Urology Department, Krankenhaus Elisabethinen, Linz, Austria.
J Endourol. 2010 Mar;24(3):415-9. doi: 10.1089/end.2009.0189.
The dilemma in management of the distal ureter and bladder cuff during nephroureterectomy (NU) for transitional-cell carcinoma (TCC) of the upper urinary tract has delayed the development of a completely minimally invasive approach to NU in cases of TCC. Our aim is to present our technique of a purely laparoscopic nephroureterectomy performed entirely through laparoscopic ports, which mimics established principles of open surgical nephroureterectomy with bladder cuff excision. Precluding the needed for patient repositioning, complex endoscopic procedures either before or after nephrectomy and leaving the bladder cuff defect to heal spontaneously.
Patient positioning and trocar arrangement are similar to those of radical nephrectomy. The simple addition of a 5 mm trocar in the lower abdomen (midline or lateral to the rectus muscle, according to patient build) allows the surgeon to adequately dissect the distal ureter, excise an adequate bladder cuff, and suture the bladder defect in a watertight manner without the need for transurethral and intraureteral instrumentation as well as intraoperative repositioning of the patient.
Eight cases were successfully treated. The operative time ranged from 110 to 200 minutes (mean 157 min). The median time for catheter removal was 7 days; in one patient, catheter removal was delayed to 15 days because of bladder extravasation. Average hospital stay was 10.2 days. During a mean follow-up of 12.1 months, three patients had Ta bladder recurrence, and one patient had local recurrence.
A complete NU with bladder cuff excision can be accomplished using this approach, with early results comparable to the gold standard of open surgery with the simple addition of a trocar.
在上尿路移行细胞癌（TCC）的肾输尿管切除术（NU）中，处理远端输尿管和膀胱袖套时面临的困境延迟了完全微创 NU 技术的发展。我们旨在介绍一种完全通过腹腔镜端口进行的单纯腹腔镜肾输尿管切除术技术，该技术模仿了开放式外科 NU 切除膀胱袖套的既定原则。该技术无需患者重新定位，也不需要在肾切除术前或术后进行复杂的内镜操作，并且可以让膀胱袖套缺陷自然愈合。
患者的体位和套管的布置类似于根治性肾切除术。只需在下腹部（根据患者体型，在中线或腹直肌外侧）增加一个 5mm 的套管，即可让外科医生充分解剖远端输尿管，切除足够的膀胱袖套，并以防水方式缝合膀胱缺陷，而无需进行经尿道和经输尿管器械操作，也无需术中重新定位患者。
8 例患者成功治疗。手术时间为 110-200 分钟（平均 157 分钟）。中位拔除导尿管时间为 7 天；1 例患者因膀胱漏尿而延迟至 15 天拔除导尿管。平均住院时间为 10.2 天。在平均 12.1 个月的随访中，3 例患者有 Ta 期膀胱复发，1 例患者有局部复发。
通过这种方法可以完成完整的 NU 切除膀胱袖套，其早期结果与开放式手术的金标准相当，仅需增加一个套管。
