Does the surgical technique for management of the distal ureter influence the outcome after nephroureterectomy?
Article first published online: 11 NOV 2010
© 2010 THE AUTHORS. BJU INTERNATIONAL © 2010 BJU INTERNATIONAL
Volume 108, Issue 1, pages 130–138, July 2011
How to Cite
Phé, V., Cussenot, O., Bitker, M.-O. and Rouprêt, M. (2011), Does the surgical technique for management of the distal ureter influence the outcome after nephroureterectomy?. BJU International, 108: 130–138. doi: 10.1111/j.1464-410X.2010.09835.x
- Issue published online: 16 JUN 2011
- Article first published online: 11 NOV 2010
- Accepted for publication 2 July 2010
- upper urinary tract urothelial carcinoma;
- bladder cuff;
- pluck technique;
- ureteral intususseption;
Study Type – Therapy (case series) Level of Evidence 4
What’s known on the subject? and What does the study add?
The resection of the distal ureter and its orifice is an oncological principle during radical nephroureterectomy which is based on the fact that it represents a part of the urinary tract exposed to a considerable risk of recurrence. After removal of the proximal part it is hardly possible to image or approach it by endoscopy during follow-up.
Recent publications on survival after nephroureterectomy do not allow the conclusion that removal of distal ureter and bladder cuff are useless. Several techniques of distal ureter removal have been described but they are not equivalent in term of oncological safety.
• The standard treatment of upper urinary tract urothelial carcinomas (UUT-UCs) must obey oncological principles, which consist of a complete en bloc resection of the kidney and the ureter, as well as excision of a bladder cuff to avoid tumour seeding.
• The open technique is the ‘gold standard’ of treatment to which all other techniques developed are necessarily compared, and various surgical procedures have been described.
• The laparoscopic stapling technique maintains a closed system but risks leaving behind the ureteric and bladder cuff segments.
• Transvesical laparoscopic detachment and ligation is a valid approach from an oncological stance but is technically difficult. The major inconvenience of the transurethral resection of the ureteric orifice and intussusception techniques is the potential for tumour seeding.
• Management of the distal ureter via the robot-assisted laparoscopic method is technically feasible, but outcomes from these procedures are still preliminary.
• Therefore, prospective comparative studies with more thorough explorations of these techniques are needed to solve the dilemma of the management of the distal ureter during nephroureterectomy. However, bladder cuff excision should remain the standard of care irrespective of the stage of the disease.