Technique for lap nephroureterectomy with transvesical open bladder cuff:
- Lateral position a la lap nephrectomy
- Ports as per nephrectomy but remember may need to do more distal/pelvic dissection – ensure arms well away and enough room
- Usual lap nephrectomy, consider early clipping of ureter if renal pelvis tumour for theoretical seeding
- Dissect ureter distally at least past the external iliac vessels
- Flip to supine
- Lower midline incision and develop Retzius, fixed table retraction
- Fill the bladder with water and make vertical cystotomy between stay sutures
- Keep bladder open and incise circumferentially around UO – can suture in a catheter to ureter to aid with traction
- Pull up on ureter and dissect circumferentially through Waldeyer’s sheath until free from detrusor and mobile with proximal dissection – pull ureter back through with specimen
- Close the posterior cystotomy in 2 layers
- Close the anterior cystotomy in 2 layers and leave a drain plus catheter for 2 weeks
If pluck – initial lithotomy, cystoscopy, resectoscope, and encircling of the UO with Collins knife. Score with diathermy around, then develop cranial incision deep until able to push bladder fibres off ureter, then complete dissection circumferentially. Cook the orifice ++ until black char – both prevents seeding and also serves as marker when pulling ureter out. Leave IDC
Open nephroureterectomy – consider if concomitant LND, large ureteric mass with concern for margins, large renal mass with likely desmoplastic reaction.
- 2 incisions – flank and lower midline/Gibson
- Complete nephrectomy through supra-12 or tip of 12 incision, clipping ureter and dissecting as low as possible (?or subcostal)
- Lower midline, develop extraperitoneal space, find ureter (?may have to open peritoneum)
- Distal ureterectomy with open bladder cuff as above
LND?
- EAU suggests template LND improves CSS in patients with T2+ disease
- But says appears to be unnecessary in Ta or T1 disease because of low risk of nodal mets
- “Template based LND should be offered to all patients with high risk UTUC having neph-u”
- In practice – not done unless concern for cN1 or very high risk
- Templates are hilar lymph nodes + para-aortic/para-caval for proximal tumours, and pelvic LND for distal ureteric tumours
Nice table from Hinman’s:
