SLIDES & TRANSCRIPTS
Saturday, December 6, 2003

Laparoscopic Management of Upper Tract TCC

Howard Winfield, M.D.

As you know, this is not an overly frequent tumor, but certainly enough that we have to deal with it, in hopefully a minimally invasive fashion. The traditional approach is en bloc removal of the kidney, ureter, ipsilateral ureteric orifice and a bladder cuff.

TOP

If we are going to approach this laparoscopically, we need to make some decisions. I have highlighted my preference in the yellow. We have to decide, are we going to approach this trans peritoneally or retro peritoneally, are you going to do it pure laparoscopically or use some type of hand assistance, and how are you going to handle the distal ureter and bladder cuff. This is where there is a lot of controversy. And are you going to do this first or last, at the end of the nephrectomy portion, and how are you going to remove the specimen, or are you going to morcelate.

TOP

As far as the approach, this is pretty much how I position the patient, in a semi-flat position, at about 70 degrees. The patient is supported with a beanbag or other type of support. I make sure that the extremities are very well padded.

TOP

I'm not going to review the steps of the laparoscopic nephrectomy. Thee are approximately seven or eight steps.

TOP

The important thing to remember is access. If I am going in trans peritoneally, I will generally place the Varis needle in the upper quadrant, the ipsilateral upper quadrant, which generally will give me a good pneumo peritoneum.

TOP

Port placement. On the right side I will generally use four ports, and then I generally place a fifth port for retracting the liver.

TOP

I found this snake retractor, which I then attach to an endo holder, excellent for holding up the liver. Generally on the left side it is not necessary to hold back the spleen. Usually with dissection it will fall over supro medially.

TOP

As far as handling the renal hilum, I am pretty choosy about the type of clips that I use. I generally will use these wet clips on the renal artery. Usually two of these wet clips are sufficient.

TOP

Handling the renal vein. I generally try and avoid placing clips like this on the tributaries of the renal vein. The reason is that when I place my endo GIA stapler, I don't want the stapler to get caught up with the clip. So generally, these branches I will hand with bipolar electro cautery, followed by harmonic shears, and that generally seals those tributaries very well.

TOP

Now, the tricky part is, how are you going to handle the distal ureter and the bladder cuff. In the vast majority of cases, you are going to be removing the specimen intact. So it would seem reasonable to make a low Pfannestiel incision to place either a hand device or perhaps just your hand alone, in order to assist you in dissecting out the distal ureter. This is in fact what we are doing here. We have actually got our hand in without a device. Generally your forearm is sufficient for occluding the opening and maintain a good pneumo peritoneum. Generally with finger dissection, you can get right down to the bladder itself.

TOP

If I am going to be using a hand device, I generally prefer this lap disk made by Ethicon.

TOP

Once you have dissected the ureter down to the bladder, you can generally tell that you are down to the detrusor muscle. I will then take an endo GI stapler across it, and staple it. If you followed it far enough down, when you look into the bladder, you may see some staples just below the mucosa.

TOP

Because you have made a low Pfannestiel incision, we generally will bring it out intact. It is really not a wise idea to morcelate these types of tumors. There have been a number of concerns about tumor spillage and more importantly, recurrence and port site recurrences.

TOP

The controversy revolves around how to handle the bladder cuff. There are different techniques that have been described, pluck technique, ureteral intussusception or unroofing electrocoagulation, the needloscopic technique, and so on.

TOP

The pluck technique was actually done at the beginning of the procedure, where the surgeon goes in and circumscribes around the ureteric orifice, then does the nephrectomy and then plucks the ureter out at the end of the case. I think that this has definitely been associated with at least three or four cases of recurrence, so I would not advise this technique.

TOP

The technique that I have used in the past is unroofing. At the end of the nephrectomy, I have taken the specimen out intact, and I have positioned the patient dorsal lithotomy, and then take a Collins knife -- basically we incise the intramural portion of the ureter back to fat, extensively fulgurate the surrounding mucosa, basically destroying the whole area around the ureteral orifice, place a Foley catheter for about one week or so, and then do a cystogram. I'm sorry this is not transmitting, this video.

Just so you get an idea of what we actually do here, we take a Collins knife, and we are basically destroying the whole intramural portion. If you have actually got your stapler from the laparoscopic portion down, often you are running into staples at this point. This whole area is extensively fulgurated and destroyed, and then we follow that with a roller ball and destroy that whole area.

TOP

Another option is the needlescopic technique that was developed by Andy Gill at the Cleveland Clinic. This seems like a bit of a complicated procedure, where they place two needlescopic ports into the bladder, and then cystoscopically come into the ureteral stent. They have got this endo loop,

TOP

then they resect around the intramural portion. They tighten up this endo loop around the ureter, and basically take it back, as perhaps you would do for a re-implant,

TOP

A technique that I have found kind of interesting and have tried in a few cases is this trans-vesicle bladder cuff technique. Since I have my hand in at the end of the procedure to remove the specimen, I can place my hand behind the bladder and then place a trocar directly into the bladder so that it is actually extra peritoneal. Through that trocar then we place a resectoscope,

TOP

and resect around the ureteric orifice. This seems like a pretty reasonable way of handling the bladder cuff and distal ureter.

TOP

But certainly the open bladder cuff incision makes sense.

If you have already got an incision, it would seem reasonable to go ahead and just complete the distal ureter and bladder cuff. So certainly if there is a situation where you are dealing with distal ureteral tumor, that would be my preference.

TOP

This is a typical patient after a nephroureterectomy, four ports here and then a low Pfannestiel incision, which certainly looks a little better than the large one incision that you would have to require for an open approach.

TOP

Again, tumors in the distal ureter we approach very cautiously. What is critical is the bladder cuff management. You obviously want to minimize urine leakage, and consider open excision.

TOP

As far as the results are concerned, what I tried to do is look at comparative studies, open versus laparoscopic nephroureterectomy. There is not a tremendous amount in the literature..

TOP

From what you can see here, certainly it takes longer to do a laparoscopic approach, but with practice and experience, this time dramatically drops down

TOP

Blood loss, a postoperative characteristic, certainly is in favor of the laparoscopic approach.

TOP

Analgesic requirement is significantly better with the laparoscopic approach, and these patients get back to normal activities much more quickly compared to the open approach.

TOP

As far as complications are concerned, it is certainly not any more with the laparoscopic approach. If anything, I think it is probably better with the laparoscopic approach compared to open nephrectomy.

TOP

What I have tried to do here now is look at the actual oncologic effectiveness, comparative studies of laparoscopic nephroureterectomy to open nephroureterectomy. What you can see here is that certainly oncologically, as far as bladder recurrences or non-bladder recurrences, it is pretty comparable. In fact, there may be a slight advantage with the laparoscopic approach, but certainly the followup is not there yet.

TOP

Looking at some of the financial aspects of doing an open versus laparoscopic nephroureterectomy. Early on, the intraoperative costs are quite high. As the time comes down, this cost comes down also. No matter how you do it, the laparoscopic equipment is more expensive than the open approach, but postoperatively is really where the big gain is. After you have done a number of these cases laparoscopically, you may be saving some money.

TOP

So in conclusion, there is no question that the laparoscopic approach will initially have longer operating times. I think a hand assisted device is reasonable. What really is in controversy at this point is how to handle the intramural ureter, but postoperatively these patients do very well. I think financially and oncologically, it is very comparable to the open approach.

TOP

Thank you.

TOP