Hand-assisted laparoscopic nephroureterectomy for the treatment of transitional cell carcinoma of the upper urinary tract

Objectives, Nephroureterectomy with removal of the bladder cuff is the stan dard of care for patients with upper tract transitional cell carcinoma. His torically, it has been performed using two separate incisions or one large incision extending from the lateral flank to the symphysis pubis. We descri be an alternative technique using endoscopic and hand-assisted laparoscopic techniques and present our experience. Methods. During the past 18 months, 22 patients at two institutions underwe nt hand-assisted laparoscopic nephroureterectomy. In 19 patients, the dista l ureter and bladder cuff were managed endoscopically. In 3 patients, the d istal ureter and the bladder cuff were removed by an extravesical, laparosc opic technique. The intraoperative parameters assessed included operative t ime, estimated blood loss, specimen weight, surgical margin status, patholo gic grade and stage, and acute complications. Postoperative endpoints inclu ded the time to sustained fluid intake, parenteral narcotic requirement (mi lliequivalents of morphine sulfate), oral narcotic requirement (number of t ablets), length of stay, time until return to normal activity, and rate of tumor recurrence. Results. The average age of our patient population was 65 years (range 42 t o 86), 10 patients were men and 12 were women, and the average American Soc iety of Anesthesiologists classification was 2.2. All but 2 patients had th eir specimens removed en bloc, No intraoperative complications occurred. Th e average operative time was 272 minutes (range 190 to 440), and the averag e blood loss was 180 ml(range 50 to 400); no patient required a transfusion . The mean specimen weight was 457 g (range 190 to 1420). All 22 patients h ad negative surgical margins. Postoperatively, the time to sustained fluid intake averaged 2.1 days (range 1 to 7), the mean parenteral narcotic requi rement was 55 mEq (range 12 to 107.8) of morphine sulfate, the mean oral na rcotic requirement was 5.8 tablets (range 1 to 14), and the average length of stay was 4.1 days (range 3 to 14). One patient developed thrombophlebiti s of the right external jugular vein from a central line and required 2 wee ks of intravenous antibiotics. The mean time to return to normal activity w as 19 days; the mean follow-up was 13 months. Six patients had disease recu rrence: four low-grade, low-stage bladder tumors and two metastatic tumors. All patients were alive at 18 months. Conclusions. Hand-assisted laparoscopic nephroureterectomy with endoscopic management of the bladder cuff is a viable and efficacious alternative to o pen nephroureterectomy. The technique allows the surgeon to perform an en b loc resection of the kidney, ureter, and bladder cuff without compromising oncologic principles. Patients benefit from a decrease in pain and hospital stay and quicker convalescence. Longer follow-up and comparative studies t o standard open techniques are underway. UROLOGY 56: 741-747, 2000. (C) 200 0, Elsevier Science Inc.