Laparoscopic radical nephroureterectomy for upper tract transitional cell carcinoma: The Cleveland Clinic experience

Purpose: We report our single institutional experience with retroperitoneal laparoscopic radical nephroureterectomy in patients with upper tract trans itional cell carcinoma and compare results to those achieved by the open te chnique. Materials and Methods: A total of 77 patients underwent radical nephrourete rectomy for pathologically confirmed upper tract transitional cell carcinom a. Of these patients 42 underwent laparoscopic nephroureterectomy from Sept ember 1997 through January 2000 and 35 underwent open surgery. All specimen s were extracted intact. Of the laparoscopic group the juxtavesical ureter and bladder cuff were excised by our novel transvesical needlescopic techni que in 27 and radical nephrectomy was performed retroperitoneoscopically in all 42. Data were compared retrospectively with 35 patients undergoing ope n radical nephroureterectomy fi om February 1991 through December 1999. Results: Laparoscopy was superior in regard to surgical time (3.7 versus 4. 7 hours, p = 0.003), blood loss (242 versus 696 cc, p <0.0001), specimen we ight (559 versus 388 gm., p = 0.04), resumption of oral intake (1.6 versus 3.2 days, p = 0.0004), narcotic analgesia requirements (26 versus 228 mg., p <0.0001), hospital stay (2.3 versus 6.6 days, p <0.0001), normal activiti es (4.7 versus 8.2 weeks, p = 0.002) and convalescence (8 versus 14.1 weeks , p = 0.007). Complications occurred in 5 patients (12%) in the laparoscopi c group, including open conversions in 2, and in 10 (29%) in the open group (p = 0.07). Followup was shorter in the laparoscopic group (11.1 versus 34 .4 months, p <0.0001). The 2 groups were similar in regard to bladder recur rence (23% versus 37%, p = 0.42), local retroperitoneal or port site recurr ence (0% versus 0%) and metastatic disease (8.6% versus 13%, p = 1.00). Mor tality occurred in 2 patients (6%) in the laparoscopic group and 9 (30%) in the open group. Cancer specific survival (97% versus 87%) and crude surviv al (97% versus 94%) were similar between both groups (p = 0.59). Conclusions: In patients with upper tract transitional cell carcinoma who a re candidates for radical nephroureterectomy the retroperitoneal laparoscop ic approach satisfactorily duplicates established technical principles of t raditional open oncological surgery, while significantly decreasing morbidi ty from this major procedure. Short-term oncological and survival data of t he laparoscopic technique are comparable to open surgery. Although long-ter m followup data are not yet available, it appears that laparoscopic radical nephroureterectomy may supplant open surgery as the standard of care in pa tients with muscle invasive or high grade upper tract transitional cell car cinoma.