Name: technical modification of the terminal ureter during total transperitoneal laparoscopic nephroureterectomy for upper urinary tract urothelial carcinoma
Uploaded: 2019-11-22T14:00:00
Description: Watch this Scientific Journal Video about Technical Modification of the Terminal Ureter During Total Transperitoneal Laparoscopic Nephroureterectomy for Upper Urinary Tract Urothelial Carcinoma at JoV

This study was sponsored by CAMS Innovation Fund for Medical Sciences,No. 2018-I2M-1-002.

All methods described here have been approved by the ethics committee of the Beijing Hospital. Indications and contraindications for surgery are according to the European Association of Urology guidelines for upper urinary tract urothelial cell carcinoma.
1. Instruments for Operation
<ol>
	<li>Ensure the availability of the laparoscopic imaging system, images of the pneumoperitoneum, and ultrasonic scalpel.</li>
</ol>
2. Preparation for Operation
<ol>
	<li>Prepare t...

<ol>
	<li>Roupret, M., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=European+guidelines+for+the+diagnosis+and+management+of+upper+urinary+tract+urothelial+cell+carcinomas:+2011+update.">European guidelines for the diagnosis and management of upper urinary tract urothelial cell carcinomas: 2011 update.</a> European Urology. 59 (4), 584-594 (2011).</li><li>Ristau, B. T., Tomaszewski, J. J., Ost, M. C. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Upper+Tract+Urothelial+Carcinoma:+Current+Treatment+and+Outcomes.">Upper Tract Urothelial Carcinoma: Current Treatment and Outcomes.</a> Urology. 79 (4), 749-756 (2012).</li><li>Ni, S., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Laparoscopic+Versus+Open+Nephroureterectomy+for+the+Treatment+of+Upper+Urinary+Tract+Urothelial+Carcinoma:+A+Systematic+Review+and+Cumulative+Analysis+of+Comparative+Studies.">Laparoscopic Versus Open Nephroureterectomy for the Treatment of Upper Urinary Tract Urothelial Carcinoma: A Systematic Review and Cumulative Analysis of Comparative Studies.</a> European Urology. 61 (6), 1142-1153 (2012).</li><li>Ghazi, A., Shefler, A., Gruell, M., Zimmermann, R., Janetschek, G. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=A+Novel+Approach+for+a+Complete+Laparoscopic+Nephroureterectomy+with+Bladder+Cuff+Excision.">A Novel Approach for a Complete Laparoscopic Nephroureterectomy with Bladder Cuff Excision.</a> Journal of Endourology. 24 (3), 415 (2010).</li><li>Hiroshi, K., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Comparison+of+Laparoscopic,+Hand-Assisted,+and+Open+Surgical+Nephroureterectomy.">Comparison of Laparoscopic, Hand-Assisted, and Open Surgical Nephroureterectomy.</a> Journal of the Society of Laparoendoscopic Surgeons. 18 (2), 288-293 (2014).</li><li>Ni, S., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Laparoscopic+Versus+Open+Nephroureterectomy+for+the+Treatment+of+Upper+Urinary+Tract+Urothelial+Carcinoma:+A+Systematic+Review+and+Cumulative+Analysis+of+Comparative+Studies.">Laparoscopic Versus Open Nephroureterectomy for the Treatment of Upper Urinary Tract Urothelial Carcinoma: A Systematic Review and Cumulative Analysis of Comparative Studies.</a> European Urology. 61 (6), 1142-1153 (2012).</li><li>Seisen, T., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=A+Systematic+Review+and+Meta-analysis+of+Clinicopathologic+Factors+Linked+to+Intravesical+Recurrence+After+Radical+Nephroureterectomy+to+Treat+Upper+Tract+Urothelial+Carcinoma.">A Systematic Review and Meta-analysis of Clinicopathologic Factors Linked to Intravesical Recurrence After Radical Nephroureterectomy to Treat Upper Tract Urothelial Carcinoma.</a> Journal of Urology. 67 (6), 1122-1133 (2015).</li><li>Michael, M. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Long-term+oncologic+outcome+after+laparoscopic+radical+nephroureterectomy+for+upper+tract+transitional+cell+carcinoma.">Long-term oncologic outcome after laparoscopic radical nephroureterectomy for upper tract transitional cell carcinoma.</a> European Urology. 6 (51), (2007).</li><li>Terakawa, T. T. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Retroperitoneoscopic+nephroureterectomy+for+upper+urinary+tract+cancer:+a+comparative+study+with+conventional+open+retroperitoneal+nephroureterectomy.">Retroperitoneoscopic nephroureterectomy for upper urinary tract cancer: a comparative study with conventional open retroperitoneal nephroureterectomy.</a> Journal of Endourology. 22 (8), 1693-1699 (2008).</li><li>Gkougkousis, E. G., Mellon, J. K., Griffiths, T. R. L. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Management+of+the+Distal+Ureter+during+Nephroureterectomy+for+Upper+Urinary+Tract+Transitional+Cell+Carcinoma:+A+Review.">Management of the Distal Ureter during Nephroureterectomy for Upper Urinary Tract Transitional Cell Carcinoma: A Review.</a> Urologia Internationalis. 85 (3), 249-256 (2010).</li><li>Li, C. C., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Significant+Predictive+Factors+for+Prognosis+of+Primary+Upper+Urinary+Tract+Cancer+after+Radical+Nephroureterectomy+in+Taiwanese+Patients.">Significant Predictive Factors for Prognosis of Primary Upper Urinary Tract Cancer after Radical Nephroureterectomy in Taiwanese Patients.</a> European Urology. 54 (5), 1127-1135 (2008).</li><li>Cormio, L., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Simultaneous+radical+nephroureterectomy+and+transurethral+distal+ureter+balloon+occlusion+and+detachment.">Simultaneous radical nephroureterectomy and transurethral distal ureter balloon occlusion and detachment.</a> World Journal of Surgical Oncology. 12 (1), 345 (2014).</li><li>Waldert, M., Remzi, M., Klingler, H. C., Mueller, L., Marberger, M. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=The+oncological+results+of+laparoscopic+nephroureterectomy+for+upper+urinary+tract+transitional+cell+cancer+are+equal+to+those+of+open+nephroureterectomy.">The oncological results of laparoscopic nephroureterectomy for upper urinary tract transitional cell cancer are equal to those of open nephroureterectomy.</a> Bju International. 103 (1), 66-70 (2010).</li><li>Liu, P., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=A+Novel+and+Simple+Modification+for+Management+of+Distal+Ureter+During+Laparoscopic+Nephroureterectomy+Without+Patient+Repositioning:+A+Bulldog+Clamp+Technique+and+Description+of+Modified+Port+Placement.">A Novel and Simple Modification for Management of Distal Ureter During Laparoscopic Nephroureterectomy Without Patient Repositioning: A Bulldog Clamp Technique and Description of Modified Port Placement.</a> Journal of Endourology. 30 (2), 195-200 (2016).</li><li>Xylinas, E., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Impact+of+distal+ureter+management+on+oncologic+outcomes+following+radical+nephroureterectomy+for+upper+tract+urothelial+carcinoma.">Impact of distal ureter management on oncologic outcomes following radical nephroureterectomy for upper tract urothelial carcinoma.</a> European Urology. 65 (1), 210-217 (2014).</li></ol>

A traditional open renal ureter resection and bladder cuff-like resection mostly involve upper and lower incisions, which require changing positions and disinfecting the surgical towels twice. The operation time is long, and the amount of trauma is large. Laparoscopic renal ureter and bladder sleeve resection have been gradually adopted by urologists since minimally invasive surgery techniques have been widely used in urology8. The methods for laparoscopic nephroureterectomy and radical resection ...

Radical nephroureterectomy is a standard procedure for treating upper tract urothelial carcinoma (UTUC)1. Traditional open surgery requires two large incisions in the lower abdomen, which is associated with a large amount of trauma and many complications2. With the rapid development of minimally invasive techniques in urology, laparoscopic surgery has been gradually applied in many research studies. Laparoscopic surgery is identical to open surgery in treating the tumors, so the traditional surgical methods have gradually been replaced by laparoscopic surgery3.
In laparoscopic surgery, treatment of the terminal ureter has been an area of focus and a known difficulty of the surgery. At present, different choices exist for treating the ureteral end in laparoscopic nephroureterectomy. However, reductions in the difficulty of the surgery and the amount of trauma has not been possible4,5.
After years of exploration, our center has improved and adopted a new method for the treatment of the terminal ureter: precutting the medial umbilical fold not only increases the operating space but also reduces the difficulty of the surgery and minimizes extra trauma to the patient.

<table>
	<tbody>
		<tr>
			<td>Laparoscopic imaging system</td>
			<td>STORZ</td>
			<td></td>
			<td></td>
		</tr>
		<tr>
			<td>Pneumoperitoneum</td>
			<td>STORZ</td>
			<td></td>
			<td></td>
		</tr>
		<tr>
			<td>Ultrasonic scalpel</td>
			<td>Johnson</td>
			<td></td>
			<td></td>
		</tr>
		<tr>
			<td>Vascular closure clip</td>
			<td>Hem-o-Lock</td>
			<td></td>
			<td></td>
		</tr>
	</tbody>
</table>

technical modification of the terminal ureter during total transperitoneal laparoscopic nephroureterectomy for upper urinary tract urothelial carcinoma

Upper tract urothelial carcinoma (UTUC) accounts for 5%&ndash;10% of all urothelial tumors. Radical nephroureterectomy is the standard treatment procedure. At present, different choices still exist for treating the ureteral end during laparoscopic ureteral bladder sleeve resection. Our center has adopted a new method for treating the ureteral end. This new method can increase the operating space and reduce the difficulty of the surgery compared with current methods.

In total, 87 patients underwent surgery without difficulties, and there were no open surgeries. The average age of the patients was 67.25 &#177; 9.90 years. Within this group, there were 47 cases of renal pelvic cancer, 10 cases of pelvic cancer with ureteral cancer, and 30 cases of ureteral cancer (10 cases of upper ureteral cancer, 9 cases of middle ureteral cancer, and 11 cases of lower ureteral cancer). In total, 49 cancers were on the left side and 38 cancers were on the right side. The average tumor diameter was 3....

Watch this Scientific Journal Video about Technical Modification of the Terminal Ureter During Total Transperitoneal Laparoscopic Nephroureterectomy for Upper Urinary Tract Urothelial Carcinoma at JoV

Technical Modification of the Terminal Ureter During Total Transperitoneal Laparoscopic Nephroureterectomy for Upper Urinary Tract Urothelial Carcinoma

Here, we present a protocol to increase the surgical field of view and reduce the difficulty of total transperitoneal laparoscopic nephroureterectomy surgery by precutting the umbilical ligament before treating the terminal ureter.

Upper tract urothelial carcinoma (UTUC) accounts for 5%&ndash;10% of all urothelial tumors. Radical nephroureterectomy is the standard treatment ...

Our center has adopted a new technique to treat the distal ureter. Comparing with the previous one, our new technique increase the operating space and reduce the difficulty of the procedure. Disconnecting the umbilical artery allows the visual field to be opened, increasing access to the surgical space and helping reduce the risk of injury to the surrounding tissues.In addition, this technique can reduce the overall operating and anesthesia time, reduce the risk of tumor implantation, and also the difficulty of the procedure. The best application of this skill is for you to see, but we can also use this skill to do other laparoscopic surgery to increase the working space. Before beginning the procedure, administer an intravenous antibiotic.After administering general anesthesia, position the healthy side of the patient in a 60-degree recline at the waist so that the patient is in a V-shaped position on the operating table. Place the second trocar near the lateral edge of the rectus abdominis along the umbilical level of the affected side. In third trocar, under the affected part of the midline of the clavicle.With the patient in the left lateral position, use the trocar to establish pneumoperitoneum and maintain the pneumoperitoneum pressure at 14 millimeters of mercury at the midline of the clavicle, and the midpoint of the inguinal ligament, and under the xiphoid process. To treat the kidney in upper and middle ureters, dissect the peritoneum on the affected side to fully release the colon. Use a vascular closure clip to free and clamp the ureter at the distal end of the tumor and dislodge the tissue upward along the ureter until the renal hilum is reached.Sequentially treat the renal artery and the renal vein to completely free the kidney. Then free the ureter to the external vascular level. To treat the terminal ureter, use an ultrasonic scalpel to open the anterior peritoneum of the ureter.After crossing the iliac vessels, identify the umbilical medial iliac crest at which the umbilical artery is located. Then cut the medial iliac crest so that the artery can reach the outside of the bladder. It is critical to cut the medial iliac crest before the terminal ureter treatment.Clamp and cut the distal end of the vascular structure according to standard protocols. Free the bladder until the point at which the ureter enters the bladder. Cut the entire layer of the bladder wall at the upper side of the uretal junction and suture the full layer of the bladder with 3-0 absorbable thread to provide traction and to allow visualization of the normal bladder mucosa.Then use a scalpel to remove the ureteral bladder wall segment and part of the bladder mucosa before completely suturing the bladder wall with absorbable lines. When the specimen has been located, extend the incision for cannula A and remove the specimen. Then load the surgical specimen into the specimen bag and layer off each incision.At the end of the procedure allow the patient to lay in bed in the postoperative care unit for approximately one hour with monitoring. When the patient is completely awake, return the patient to the ward. In this representative analysis of 87 patients who underwent the surgery as demonstrated, the average patient age was 67.25 plus or minus 9.9 years, with 47 cases of renal pelvic cancer, 10 cases of pelvic cancer with ureteral cancer, 10 cases of upper ureteral cancer, 9 cases of middle ureteral cancer, and 11 cases of lower ureteral cancer.49 cancers were on the left side of the patient, and 38 were on the right side. The average tumor diameter was 3.24 plus or minus 1.47 centimeters, and the average operation time was 162.5 plus or minus 45.64 minutes. The volume of intraoperative blood loss was 113.33 plus or minus 59.74 millileters, and no patients required perioperative blood transfusion.On average, the drainage tubes were in place for 4.56 plus or minus 1.12 days, and the catheters were in place for 5.63 plus or minus 2.17 days. The postoperative pathological stages ranged from T-1, N-0, N-0 to T-4, N-0, N-0. No complications occurred during the operations, although two patients had complications after the surgery.The follow-up time was one to 44 months with the median follow-up time of 13 months. Eight patients had postoperative tumor recurrence, all of which were bladder recurrence. Excision of the umbilical medial iliac crest can significantly increase the surgical field of vision and improve the success of the procedure.Maybe cutting the medial iliac crest can be a performed right here with scissors. But it has not been often reported in the literature to present.

Research

JoVE Journal

Medicine

Probe-based Confocal Laser Endomicroscopy of the Urinary Tract: The Technique

Probe-based  confocal laser endomicroscopy (CLE) is an emerging optical imaging technology  that enables real-time in vivo microscopy of mucosal surfaces ...

Technical Aspects of the Mouse Aortocaval Fistula

Technical aspects of creating an arteriovenous fistula in the mouse are discussed. Under general anesthesia, an abdominal incision is made, and the aorta ...

Dual-phase Cone-beam Computed Tomography to See, Reach, and Treat Hepatocellular Carcinoma during Drug-eluting Beads Transarterial Chemo-embolization

The advent of cone-beam computed tomography (CBCT) in the angiography suite has been revolutionary in interventional radiology. CBCT offers 3 ...

Bladder Smooth Muscle Strip Contractility as a Method to Evaluate Lower Urinary Tract Pharmacology

We describe an in vitro method to measure bladder smooth muscle contractility, and its use for investigating physiological and pharmacological properties ...

Ultrasonography of the Adult Male Urinary Tract for Urinary Functional Testing

The incidence of clinical benign prostatic hyperplasia (BPH) and lower urinary tract symptoms (LUTS) is increasing due to the aging population, resulting ...

Technical Detail for Robot Assisted Pancreaticoduodenectomy

Since its first report in 2003, robotic pancreaticoduodenectomy (RPD) has gained popularity among pancreatic surgeons. Inherent advantages of the robotic ...

Surgical Techniques to Optimize Ovarian Reserve during Laparoscopic Cystectomy for Ovarian Endometrioma

Surgical management of ovarian endometrioma in patients desiring fertility is complicated by the need to balance maximal resection of disease with efforts ...

Laparoscopic Pancreatoduodenectomy for Pancreatic Cancer Using In-Situ No-Touch Isolation Technique

Laparoscopic Pancreatoduodenectomy for Pancreatic Cancer Using In-Situ No-Touch Isolation Technique

Laparoscopic pancreatoduodenectomy (LPD) is a standard radical operation for pancreatic head malignant tumors by now. Due to the complex laparoscopic ...

Laparoscopic Oocyte Retrieval and Cryopreservation during Vaginoplasty for Treatment of Mayer-Rokitansky-Kuster-Hauser Syndrome

In Mayer-Rokitansky-Kuster-Hauser Syndrome (MRKHS) patients who are scheduled for laparoscopic vaginoplasty and have a desire for biological motherhood, ...

Laparoscopic Non-Mesh Cerclage Pectopexy for Pelvic Organ Prolapse

Pelvic organ prolapse (POP) is widespread among the female population and significantly impairs the patient's quality of life. It is important to restore ...