerin and had no recurrence in the next
5 years. In the other patient ureteroscopic resection of the
tumor before laparoscopic nephroureterectomy demonstrated
grade 1 transitional cell carcinoma. Subsequently a stage Ta
tumor that recurred in the bladder was resected 17 months
later. The patient was doing well until he died of a cardiac
event 50 months after laparoscopic nephroureterectomy.
Pathological evaluation revealed a grade 1 tumor in 7
patients, of whom 4 had no recurrence at an average followup
of 75 months (range 70 to 79). One patient who underwent
transurethral resection of a recurrent stage Ta bladder lesion
at 23 months is doing well at 32 months of followup. One
patient with a grade 1, stage T2 primary tumor had lung
metastases at 7-month followup. Cisplatin, methotrexate and
vinblastine chemotherapy was administered, and there was
no progression at 29 months of followup. He was lost to
followup after October 1997, although at that time chest
x-ray showed no metastatic lesions. The remaining patient
with a grade 1 primary tumor died 2 months after laparo-
scopic nephroureterectomy. In another case the final patho-
logical evaluation revealed renal cell carcinoma.
Of the laparoscopic group 2 patients had major postopera-
tive complications (table 2). Bleeding developed in a 73-year-
old man (ASA 4). Open surgical exploration 7 hours after the
laparoscopic procedure revealed bleeding along the inferior
edge of the adrenal gland. The patient received 13 units of
blood. Postoperatively the adult respiratory distress syn-
TABLE 1. Demographic data
A total of 13 patients who underwent laparoscopic or open
nephroureterectomy had a tumor grade 2 or greater as well
as long-term followup (table 3). Followup was insufficient in
1 and 4 cases in the laparoscopic and open groups, respec-
tively. At a mean cystoscopic followup of 24 months for lapa-
roscopic and 43 months for open nephroureterectomy the rate
of lower tract recurrence was 23% and 54%, respectively
Laparoscopic
Open
p Value
Nephroureterectomy Nephroureterectomy
No. pts.
25
17
11/6
(28–84)
24.8 (17.1–33.6)
(2–4)
No. men/women
Av. age (range)
Av. body mass index
Av. ASA score
14/11
69.7
(50–87)
62
0.08
0.8
0.5
28.4 (20.5–47.3)
2.84 (2–4)
3

1102
LAPAROSCOPIC NEPHROURETERECTOMY FOR UPPER TRACT TRANSITIONAL CELL CANCER
TABLE 2. Operation and convalescence data
Laparoscopic
Nephroureterectomy
Open
Nephroureterectomy
p Value
Av. hrs. ureteral unroofing and stent placement (range)
0.7 (0.25–1.3)
Av. hrs. overall operating time (range)
Av. cc estimated blood loss (range)
Pathological grade/stage
Av. gm. specimen wt. (range)
Av. mg. morphine equivalent (range)
Av. hrs. to oral intake (range)
Av. days hospital stay (range):
All pts.
Excluding major complications
Wks. to normal activity (range)
No. complications (%):
Major
Minor
7.7
199
(4.4–11)
(25–400)
3.9
(2.1–6)
Ͻ0.001
441 (150–1000)
2–4/pT1–pT3
0.002
1–4/pTa–pT3
445 (110–1,350)
380
144
116
(132–895)
(24–365)
(72–288)
0.5
Ͻ0.01
Ͻ0.001
37
23
(0–168)
(6–72)
6.1
3.6
2.8
(2–65)
(2–7)
(1–9)
12
(4–34)
(4–34)
(4–16)
0.108
Ͻ0.001
0.002
9.6
10
2
10
(8)
(40)
5
5
(29)
(29)
TABLE 3. Pathology and followup data
Three patients in the laparoscopic group had distant me-
tastases (table 3). One patient with grade 3, stage T4N1
transitional cell carcinoma had liver metastases 8 months
postoperatively and died 2 months later. In another patient
with grade 4, stage T2 disease ipsilateral pelvic and lung
metastases developed. The remaining patient with a grade 3,
stage T4 lesion had liver metastases.
No patients in the open group had retroperitoneal recur-
rence, although distant metastasis developed in 3 (table 3). A
patient with a grade 4, stage T3N0 distal ureteral tumor died
of diffuse metastatic disease 18 months after surgery. A
patient with a grade 2, stage T1N0 lesion who had liver
metastases at 23 months died a month later. The remaining
patient with grade 2, stage T2Nx disease had bone metasta-
sis 2 months postoperatively. Lung metastases developed
and the patient died 4 months later.
In an effort to try to relate the pathological grade and stage
of upper tract transitional cell carcinoma to the subsequent
development of metastatic disease we divided cases into
low (grade 1, T1; grade 1, T2; grade 2, T1; grade 2, T2),
medium (grade 3, T1; grade 3, T2; grade 4, T1; grade 4,
T2; grade 1, T3; grade 1, T4; grade 2, T3; grade 2, T4) and
high (grade 3, T3; grade 3, T4; grade 4, T3; grade 4, T4) risk
groups for metastatic disease (table 4). However, in our anal-
ysis it was interesting that in each category at least 1 patient
had metastatic disease and the risk of bladder transitional
cell carcinoma was equivalent in all 3 risk categories.
Laparoscopic
Open
Nephroureterectomy
Nephroureterectomy
No. grade 2 disease or
greater
Final pathological grade:
2
3–4
Mos. cystoscopic followup
(range)
No. lower tract recurrences
(%)
No. recurrence location:
Bladder
Urethra
13
13
6
7
8
4
24 (4–77)
43 (23–70)
3
(23)
7
(54)
3
0
4
6
1
3
No. transitional cell Ca
metastasis
(31%)
(23%)
No. metastatic location:
Retroperitoneum
Pelvis
2
1*
1
1*
0
0
0
0
Liver
1
Lung
1†
1†
1
Bone
Diffuse
Wks. to transitional cell Ca
recurrence
76 (28–250)
92 (32–224)
No. crude survival (%)
No. specific survival (%)
10
10
(77)
(77)
9
10
(69)
(77)
* Same patient.
† Same patient.
(table 3). However, at 24 months there were only 4 lower
tract recurrences (24%) in the open group, similar to that in
the laparoscopic group. All of these cases were treated with
transurethral resection.
DISCUSSION
In 1995 we reported what is to our knowledge the initial,
There were 3 cases of retroperitoneal metastases in the completely described series in the peer reviewed literature on
laparoscopic group (table 3). Despite adjuvant chemotherapy laparoscopic nephroureterectomy for transitional cell carci-
for a grade 4, stage T3b tumor that developed 9 months noma of the upper tract.7 Since then, our experience has
postoperatively the patient with metastatic disease died at increased to 25 patients (table 1). To date only 3 series of
12 months. Another patient with grade 3, stage T4 tumor laparoscopic nephroureterectomy for upper tract transitional
invading the adrenal gland and radiation cystitis had recur- cell cancer have been reported and none provides followup
rence in the renal bed at 8 months. He received chemother- beyond 2 years9–11 (table 5). Chung et al described 6 cases,
apy and radiation therapy but died with liver metastases 10 including 1 conversion to open surgery, in which the laparo-
months after surgery. The remaining patient had a grade 4, scopic retroperitoneal approach was used for nephrectomy,
stage T2 tumor. Ipsilateral pelvic and lung metastases were and an open infraumbilical approach for distal ureter and
identified 4 months postoperatively and the patient died at 9 bladder cuff management as well as for intact specimen
months. To date there has been no port site or intraperito- removal.9 They stated that operative time for the laparo-
neal seeding in the laparoscopic group.
scopic part of the procedure was 4.6 hours but unfortunately
TABLE 4. Risk of bladder recurrence and retroperitoneal or distant metastatic disease according to combined pathological grade and stage
Laparoscopic Nephroureterectomy Open Nephroureterectomy
Risk
No. Pts.
Bladder
Retroperitoneal
Distant
No. Pts.
Bladder
Retroperitoneal
Distant
Low
Medium
High
4
2
4
2
1
0
0
1*
2
0
1*
1
5
2
3
3
1
1
0
0
0
1
0
1
* Same patient.

LAPAROSCOPIC NEPHROURETERECTOMY FOR UPPER TRACT TRANSITIONAL CELL CANCER
1103
TABLE 5. Laparoscopic nephroureterectomy literature review of reports on more than 2 patients
References
Chung et al9
Keeley and Tolley10
Salomon et al11
Present Study
No. pts./No. conversions
Approach
6/1
18/3
4
25
Retroperitoneal
Transperitoneal
Retroperitoneal
Transperitoneal
Ureter handling
Specimen removal
Operating time (hrs.)
Estimated blood loss (cc)
Pathological grade/stage
Hospital stay (days)
Convalescence (wks.)
Followup (mos.)
No. Recurrences:
Bladder
Open bladder cuff
Pluck
Open bladder cuff
Intact Gibson
Stapled
Intact infraumbilical
Intact infraumbilical
17 Intact, 8 morcellated
4.6
2.6
3.6
220
7.7
199
Not available
Not available
Not available
Not available
2–3/T2–T3
1–4/Ta–T3
9
5.9
12.6
1
5.5
5.7
3.6
2.8
39
13
7
Not available
Not available
Not available
18
1
2
1
Not available
0
Local
Metastasis
0
1
1
1
3†
3†
0
0
Ipsilateral pelvis and lung metastases in same patient.
did not indicate pathological tumor stage and grade. During staples were visible in the ureteral stump. Cystoscopy 31⁄
2
an average followup of 12.6 months they noted only 1 bladder years after laparoscopic nephroureterectomy showed no
recurrence. They prefer the retroperitoneal approach due to signs of encrustation or infection. Titanium is well tolerated
the hypothesized decrease in bowel injury. Chung et al also in the urinary tract due to its corrosive resistant nature, low
prefer traditional open bladder cuff removal to avoid the risk toxicity, and excellent tissue and fluid biocompatibility.16, 17
of urine leakage and tumor cell implantation in the pelvis, as
reported by others after transurethral resection of the ure- ically we believe that the entrapped specimen may be treated
teral tunnel and plucking the ureter cephalad.12–14
differently for ureteral tumors and when biopsy of a papillary
During the years we have modified our technique. Specif-
Salomon et al used a similar approach to laparoscopic grade I noninvasive renal pelvic tumor is largely excisional.
nephroureterectomy in 4 patients with renal pelvic transi- For ureteral tumors the bladder cuff may be clipped with a 9
tional cell carcinoma.11 To secure the distal ureter and blad- mm. clip to the mouth of the entrapment sack, so that when
der cuff they used the retroperitoneal approach to the kidney the mouth of the sack is delivered onto the abdominal wall
and made a Gibson incision. However, instead of opening the the bladder cuff side of the specimen is delivered simulta-
bladder the cuff was taken from the outside of the bladder neously. The whole ureter may then be pulled from the sack,
using a large right angle clamp, so that the urinary tract was clipped and cut proximally. The ureter is then opened away
never opened. By this method they decreased operating time from the operating table. Provided that the whole ureteral
to 3.6 hours. There was no bladder recurrence and 1 local tumor has been retrieved the remaining kidney is morcel-
recurrence during the average followup of 18 months.
lated via a 12 mm. port site, precluding enlargement of the
Keeley and Tolley reported 18 cases, including 3 conver- port site to 7 to 10 cm. This maneuver holds true for grade 1,
sions to open surgery, in which they used the pluck technique low stage transitional cell carcinoma. In these cases the neck
for the bladder cuff and removed the specimen intact via a of the sack is triple draped, and a high-speed electrical tissue
lower port extension.10 The pluck technique essentially in- morcellator is used to fragment and evacuate the specimen.
volves thorough transurethral resection of the ureteral ori- Urban et al reported that a commercially available laparos-
fice and intramural ureter to allow the distal ureter to be copy sack, which is constructed of a double layer of plastic
easily detached from the bladder after the kidney and prox- and nondistensible nylon, is impermeable and remains so
imal ureter are mobilized. Total operating time was 2.6 even after specimen morcellation.18 Thus, currently our pol-
hours, which is rapid (table 5). Pathological tumor stage and icy is to remove only higher grade or higher stage renal pelvic
grade were not indicated for all of their patients and followup tumors intact because in these cases accurate staging and
was not stated. During followup they observed only 1 bladder grading may lead to effective adjunct chemotherapy.
and 1 retroperitoneal recurrence in a patient with a stage
We observed that the oncological efficacy of laparo-
pT3 ureteral tumor. In 3 patients with mid and/or distal scopic nephroureterectomy is largely equivalent to that of
ureteral tumors the ureter and bladder cuff were managed open nephroureterectomy. In each group cancer specific sur-
through an open lower abdominal incision at the end of vival was similar, metastatic disease was diagnosed within 2
surgery. In obese patients Keeley and Tolley performed hand years of surgery and the lower tract recurrence rate was
assisted laparoscopy via a 7 to 10 cm. incision into which a similar at 24 months of followup (table 3). However, it is
plastic sleeve was placed. This maneuver resulted in an even disconcerting that in our laparoscopic group 3 of the 7 pa-
shorter operating time of less than 2 hours.
tients with grade 4, stages T2 to 4 disease had local retro-
Open nephroureterectomy for upper tract transitional cell peritoneal tumor metastasis. None of the 4 patients with a
carcinoma includes removal of a generous cuff of bladder similar grade of disease who underwent the open procedure
with the ureter. In this regard there have been concerns had evidence of retroperitoneal recurrence. In this regard it
about using titanium staples to secure the bladder cuff in is noteworthy that patients who present with upper tract
laparoscopic nephroureterectomy. However, Figenshau et al transitional cell carcinoma with extension of the disease out-
established that the laparoscopic endoscopic gastrointestinal side of the kidney and/or ureter have a high rate of local
anastomosis tissue stapler reliably secures the bladder recurrence and a median survival of only 6 months. Our only
cuff.15 This technique minimizes the risk of tumor spillage laparoscopic group patient with stage T4 disease died 10
since the bladder cuff just caudal to the ureter is secured and months after surgery.19 Despite the seemingly higher inci-
occluded with 6 rows of titanium staples before it is incised. dence of retroperitoneal recurrence in the laparoscopic group,
Postoperative followup cystography confirmed a watertight the incidence of metastatic disease, and crude and cancer
bladder closure with this technique. To our knowledge nei- specific survivals were similar in each group.
ther animal studies nor clinical reports have indicated any
In addition, in both groups metastatic disease was diag-
problems associated with staples, including our series with nosed within less than 24 months postoperatively. Therefore,
followup of just greater than 7 years. In 1 patient 2 titanium the longer followup in the open group does not necessarily

1104
LAPAROSCOPIC NEPHROURETERECTOMY FOR UPPER TRACT TRANSITIONAL CELL CANCER
suggest that the laparoscopic group will have more meta- is the longer operating time, although our operative approach
static disease at a longer followup. Overall the laparoscopic continues to evolve to address this issue. We recently began to
group had 3 retroperitoneal recurrences and 1 case more take advantage of the incision required for intact specimen
than the open group with metastatic disease. However, 54% removal to allow hand assistance for mobilizing the kidney and
of the laparoscopic group and only 38% of the open group had ureter. We believe that with increasing surgeon experience
grade 3 or 4 disease. Also, the only patient with stage T4 and greater acceptance of hand assisted laparoscopy operating
disease was in the laparoscopic group and he had metastatic time will markedly decrease. When operating time decreases
disease.
and if the question of retroperitoneal seeding is answered sat-
From an efficiency standpoint laparoscopic nephroureter- isfactorily, laparoscopic nephroureterectomy may well become
ectomy was far inferior to open nephroureterectomy. Oper- the procedure of choice for the ablative management of upper
ating time for the laparoscopic procedure was twice as long as tract transitional cell carcinoma.
for open surgery (table 2). Part of the problem in this regard
is the relative lack of surgeon experience with laparoscopic
REFERENCES
nephroureterectomy. As we became more experienced, oper-
1. Cummings, K. B.: Nephroureterectomy: rationale in the man-
agement of transitional cell carcinoma of the upper urinary
tract: Urol Clin N Amer, 7: 569, 1980
2. Blute, M.: Endourology: management of upper tract genitouri-
nary pathology: Curr Prob Urol, 1: 4, 1991
3. Clayman, R. V. and Kavoussi, L. R.: Endosurgical techniques for
the diagnosis and treatment of noncalculous disease of the
ureter and kidney: In: Campbell’s Urology, 6th ed. Edited by
P. C. Walsh, A. B. Retik, T. A. Stamey et al. Philadelphia:
W. B. Saunders, pp. 2231–2303, 1992
4. Eraky, I., el-Kappany, H., Shamaa, M. A. et al: Laparoscopic
nephrectomy: an established routine procedure. J Endourol, 8:
275, 1994
5. Gill, I. S., Clayman, R. V. and McDougall, E. M.: Advances in
urological laparoscopy. J Urol, 154: 1275, 1995
6. Clayman, R. V., Kavoussi, L. R., Figenshau, R. S. et al: Laparo-
scopic nephroureterectomy: initial clinical case report. J Lapa-
roendosc Surg, 1: 343, 1991
7. McDougall, E. M., Clayman, R. V. and Elashry, O.: Laparoscopic
nephroureterectomy for upper tract transitional cell cancer:
the Washington University experience. J Urol, 154: 975, 1995
8. Shalhav, A. L., Elbahnasy, A. M., McDougall, E. M. et al: Lapa-
roscopic nephroureterectomy for upper tract transitional cell
cancer: technical aspects. J Endourol, 12: 345, 1998
9. Chung, H. J., Chiu, A. W., Chen, K. K. et al: Retroperitoneoscopy-
assisted nephroureterectomy for the management of upper tract
urothelial cancer. MIT, 5: 266, 1996
ating time decreased by 21% to 6 hours. In addition, time-
saving maneuvers may be used. Using pluck ureterectomy
with a hand assisted approach Keeley and Tolley achieved an
operating time equivalent to that of open nephroureterec-
tomy.10
Laparoscopic nephroureterectomy had several benefits
over open nephroureterectomy in regard to patient equanim-
ity. Patients lost half as much blood, required 4-fold less
morphine sulfate equivalent for postoperative analgesia, re-
sumed oral intake 6 times more rapidly, were discharged
from the hospital almost 3 times sooner and returned to
normal activity 2 times sooner. In our series the major com-
plication rate was lower for laparoscopic nephroureterectomy
(table 2). Notably there was a higher incidence of pulmonary
complications in the open than in the laparoscopic group (4 of
17 cases or 24% versus 0%). This finding is similar to that
reported by Keeley and Tolley, who noted pulmonary compli-
cations in 19% and 4.5% of patients in the open and laparo-
scopic groups, respectively.10 The difference may correlate
with postoperative pain and splinting due to the subcostal
incision made for the renal portion of 2-incision open
nephroureterectomy as well as with the tendency of patients
treated laparoscopically to hyperventilate to avoid hypercar-
bia.
10. Keeley, F. X., Jr. and Tolley, D. A.: Laparoscopic nephroureter-
ectomy: making management of upper-tract transitional cell
carcinoma entirely minimally invasive. J Endourol, 12: 139,
1998
11. Salomon, L., Hoznek, A., Cicco, A. et al: Retroperitoneoscopic
nephroureterectomy for renal pelvic tumors with a single iliac
incision. J Urol, 161: 541, 1999
CONCLUSIONS
At this time the efficacy of laparoscopic nephroureterec-
tomy for upper tract transitional cell cancer appears to be
similar to that of open nephroureterectomy in regard to blad-
der recurrence, metastatic disease, and crude and cancer
specific survival. While concerns over port site and intraperi- 12. Jones, D. R. and Moisey, C. U.: A cautionary tale of the modified
“pluck” nephroureterectomy. Br J Urol, 71: 486, 1993
13. Hetherington, J. W., Ewing, R. and Philip, N. H.: Modified
nephroureterectomy: a risk of tumour implantation. Br J Urol,
58: 368, 1986
toneal seeding have been voiced and duly noted, to our
knowledge this complication has not developed to date. A
disconcerting point involves the higher incidence of retroper-
itoneal recurrence in the laparoscopic group. Whether this
incidence is due to the laparoscopic approach or the high
grade and stage of disease treated in our series cannot yet be
determined due to our small number of cases and limited
followup. In this regard the importance of the accurate re-
porting of grade and stage, and the need for thorough metic-
ulous followup cannot be overemphasized. Given the small
number of cases of upper tract transitional cell carcinoma, it
is important for investigators interested in laparoscopic
nephroureterectomy to present data in a consistent fashion
to allow the proper pooling of information.
14. Arango, O., Bielsa, O., Carles, J. et al: Massive tumor implan-
tation in the endoscopic resected area in modified nephroure-
terectomy. J Urol, 157: 1983, 1997
15. Figenshau, R. S., Albala, D. M., Clayman, R. V. et al: Laparo-
scopic nephroureterectomy: initial laboratory experience. Min
Invasive Ther, 1: 93, 1991
16. Williams, D. F.: Titanium as a metal for implantation. Part 1:
physical properties. J Med Eng Technol, 1: 195, 1977
17. Williams, D. F.: Titanium as a metal for implantation. Part 2:
biological properties and clinical applications. J Med Eng
Technol, 1: 266, 1977
18. Urban, D. A., Kerbl, K., McDougall, E. M. et al: Organ entrap-
ment and renal morcellation: permeability studies. J Urol,
150: 1792, 1993
Laparoscopic nephroureterectomy provides patients with ob-
vious benefits, including fewer pulmonary complications, less
postoperative discomfort, a shorter hospital stay, a better cos-
metic result and a brief convalescence. The major drawback to
19. Wagle, D. G., More, R. H. and Murphy, G .P.: Primary carcinoma
of the renal pelvis. Cancer, 33: 1642, 1974