MODIFIED LAPAROSCOPIC RADICAL NEPHROURETERECTOMY WITH TRANSURETHRAL EXCISION OF INTRAMURAL URETER BURKHARD UBRIG AND STEPHAN ROTH ABSTRACT We report a modified technique for laparoscopic nephroureterectomy that results in complete removal of the specimen, including a cuff of bladder mucosa, while avoiding tumor cell spillage. A modified lithotomy position allows simultaneous laparoscopic and transurethral access without repositioning. Contraindications are juxtavesical or intramural ureteral tumor. UROLOGY 65: 786–788, 2005. © 2005 Elsevier Inc. T he management of the distal ureter in laparo- scopic nephroureterectomy for transitional cell carcinoma (TCC) of the upper urinary tract is still in dispute. 1–3 The principles of surgical oncol- ogy dictate en bloc resection with avoidance of tu- mor seeding. The main concern is to ensure com- plete excision of the distal ureter, including a cuff of bladder mucosa, and securely preventing spill- age of potentially tumor cell-laden urine into the operative field. We have recently modified our technique for laparoscopic nephroureterectomy as described below. MATERIAL AND METHODS From March 2003 to May 2004, 6 patients (2 men and 4 women; mean age 62.4 years, range 35.3 to 73.9) underwent laparoscopic transperitoneal nephroureterectomy for upper tract TCC using the technique described below. The patient was placed in a 30° lateral decubitus position with the diseased side up and the legs outstretched on well- padded English stirrups (modified lithotomy position; Fig. 1). After disinfection and draping, the table was rotated so that the abdominal wall was nearly parallel to the floor, and a pneumoperitoneum was established. The camera trocar (10 mm) was inserted by way of an infraumbilical incision. The table was then rotated back, and two working trocars were placed in the medioclavicular line: one (5 mm) 2 cm below the costal margin and one (12.5 mm) at about 4 cm above the level of the anterior superior iliac spine. An additional 5-mm trocar for the assistant (retraction or suction) was placed caudal and lateral to the camera trocar. Laparoscopic transperitoneal nephrectomy was then per- formed, as described previously. 4 The ureter may be clipped early in the procedure to prevent the flow of tumor cells down- stream, but not transected. The kidney was positioned into the lower abdomen. Subsequently, the assistant grasped the mid-ureter with blunt fenestrated forceps, and the surgeon performed ureter- olysis down to a point about 3 cm above the ureterovesical junction, which was identified visually. The ureter was again sealed with a clip (Hem-o-Lok, Weck Closure Systems, Re- search Triangle Park, NC) or suture ligated. The table was rotated back into the horizontal position. A ureteral catheter was inserted into the targeted ureter using a cystoscope up to the point of ligation. The distal ureter and bladder were generously flushed with 10% Betadine solution. Next, the cystoscope was extracted and a resectoscope intro- duced alongside the ureteral catheter. With a hook electrode, the bladder mucosa was scored in a 1-cm radius around the ureteral orifice. The ureteral catheter was a great aid in straightening the ureter and lifting up the targeted hemi- trigone. The incision was then carried down to the level of the perivesical fat until the intramural ureter was completely de- tached (Fig. 2). The ureteral catheter was then extracted and the excised orifice coagulated. After complete hemostasis, a transurethral catheter was inserted. The table was rotated back, and the laparoscopist dissected the remaining attachments of the ureter until it could be easily extracted. It was occasionally useful to insert an additional 5-mm trocar in the midline about 5 cm above the symphysis pubis and use a retractor to bring the ureterovesical junction into clear view. The specimen was immediately put into an extraction bag. The bladder defect was laparoscopically sutured with 3-0 Vi- cryl. The specimen was extracted by way of a muscle-splitting extension of the 12.5-mm trocar site. The extraction incision generally measured between 5 and 8 cm. The urethral catheter was extracted after cystography 5 days postoperatively. From the Department of Adult and Pediatric Urology, Witten/ Herdecke University, HELIOS Klinikum Wuppertal, Wuppertal, Germany Reprint requests: Burkhard Ubrig, M.D., Klinik für Urologie und Kinderurologie, Witten/Herdecke University, HELIOS Klini- kum Wuppertal, Heusnerstrasse 40, Wuppertal D-42283, Ger- many. E-mail: bubrig@wuppertal.helios-kliniken.de Submitted: September 12, 2004, accepted (with revisions): De- cember 16, 2004 SURGEON’S WORKSHOP © 2005 ELSEVIER INC. 0090-4295/05/$30.00 786 ALL RIGHTS RESERVED doi:10.1016/j.urology.2004.12.048