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Open and Laparoscopic Nephroureterectomy: Technique and Complications

Indications for Nephroureterectomy

• Upper tract urothelial carcinoma
• Non-functioning kidney with vesicoureteral reflux

Contraindications

Coagulation disorders. The further contraindications depend on the surgical risk due to the comorbidity of the patient, the renal function of the contralateral kidney and the impact of the surgical procedure on the life expectancy of the patient. Kidney-sparing surgery is first-choice for low-risk tumors if technically feasible. Kidney-sparing surgery must be considered even for high-risk tumors, if the preservation of kidney function is mandatory for the patient.

Surgical Approaches for Nephroureterectomy

Several different surgical approaches exist for nephroureterectomy, which have not been prospectively tested against each other. In retrospective comparisons, (robotic-assisted) laparoscopy lowers the complication rate and shortens the hospital stay (Hanna et al., 2012). All techniques have in common the surgical removal of the kidney including the perirenal fat, the ureter with bladder cuff and the associated lymph nodes (paracaval/paraaortal/pelvic depending on tumor location).

Preoperative patient preparation:

Perioperative antibiotic prophylaxis, if risk factors for wound infection are present, perioperative indwelling catheter with options for sterile bladder filling, gastric tube, consider epidural anesthesia for open surgery.

Extraperitoneal Pararectal Nephroureterectomy

Surgical approach:

Flank incision from the 11th rib to the suprapubic region in a modified flank position.

Nephrectomy:

The tumor-bearing kidney is removed using an extraperitoneal technique, see section radical nephrectomy with a flank incision. The ureter is ligated early but not transected to avoid tumor cell seeding to the bladder. Aortic, interaortocaval, or caval lymphadenectomy is possible for proximal and mid ureteral carcinoma.

Bladder cuff:

The ureter is mobilized with its surrounding fatty tissue down to the urinary bladder. Ligation and transection of the medial umbilical ligament is helpful before circular incision of the detrusor muscle to dissect the intramural ureter. Place stay sutures to the bladder wall before excising the ureter with the bladder cuff. A combined extravesical and intravesical dissection (using a anterior cystotomy) is also possible. Iliac and pelvic lymph nodes are removed for distal ureteral carcinoma.

Transurethral techniques to develop the bladder cuff have been published. However, the irrigation flow with extravasation increases the risk of tumor cell dissemination, and incomplete ureter excision is of concern. Transurethral techniques to minimize the surgical approach are not recommended.

Advantages:

Extraperitoneal procedure. Nephroureterectomy can be performed without transection of the ureter, and dissection of the distal ureter is oncologically safe.

Disadvantages:

Long surgical approach through the abdominal wall muscles.

Transperitoneal Nephroureterectomy

Surgical approach:

Midline incision from the xyphoid to below the umbilicus. Using a transperitoneal approach, the tumor-bearing kidney is removed together with the perirenal fat and regional lymph nodes, see section radical nephrectomy.

Advantages:

Nephroureterectomy can be performed without transection of the ureter, and dissection of the distal ureter is oncologically safe. The approach avoids transection of the abdominal wall muscles over a long distance. Ideal approach for extensive lymphadenectomy.

Disadvantages:

Transperitoneal approach.

Nephroureterectomy With Two Incisions

Nephrectomy is done using a flank incision between the 11th and 12th rib, see section flank incision and extraperitoneal technique described above. The ureter is ligated and transected at the level of the iliac vessels.

Distal ureteral resection and bladder cuff: after wound closure of the flank incision, the patient is turned in the supine position. The distal ureter and bladder cuff are done via a second incision (e.g., Pfannenstiel incision, extraperitoneal lower midline incision, or Gibson incision).

Advantages:

Extraperitoneal approach, less transection of the abdominal wall muscles due to two incisions.

Disadvantages:

Not suitable for ureteral carcinoma in the mid third, as the ureter has to be divided. The patient must be repositioned. Interaortocaval lymphadenectomy is more difficult.

Laparoscopic Nephroureterectomy

Nephrectomy:

See technique of radical laparoscopic nephrectomy. The ureter is clipped early but not transected to avoid tumor cell seeding to the bladder.

Bladder cuff:

Organ retrieval is done via a small oblique pararectal lower abdominal incision, this incision can be used distal ureteral dissection with bladder cuff. Iliac and pelvic lymphadenectomy for distal ureteral carcinoma is also possible with this approach.

Alternatively, laparoscopic dissection of the ureter down to the urinary bladder is possible. Dissection of the ureter with bladder cuff can be performed using a laparoscopic stapler. A small incision is necessary for organ retrieval, morcellation is not advisable.

Transurethral techniques to develop the urinary bladder cuff have been published. However, the irrigation flow with extravasation increases the risk of tumor cell dissemination, and incomplete ureter excision is of concern. Transurethral techniques to minimize the surgical approach are not recommended.

Advantages:

Minimal surgical trauma.

Disadvantages:

Not suitable for advanced tumors with lymph node metastases.

Drains:

Drainage of the pelvic cavity for 1--2 days.

Postoperative Care

General measures:

Early mobilization, intensive respiratory therapy, thrombosis prophylaxis, laboratory tests (hemoglobin, creatinine), regular physical examination of the abdomen and incision wound.

Analgesics:

With a combination of NSAIDs and opioids. A peridural anesthesia facilitates postoperative pain management after open surgery.

Diet advancement:

Remove of the nasogastric tube after surgery. Allow small sips of clear liquids after surgery. Increase amounts of clear liquids and allow yoghurt or pudding on postoperative day 1 and 2. If the patients feels well, allow small amounts of solid food (appetite driven) starting postoperative day 3.

Drains and catheters:

Wound drainage for 1–2 days. Removal of the bladder catheter after 5–7 days (with cystography in difficult cases).

Postoperative intravesical chemotherapy:

Tumor cell seeding during nephroureterectomy can result in urothelial carcinoma recurrence in the bladder. In the randomized ODMIT-C trial, a single postoperative intravesical chemotherapy with mitomycin C before catheter removal reduced the risk by 11% (16% vs. 27%). Number needed to treat is nine (OBrien et al., 2011).

Complications of Nephroureterectomy

See also complications of radical nephrectomy. Additional complications are persistent extravasation or urinoma due to an insufficient bladder cuff closure.

Risk of significant hemorrhage:

The risk of significant blood loss during radical nephrectomy is below 5%; the risk increases up to 35% if a tumor thrombus is present.

Injury of neighboring organs:

Liver injury, spleen injury (risk of splenectomy), paralytic ileus, injury of the bowel, peritonitis, injury of the pancreatic tail with fistula, pneumothorax, chylous fistula due to injury of intestinal lymphatic vessels.

General complications:

Wound infection, heart attack, stroke, heart failure, thrombosis, pulmonary embolism, atelectasis, pneumonia, acute renal failure.

Mortality:

Mortality due to bleeding, cardiovascular diseases, arrhythmia, acute renal failure, and pulmonary embolism is around 2%.

References

Hanna, N.; Sun, M.; Trinh, Q.; Hansen, J.; Bianchi, M.; Montorsi, F.; Shariat, S. F.; Graefen, M.; Perrotte, P. & Karakiewicz, P. I. Propensity-score-matched comparison of perioperative outcomes between open and laparoscopic nephroureterectomy: a national series.
Eur Urol, 2012, 61, 715-721.

O'Brien, T.; Ray, E.; Singh, R.; Coker, B.; Beard, R. & of Urological Surgeons Section of Oncology, B. A. Prevention of bladder tumours after nephroureterectomy for primary upper urinary tract urothelial carcinoma: a prospective, multicentre, randomised clinical trial of a single postoperative intravesical dose of mitomycin C (the ODMIT-C Trial).
Eur Urol, 2011, 60, 703-710.

  Deutsche Version: offen-chirurgische und laparoskopische Nephroureterektomie