Category: Laparoscopy: Upper Tract - Malignant

VS14-7 - En-bloc laparoscopic nephroureterectomy without bladder opening

Sun, Sep 23
10:00 AM - 12:00 PM

Introduction & Objective : To present our technique of lapraoscopic nephroureterctomy without bladder opening for the distal removal of the ureter.


Methods :

Patient lies on the controlateral flank. Penumoperitoneum is induced by Hasson trocar with an open access. 2 to 3 other trocars are inserted to perform the nephrectomy. Peritoneum is opened along the parietocolic recess from upper pole fo the kidney to iliac vas. Ureter is identified and isolated up to the iliac cross. Following the ureter the lower pole of the kidney is then mobilized and the vascular pedicle of the kidney identified. Artery and vein are then isolated and clipped. Artery is clipped with 3 Hem-o-lock clips, whilst vien is either clipped with Hem-o-lock or sutured with vascular stapler. The kindey is then freed from his attachments and the adrenal gland is spared. The kidney is the placed in a laparoscopic bag. Trocar are removed and patient position is changed. With supine patient, Hasson's trocar is reinserted and 2 other trocars are placed. Ureter is identified. Isolation and progressive suspension is then carried out from iliac cross to bladder. Once the intramural tract is reached the lateral aspect fo the bladder is freed to allow its manipulation. Ureter is then grasped and suspended with a Forceps to appreciate the intramural tract. A vascular stapler is the placed and closed over the intramural portion of the ureter on the bladder wall to allow either complete detachment of the ureter and baldder integrity without urine spillage in the pelvis. The ureter detached is then allocated in the retrieval bag with the kidney. Bladder is then distended with either saline solution or methylene blue to check the bladder wall integrity over the suture line. Two drains are placed, one over the nephrectomy field another in the pelvis. A small abdominal incision is then performed and the specimen removed. 


Results : A total of 33 patients underwnt this type of surgery. No significant complication (Clavien > II) were observed in the perioperative. One patient developed a penumonia in the post-operative and was treated with antibiotics. Patients were discharged home after a median of 5 days without catheter, after a voiding cystourethrogram showing no leakage.


Conclusions :

This technique:
1. avoid any leakage of urine in the pelvis during the surgery, eventually reducing the risk of tumor spillage during the ureter detachment manoeuvres particularly in those cases where a small TCC is found in the bladder and resected at the same time.
2. avoid the need of a bladder wall suture with time saving and reduced risk of post-operative urine leakage 

Carlo Luigi Augusto Negro

Consultant Urologic Surgeon
Dept. of Urology - Ospedale Cardinal Massaia - ASL AT
Asti, Piemonte, Italy

Dr Carlo Luigi Augusto Negro, M.D., Urologic & andrologic Consultant Surgeon, dept. of Urology, Ospedale Cardinal Massaia, ASL AT (Asti - Italy).

Giovanna Berta

Consultant Urologic Surgeon
Dept. of Urology - Ospedale Cardinal Massaia - ASL AT
Asti, Piemonte, Italy

Francesco Morabito

Consultant Urologic Surgeon
Dept. of Urology - Ospedale Cardinal Massaia - ASL AT
Asti, Piemonte, Italy

Giovanni Zarrelli

Head of the Department and Consultant Urologic Surgeon
Dept. of Urology - Ospedale Cardinal Massaia - ASL AT
Asti, Piemonte, Italy