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Mentions: The patient is placed in the standard 70° flank position and maintained this posture throughout the entire procedure. The operating table can be rotated from side to side to facilitate exposure during the different steps of the procedure. A 7 cm ipsilateral lower pararectal skin incision is made (Fig. 1). The anterior and posterior fasciae of the rectus muscle are incised, but the peritoneum is left intact. The retroperitoneal working space is entered by blunt finger dissection. The left hand of the surgeon (in left retroperitoneoscopic nephroureterectomy) or of the assistant (in right retroperitoneoscopic nephroureterectomy) is inserted into the retroperitoneal space (Fig. 2). Balloon dissection can be performed through the pararectal incision if more space is required. The first 10-mm port for the 30° laparoscope is inserted in the mid-axillary line at umbilicus level under the guidance of the left index finger. The pararectal incision is closed in watertight manner with a running 1-0 Vicryl suture. A 10-mm and a 5-mm trocar are placed in the anterior and posterior axillary lines at the umbilicus level under direct laparoscopic vision. Initially, distal ureter and bladder cuff are identified, dissected from the fatty tissue and clipped at the level of the pelvic brim to prevent possible seeding of tumor cells. Then the kidney and Gerota's fascia are dissected en bloc. The kidney is identified and the peritoneal attachments are resected. The ipsilateral adrenal gland is conserved. After circumferentially mobilizing the kidney, except for the renal pedicle, the pararectal incision is reopened and the left hand of the surgeon or of the assistant is inserted into the retroperitoneal space without the use of a hand-assisted device. After renal pedicle is identified by arterial pulsation, renal artery and vein are isolated. The renal artery is circumferentially mobilized, clipped, and divided, with 2 clips on the vascular stump and 1 on the renal side. The renal vein is then secured and simultaneously transected with a vascular endo-gastrointestinal anastomosis device (United States Surgical Corp., Norwalk, CT, U.S.A.). Subsequently, the ureter is dissected as far as possible towards the pelvis with the aid of a manual blunt dissection to ensure that the cut edge of the distal ureter is removed. Without repositioning, the operating table is tilted towards the ipsilateral side, for make 30° flank position to provide a better view of the distal ureter. In this position, open distal ureterectomy and bladder cuff resection can be done in the usual manner. At the end of the laparoscopic procedure, the entire nephroureterectomy specimen is removed en bloc via the hand assistance incision without opening the urinary tract. The entire procedure is performed completely retroperitoneally, without transgressing the peritoneal cavity.
Hand-Assisted Retroperitoneoscopic Nephroureterectomy without Hand-assisted Device
Bottom Line: Complication did not occur and conversion to open surgery was not necessary in all cases.At the average follow-up of 8.1 months, no regional recurrence, port-site metastasis, bladder recurrence, or distant metastasis were noted in any patient.We described our initial experience with the described technique, which obviates the need for midprocedural patient repositioning.
Affiliation: Department of Urology, Kon-Kuk University College of Medicine, Seoul, Korea.
Various laparoscopic nephroureterectomy techniques for urothelial carcinoma of the upper urinary tract have been developed to minimize postoperative discomfort and the necessity for a lengthy convalescence. We performed hand-assisted retroperitoneoscopic nephroureterectomy without hand-assisted device in 3 male patients with urothelial carcinoma of the distal ureter. Average operative time and estimated blood loss were 251 min (range 235 to 280) and 250 mL (range 200 to 300), respectively. Complication did not occur and conversion to open surgery was not necessary in all cases. Postoperative analgesic requirements were moderate and the time to regular diet intake averaged 3 days (range 2 to 4). None of the patients had a positive margin on the final pathologic specimen. At the average follow-up of 8.1 months, no regional recurrence, port-site metastasis, bladder recurrence, or distant metastasis were noted in any patient. We described our initial experience with the described technique, which obviates the need for midprocedural patient repositioning.
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