How is open radical nephroureterectomy performed for the treatment of urothelial tumors of the renal pelvis and ureters?

Updated: Aug 07, 2020
  • Author: Kyle A Richards, MD, FACS; Chief Editor: Bradley Fields Schwartz, DO, FACS  more...
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Answer

Nephroureterectomy is the standard for large, high-grade tumors of the renal pelvis and proximal ureter that are organ-confined or locally advanced. Nephroureterectomy is also recommended for multifocal, recurrent, low-grade tumors, which are found to be less amenable to ureteroscopic management.

Classically, this procedure involves removal of the kidney, ureter, and bladder cuff via a thoracoabdominal or flank approach, with a separate lower-quadrant Gibson incision. Laparoscopic approaches to the radical nephroureterectomy are now commonplace and offer some postoperative benefits. Open, pure laparoscopy; hand-assisted laparoscopy; and, recently, robotic-assisted laparoscopic nephroureterectomy are the currently employed techniques.

National Surgical Quality Improvement Program (ACS NSQIP) data on nephroureterectomy showed that 69% of cases between 2006 and 2012 were completed with a minimally invasive approach and that perioperative complications were similar for open and minimally invasive techniques. Length of hospital stay, however, was shorter for minimally invasive nephroureterectomy. [45]

In both open and laparoscopic surgeries, care is taken to excise the entire distal ureter and bladder cuff to prevent local recurrence. Excision of the cuff has a survival benefit. [46]

There are multiple effective approaches, [47] as follows:

  • Open excision and repair of cystotomy

  • Endoscopic ”pluck” technique

  • Transurethral resection of the intramural ureter

  • Intussusception technique

Xylinas et al retrospectively compared transvesical, extravesical, and endoscopic methods of bladder cuff excision, and found that  recurrence-free survival, cancer-specific survival, and overall survival were similar with all three approaches. However, the endoscopic approach was associated with a higher risk of subsequent bladder recurrence. The study population included 2681 patients from 24 international centers. [48]

Lymphadenectomy, which generally requires little additional operative time, is performed for staging purposes, and potentially offers a therapeutic benefit.


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