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Minerva Urologica e Nefrologica 2020 Apr 10

DOI: 10.23736/S0393-2249.20.03711-X


lingua: Inglese

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

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

BACKGROUND: Concerns have been raised in regard to the management of bladder cuff with these minimally invasive approaches. This study is 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 Aug 2017 to Aug 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: Laparoscopic radical nephroureterectomy; Bladder cuff excision; Upper tract urothelial carcinoma (UTUC)

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