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Laparoscopic Nephroureterectomy: Step-by-Sep Technique and Complications

Indications for Nephroureterectomy

• Upper tract urothelial carcinoma
• Non-functioning kidney with vesicoureteral reflux

Several different surgical approaches exist for nephroureterectomy, which have not been prospectively tested against each other. In retrospective comparisons, (robotic-assisted) laparoscopy lowers the complication rate and shortens the hospital stay (Hanna et al., 2012). All techniques have in common the surgical removal of the kidney, including the perirenal fat, the ureter with bladder cuff, and the associated lymph nodes (paracaval/paraaortal/pelvic, depending on tumor location). Consider laparoscopic nephroureterectomy for smaller tumors or benign indications (Simone et al., 2009).

Contraindications

Coagulation disorders. The further contraindications depend on the surgical risk due to the comorbidity of the patient, the renal function of the contralateral kidney, and the surgical procedure's impact on the patient's life expectancy. Kidney-sparing surgery is the first-choice for low-risk tumors if technically feasible. Kidney-sparing surgery must be considered even for high-risk tumors, if the preservation of kidney function is mandatory for the patient. Consider the open surgical approach for advanced tumors (T3–4) and high-grade tumors (Simone et al., 2009).

Preoperative patient preparation:

Perioperative antibiotic prophylaxis, if risk factors for wound infection are present, perioperative indwelling catheter with options for sterile bladder filling, gastric tube.

Laparoscopic Nephroureterectomy

Nephrectomy:

See technique of radical laparoscopic nephrectomy. The ureter is clipped early but not transected to avoid tumor cell seeding to the bladder.

Bladder cuff:

Organ retrieval is done via a small oblique pararectal lower abdominal incision; this incision can be used for distal ureteral dissection with a bladder cuff. Iliac and pelvic lymphadenectomy for distal ureteral carcinoma is also possible with this approach.

Alternatively, laparoscopic dissection of the ureter to the urinary bladder is possible. Dissection of the ureter with a bladder cuff can be performed using a laparoscopic stapler. A small incision is necessary for organ retrieval, morcellation is not advisable.

Transurethral techniques to develop the urinary bladder cuff have been published. However, the irrigation flow with extravasation increases the risk of tumor cell dissemination, and incomplete ureter excision is of concern. Transurethral techniques to minimize the surgical approach are not recommended.

Advantages:

Minimal surgical trauma.

Disadvantages:

Not suitable for advanced tumors with lymph node metastases.

Drains:

Drainage of the pelvic cavity for 1--2 days.

Postoperative Care

General measures:

Early mobilization, intensive respiratory therapy, thrombosis prophylaxis, laboratory tests (hemoglobin, creatinine), regular physical examination of the abdomen and incision wound.

Analgesics:

With a combination of NSAIDs and opioids.

Diet advancement:

Remove of the nasogastric tube after surgery. Allow small sips of clear liquids after surgery. Increase amounts of clear liquids and allow yoghurt or pudding on postoperative day 1 and 2. If the patients feels well, allow small amounts of solid food (appetite driven) starting postoperative day 3.

Drains and catheters:

Wound drainage for 1–2 days. Removal of the bladder catheter after 5–7 days (with cystography in difficult cases).

Postoperative intravesical chemotherapy:

Tumor cell seeding during nephroureterectomy can result in urothelial carcinoma recurrence in the bladder. In the randomized ODMIT-C trial, a single postoperative intravesical chemotherapy with mitomycin C before catheter removal reduced the risk by 11% (16% vs. 27%). The number needed to treat is nine (OBrien et al., 2011).

Complications of Nephroureterectomy

See also complications of radical nephrectomy. Additional complications are persistent extravasation or urinoma due to an insufficient bladder cuff closure.

Risk of significant hemorrhage:

The risk of significant blood loss during radical nephrectomy is below 5%.

Injury of neighboring organs:

Liver injury, spleen injury (risk of splenectomy), paralytic ileus, bowel injury, peritonitis, pancreatic tail injury with fistula, pneumothorax, and chylous fistula due to injury of intestinal lymphatic vessels.

General complications:

Wound infection, heart attack, stroke, heart failure, thrombosis, pulmonary embolism, atelectasis, pneumonia, acute renal failure.

Mortality:

Mortality due to bleeding, cardiovascular diseases, arrhythmia, acute renal failure, and pulmonary embolism is around 1–2%, with advanced tumor stage being the leading risk factor.

References

Hanna, N.; Sun, M.; Trinh, Q.; Hansen, J.; Bianchi, M.; Montorsi, F.; Shariat, S. F.; Graefen, M.; Perrotte, P. & Karakiewicz, P. I. Propensity-score-matched comparison of perioperative outcomes between open and laparoscopic nephroureterectomy: a national series.
Eur Urol, 2012, 61, 715-721.

O'Brien, T.; Ray, E.; Singh, R.; Coker, B.; Beard, R. & of Urological Surgeons Section of Oncology, B. A. Prevention of bladder tumours after nephroureterectomy for primary upper urinary tract urothelial carcinoma: a prospective, multicentre, randomised clinical trial of a single postoperative intravesical dose of mitomycin C (the ODMIT-C Trial).
Eur Urol, 2011, 60, 703-710.

G. Simone et al., “Laparoscopic versus open nephroureterectomy: perioperative and oncologic outcomes from a randomised prospective study.,” Eur Urol, vol. 56, no. 3, pp. 520–526, 2009, doi: 10.1016/j.eururo.2009.06.013.

  Deutsche Version: offen-chirurgische und laparoskopische Nephroureterektomie