V06-09: Introduction of supine extraperitoneal laparoscopic nephroureterectomy without patient repositioning
Nephroureterectomy (NUx) with ipsilateral bladder cuff excision is the gold standard treatment for upper urinary tract urothelial carcinoma (UTUC). Despite several advantages of laparoscopic and robotic NUx as a minimally invasive surgery, technical difficulties include patient or port repositioning, management of bladder cuff and lymphadenectomy (LND). Our objective is to introduce a novel technique - supine extraperitoneal laparoscopic nephroureterectomy (SELNUx) - that allows for completion of all of NUx, bladder cuff excision and LND in a complete supine position, without patient repositioning.
Between January 2016 and October 2017, eighteen consecutive patients with UTUC underwent SELNUx performed by a single surgeon. We excluded patients with previous pelvic surgery, invasive tumor (cT3/T4 and/or cN+/M+) or severe hydronephrosis. The patients were placed in the complete supine without tilt position with tucking the contralateral side of arm. The surgeon and the assistants stood on the affected side of the patient. A 4-cm pararectal skin incision was placed just caudal to the anterior superior iliac spine, the extraperitoneal space was developed. We demonstrated a unique port placement that allows for complete access for NUx, bladder cuff excision and concomitant LND. Operative parameters and pathologic data were analyzed.
Median age was 70 (range 49 to 82), mean operative time was 243 minutes (range 194 to 293) and mean estimated blood loss was 67ml (range 50 to 150ml). There were no intraoperative complications, transfusion requirement or open conversion. All of the 18 cases showed urothelial carcinoma. Tumor location was renal pelvis in 10 patients (55%) and ureter in 8 patients (45%). The pathological grade was high grade in 10 patients (55%) and low grade in 8 patients (45%). The pathological stage was pTa in 9 patients (50%), pT1 in 7 patients (39%), pT2 in 1 patient (5.5%), and pT3 in 1 patient (5.5%). The median number of removed lymph nodes was 10, and only one patient had lymph node metastasis.
We describe a novel technique of SELNUx which enables completion of all of Nux, bladder cuff excision and LND without patient repositioning. Our technique is safe and feasible. We believe this approach may become a standard option for patients with UTUC that minimizes surgical invasion and operative time, while maintaining oncological efficacy.