Review Article Management of Distal Ureter in Laparoscopic Nephroureterectomy—A Comprehensive Review of Techniques Amanda M. Macejko, Joseph F. Pazona, Stacy Loeb, Simon Kimm, and Robert B. Nadler Approximately 5% of all urothelial tumors in adults arise from the upper tracts. While the gold standard treatment is open nephroureterectomy, laparoscopic nephroureterectomy is becoming increasingly popular. Oncologic principles dictate that complete excision of the transmural ureter and bladder cuff and avoidance of urine spillage are paramount. This can be challenging laparoscopically and multiple techniques have been described. We review described surgical techniques, published oncologic data, as well as advantages and disadvantages for each technique including open excision, cystoscopic detachment and ligation, laparoscopic stapling, ureteral intussusception, transurethral resection of ureteral orifice (TURUO) and modifications of TURUO. To date, no controlled studies have been performed demonstrating one technique’s superiority. UROLOGY 72: 974 –981, 2008. © 2008 Elsevier Inc. A pproximately 5% of all urothelial tumors in adults arise from the upper tracts (renal pelvis and ureter). 1 The first laparoscopic nephroure- terectomy (LNU) was performed in 1991 at Washington University. 2 With the advancement of minimally inva- sive techniques, LNU is becoming an effective option for the treatment of upper tract transitional cell carcinoma (TCC). Studies have demonstrated that patients under- going LNU might have decreased blood loss, postopera- tive pain, and length of hospitalization and a more rapid return to normal activities compared with those under- going open nephroureterectomy (ONU). 3-5 More impor- tantly, LNU appears to have comparable oncologic out- comes to the open surgical approach. Despite concerns of intra-abdominal tumor seeding and port site metastases, very few cases have been reported. 6,7 Studies to date have reported that the margin-free rates and local recurrence rates after LNU are equivalent to those after open pro- cedures. 8,9 Additionally, studies comparing LNU and ONU have demonstrated similar disease-specific survival between the 2 procedures. 10,11 A wide variety of techniques have been used to per- form LNU. The first step involves the mobilization of the kidney, which can be performed using several ap- proaches, including transperitoneal LNU (TPLNU), hand-assisted LNU (HALNU), and retroperitoneal LNU (RPLNU). The second, and more challenging and con- troversial, aspect of LNU is the management of the distal ureter and ipsilateral bladder cuff. The importance of a complete excision is highlighted by reports of tumor recurrence in 30% of inadequately resected distal ure- ters. 12,13 As such, multiple techniques of ureter and blad- der cuff resection have been described, including open excision, cystoscopic detachment and ligation, transure- thral resection of the ureteral orifice (TURUO) with various modifications, laparoscopic stapling, and ureteral intussusception. Each technique has inherent advantages and disadvantages; however, thus far, no prospective, randomized trials have compared the different ap- proaches. We present a review of the different methods of distal ureteral and bladder cuff resection. APPROACHES Open Excision Open excision of the distal ureter and bladder cuff after LNU is similar to the technique used during ONU. After complete mobilization of the kidney and more proximal ureter, transvesical or extravesical excision of the distal ureter and bladder is performed. A variety of incisions can be made to provide adequate exposure of the perives- ical space (lower midline, Pfannenstiel, or Gibson). Al- ternatively, if HALNU is performed, the hand port can be removed and a self-retaining retractor used. In the largest published series of patients who under- went open bladder cuff resection during LNU, Hsueh et al. 14 showed comparable outcomes to those with ONU. Their technique involved placing the hand-assist device into a Gibson incision and performing retroperi- toneal HALNU. After 16 months of follow-up, the rates of bladder recurrence, local recurrence, and metastatic disease were statistically similar to the corresponding rates from a similarly matched open cohort. The inves- From the Department of Urology, Northwestern University Feinberg School of Medi- cine, Chicago, Illinois; and Department of Urology, Johns Hopkins Medical Institu- tions, Baltimore, Maryland Reprint requests: Robert B. Nadler, M.D., Northwestern Medical Faculty Founda- tion, 675 North Saint Clair Street, Suite 20-150, Chicago, IL 60611. E-mail: r-nadler@northwestern.edu Submitted: October 15, 2007, accepted (with revisions): April 6, 2008 974 © 2008 Elsevier Inc. 0090-4295/08/$34.00 All Rights Reserved doi:10.1016/j.urology.2008.04.022