Nephroureterectomy with excision of a cuff of bladder is the typical surgical approach for carcinoma of the renal pelvis or ureter. However, conservative surgery may be indicated in those patients diagnosed with a small, solitary, well-differentiated papillary tumor. Most of the cases of ureteral tumors involve at least the musculature and in addition there is a high incidence of multiple ipsilateral tumors.
During a nephroureterectomy the choice of incision, approac and the extent of surgery should be decided to perform a lymph node dissection, excision of bladder cuff and distal ureter.
Two-Incision Approach
An intrathoracic, extrapleural, extraperitoneal approach, removing the kidney within Gerota’s fascia without removing the adrenal gland, is a preferred procedure. In order to gain proper exposure, a tenth interspace or supra-11th-rib incision is generally utilized. The patient is placed in a modified flank position with the table flexed and the kidney rest elevated. The patient is taped into position with wide adhesive tape and an arm rest is utilized. The patient is adequately padded with an axillary roll, pillows and sheets and is prepped and draped from nipples to the symphysis pubis in the usual sterile fashion.
The 11th rib and the tenth intercostal space are identified and a supra-11th-rib incision is made in the tenth intercostal space. A self-retaining retractor is placed into the wound for optimal exposure. A Balfour or Finochietto retractor may be used, but a multibladed ring retractor that is secured to the operating table such as a Buckwalter retractor is preferable. The renal mass within Gerota’s fascia is rotated medially and the dissection is carried posteriorly off the psoas and quadratus musculature. The iliohypogastric and ilioinguinal nerves and 12th thoracic neurovascular bundle can usually be identified .
The colon is then held medially and superiorly, an avascular plane between the colonic mesocolon and Gerota’s fascia is developed and the renal mass is sharply separated from the peritoneum. By use of sharp and blunt dissection, the superior and inferior aspects of the kidney are dissected free of the adrenal gland and surrounding tissues, respectively. The vessels between the adrenal gland and the kidney will be ligated with ligaclips. The kidney is dissected posteriorly to the level of the renal hilum. Attention is directed to the main renal vessels. The pulsating renal artery is identified by palpation, double ligated as it exits the aorta with 0 silk sutures and then divided.
If there is a large tumor mass on the right side, the artery may be approached anteriorly or in the interaortocaval region. On the left side, the gonadal and adrenal veins are identified anteriorly, as is the renal vein. The gonadal and any lumbar veins are ligated before double ligating the renal vein with a suitable suture. Careful palpation for a second renal artery is important before ligation of the renal vein. The remaining soft tissue attachments to the kidney should be divided so that the only remaining attachment is to the ureter.
Attention is then directed to the inferior aspect of the kidney. The ureter is identified and dissected free to a level distal to the bifurcation of the iliac vessels. The ureter is ligated distally with a 0 silk suture, making sure not to include any surrounding tissue in the ligature. A large straight clip is placed proximally to prevent urine spillage and the ureter is divided. The specimen is then removed.
Transitional-cell carcinoma may spread by direct extension or metastasis by hematogenous or lymphatic routes. Therefore, a regional lymphadenectomy should be performed as part of the surgical procedure. A lymph node dissection is performed by identifying the midline of the aorta for a left-sided tumor and the vena cava for a right-sided tumor. Starting from just cephalad to the renal hilum to the level of the inferior mesenteric artery, the lymphatic tissue is dissected using a “split and roll technique” with ligaclips placed on the lymphatics to avoid a lymphocele.
Hemostasis is obtained using electrocautery. The diaphragm is not repaired if only the lateral attachments have been taken down. If a pleurotomy has been made, a red rubber catheter with additional side holes cut out is placed into the pleural space, and the pleurotomy is closed with a running suture. The kidney rest is lowered, the table is taken out of flexion, and the wound is closed in two layers using a continuous suture . The skin is closed using staples. The pleural cavity is then bubbled out with the red rubber catheter in a basin of saline. When fluid and bubbles cease to emerge from the catheter, it is removed and additional skin staples are applied. Auscultation of the chest at the apex of the lung as well as a chest x-ray should be performed postoperatively to diagnose a pneumothorax. If there are any concerns, a temporary chest tube may be placed.
The patient is taken out of flank position, placed in supine position over the break of the operating room table with the table flexed and prepped and draped in the usual sterile fashion. A Foley catheter is passed into the bladder and the bladder is then filled with 200 to 300 cc of normal saline. A lower midline abdominal incision is made and carried down through the rectus and transversalis fascia. A Balfour retractor is placed. The bladder is identified and opened longitudinally between two laterally placed Vicryl stay sutures. Additional stay sutures are placed at the apex of the incision in the bladder. The ureteral orifices are identified, the bladder is packed with several sponges and the bladder blade is placed in the dome of the bladder. A feeding tube is placed in the ipsilateral ureteral orifice and sewn in place with a chromic suture. The ureteral orifice is circumscribed sharply, including a 1-cm cuff of bladder. The ureter is dissected from its orifice using a pinpoint electrocautery and sharp dissecting scissors .
A Davol drain is placed in the pelvis and secured with a nylon suture. The abdomen is closed with a continuous suture. The skin is closed with staples.
Surgery takes approximately 3-4 hours and the hospital stay is usually one to two days. Full recovery usually takes two to three weeks.
Advantages of Laparoscopic Nephroureterectomy include:
The other Urology Procedures are:
Few Major Hospitals for Nephroureterectomy & Bladder Cuff Excision are:
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