Department of Urology, First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China.
Department of Urology, Changzheng Hospital, Second Military (Naval) Medical University, Shanghai, China.
Minerva Urol Nephrol. 2021 Jun;73(3):392-400. doi: 10.23736/S2724-6051.20.03711-X. Epub 2020 Apr 10.
Concerns have been raised regarding the management of bladder cuff with these minimally invasive approaches. The aim of this study was to describe a modified radical nephroureterectomy (RNU) with pure retroperitoneoscopic extravesical standardized seeable (PRESS) bladder cuff excision (BCE) and to assess its outcomes based on a novel concept of intraoperative "trifecta."
Twenty-four patients with upper urinary tract urothelial carcinoma underwent retroperitoneoscopic RNU from August 2017 to August 2019. A modified RNU with PRESS BCE and lymph node dissection (LND) was performed. Descriptive analysis of patients' characteristics, surgical technique, perioperative outcomes, and follow-up data was performed. BCE trifecta was defined as en-bloc excision, mucosa-to-mucosa reliable closure and no urine spillage.
In 23 out of 24 cases (95.8%) the procedure was successfully completed. One patient was converted to open distal ureterectomy with a Gibson incision due to peritoneum rupture during dissection of the distal ureter. BCE trifecta was achieved in 95.7% (22/23) cases of all patients finished with PRESS technique. Median OT was 260 min (IQR: 220-305) with median EBL of 100 mL (IQR: 100-250). Median OT for distal ureterectomy was 52 min (IQR: 40-69). No positive surgical margin occurred. Median postoperative hospital stay was 6 d (IQR: 5-7). Median follow-up time was 7 mo (IQR: 5-17). One patient (4.3%) experienced bladder recurrence and no patient developed distant metastasis or died of the disease.
Herein, we demonstrate a standardized retroperitoneoscopic RNU technique that is safe and reproducible, enabling the visual confirmation of complete BCE and facilitating LND. BCE trifecta should be a routine goal in minimally invasive RNU. Prospective comparison with the standard open surgical technique is warranted.
人们对这些微创方法处理膀胱袖套提出了担忧。本研究的目的是描述一种改良的根治性肾输尿管切除术（RNU），采用纯后腹腔镜经膀胱外标准可视（PRESS）膀胱袖套切除术（BCE），并基于术中“三联征”的新概念评估其结果。
2017 年 8 月至 2019 年 8 月，24 例上尿路尿路上皮癌患者接受了后腹腔镜 RNU。采用改良的 RNU 联合 PRESS BCE 和淋巴结清扫（LND）。对患者的特征、手术技术、围手术期结果和随访数据进行描述性分析。BCE 三联征定义为整块切除、黏膜对黏膜可靠闭合且无尿液溢出。
24 例患者中有 23 例（95.8%）手术成功完成。1 例患者因远端输尿管分离时腹膜破裂而转为开放远端输尿管切除术和 Gibson 切口。采用 PRESS 技术完成的 23 例患者中，有 95.7%（22/23）例达到 BCE 三联征。中位手术时间为 260 分钟（IQR：220-305），中位出血量为 100 毫升（IQR：100-250）。远端输尿管切除术的中位手术时间为 52 分钟（IQR：40-69）。无切缘阳性。中位术后住院时间为 6 天（IQR：5-7）。中位随访时间为 7 个月（IQR：5-17）。1 例患者（4.3%）发生膀胱复发，无患者发生远处转移或死于疾病。
本文展示了一种安全且可重复的标准化后腹腔镜 RNU 技术，能够可视化确认完整的 BCE，并有利于 LND。BCE 三联征应成为微创 RNU 的常规目标。需要与标准开放手术技术进行前瞻性比较。
