VIDEO/ILLUSTRATED ARTICLE   Open access

Minerva Urology and Nephrology 2021 June;73(3):392-400

DOI: 10.23736/S2724-6051.20.03711-X

Copyright © 2020 THE AUTHORS

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language: English

Pure retroperitoneoscopic extravesical standardized seeable (PRESS) excision of distal ureter and bladder cuff in radical nephroureterectomy: step-by-step technique

Zhenjie WU ^{1, 2}, Mingmin LI ³, Jianchao WANG ², Alessandro VECCIA ^{4, 5}, Yifan XU ², Chao ZHANG ⁶, Jizhong REN ², Lei YIN ², Ming CHEN ², Junkai WANG ², Dongliang XU ², Zongqin ZHANG ², Bing LIU ², Bo YANG ⁶, Liping XIE ¹ ✉, Le QU ⁷, Linhui WANG ²

¹ Department of Urology, First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China; ² Department of Urology, Changzheng Hospital, Second Military (Naval) Medical University, Shanghai, China; ³ Department of Radiology, Changhai Hospital, Second Military (Naval) Medical University, Shanghai, China; ⁴ Division of Urology, Virginia Commonwealth University Health System, Richmond, VA, USA; ⁵ Unit of Urology, Department of Medical and Surgical Specialties, Radiological Science and Public Health, ASST Spedali Civili Hospital, University of Brescia, Italy; ⁶ Department of Urology, Changhai Hospital, Second Military (Naval) Medical University, Shanghai, China; ⁷ Department of Urology, East Region Military Command General Hospital (Jinling Hospital), Clinical School of Medical College, Nanjing University, Nanjing, China

BACKGROUND: 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.”
METHODS: 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.
RESULTS: 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.
CONCLUSIONS: 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.

KEY WORDS: Laparoscopy; Nephroureterectomy; Carcinoma, transitional cell