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

Background and Purpose: For patients with upper tract transitional-cell car cinoma (TCC), nephroureterectomy with removal of a bladder cuff is the stan dard of care. Historically, it has been performed using two incisions or on e large incision extending from the lateral flank to the symphysis pubis. W e describe an alternative using endoscopic management of the bladder cuff c ombined with hand-assisted laparoscopic (HAL) nephroureterectomy. We compar ed our results using these minimally invasive advances with those of a cont emporary open nephroureterectomy series. Patients and Methods: Between May 1998 and June 1999, we performed II HAL n ephroureterectomies with endoscopic management of the bladder cuff for the treatment of upper tract TCC. The results were compared with those in a con temporary series of 11 patients undergoing the traditional open operation a t our institution. The patient age, male:female ratio, and ASA classificati on were similar in the two groups. Intraoperative measures considered were operative time, estimated blood loss, need for transfusion, complications, specimen weight and volume, pathologic stage and grade of the tumor, and th e status of the surgical margins. Postoperative endpoints were time to sust ained fluid intake; epidural, parenteral, and oral narcotic requirements; l ength of stay; and complications. Follow-up, specifically disease recurrenc e and overall survival, was recorded. Results: The mean operative time was 291 minutes for HAL nu 232 minutes for the open operation (P = NS). The average blood loss was 144 nu 311 mL (P = 0.04), the mean specimen weight 368 nu 392 g (P = NS), and the mean specim en volume was 630 nu 693 cc (P = NS). No patient in the HAL group had a pos itive surgical margin, but one patient in the open surgery group did. The t ime to sustained fluid intake postoperatively averaged 1.4 nu 2.3 days for the HAL and open groups, respectively (P = NS). The epidural narcotic requi rement was 0 nu 2.7 days (P < 0.001), the mean parenteral narcotic requirem ent was 45 nu 44 mg of morphine sulfate equivalent (P = NS), and the oral n arcotic requirement was 5.8 nu 16 tablets (P < 0.04). The average length of stay was 4.6 days for the HAL group <nu> 6.1 days for the open group (P = 0.04). In both groups, 7 of the 11 patients (63%) were without evidence of disease with a mean follow-up of 13 (HAL) and 17 (open) months. Conclusions: Hand-assisted laparoscopic nephroureterectomy with endoscopic management of the bladder cuff is an efficacious alternative to open surger y. The operative time, specimen weight and size, and risk of recurrence for the two procedures are similar. However, convalescence, as measured by pai n medication requirements and length of stay, is significantly better with laparoscopy. Longer follow-up with larger numbers of patients is in progres s.