Name: technical modification of the terminal ureter during total transperitoneal laparoscopic nephroureterectomy for upper urinary tract urothelial carcinoma
Uploaded: 2019-11-22T14:00:00.000+00:00
Duration: 6 min 39 s
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 the patient with a bowel cleansing before the operation. Have the anesthesiologist perform an anesthesia risk assessment of the patient prior to surgery. Have patients taking aspirin before surgery stop taking it.</li>
	<li>Prepare the skin around the surgical site.</li>
	<li>Preoperatively administer an intravenous antibiotic 30 min before the operation to all patients. Use cefuroxime sodium 1.5 g with 100 mL of 0.9% sodium chloride solution.</li>
	<li>Before administering general anesthesia, lay the patient down on the operating table.</li>
	<li>After general anesthesia, place the healthy side of the patient in a 60&#176; recline at the waist, so the patient is in a V-shaped position on the operating table.</li>
</ol>
3. Procedure
<ol>
	<li>Place trocars (see Figure 1).
	<ol>
		<li>Begin the operation with the patient in the right lateral position.</li>
		<li>Establish pneumoperitoneum by inserting a pneumoperitoneal needle using the Veress method. Maintain the pneumoperitoneum pressure at 14 mmHg.</li>
		<li>Implant a trocar at the umbilical level near the outer edge of the left rectus abdominis muscle. Then, insert the laparoscope.</li>
		<li>Place the other trocars.</li>
	</ol>
	</li>
	<li>Treat the kidney and upper and middle ureters.
	<ol>
		<li>Rotate the operating bed axially so that the patient is in an ~80&#176;&#8211;90&#176; lateral position. 
		NOTE: This position allows for the intestines to fall to the side, which better exposes the renal hilum for treatment.</li>
		<li>Dissect the peritoneum on the affected side and fully release the colon downwards.</li>
		<li>Free and clamp the ureter at the distal end of the tumor with a vascular closure clip and then dislodge upwards along the ureter until reaching the renal hilum level.</li>
		<li>Treat the renal artery and renal vein successively and completely free the kidney.</li>
		<li>Free the ureter to the external vascular level.</li>
	</ol>
	</li>
	<li>Treat the terminal ureter.
	<ol>
		<li>Rotate the operating bed axially so that the patient is in a 50&#176; lateral position. 
		NOTE: This position is optimal for surgery inside the pelvic area and avoids having the surgeon operate in a position that is too low.</li>
		<li>Open the anterior peritoneum of the ureter with an ultrasonic scalpel and after crossing the iliac vessels, identify the umbilical medial iliac crest, where the umbilical artery is located6 (Figure 2).</li>
		<li>Cut the medial iliac crest so that the artery can reach the outside of the bladder (Figure 3).</li>
		<li>Clamp and cut the distal end of the vascular structure as is the norm. Free the bladder until the ureter enters the bladder.</li>
		<li>Cut the entire layer of the bladder wall at the upper side of the ureteral junction. Suture the full layer of the bladder with 3-0 absorbable thread to indicate and provide traction to see the normal bladder mucosa5,7.</li>
		<li>Remove the ureteral bladder wall segment and part of the bladder mucosa with a scalpel. While making the incision, completely suture the bladder wall with absorbable lines (Figure 4).</li>
	</ol>
	</li>
	<li>Take out the specimen.
	<ol>
		<li>Load the surgical specimen into the specimen bag.</li>
		<li>According to the conditions, extend the incision for cannula A and take out the specimen.</li>
		<li>Layer off each incision.</li>
	</ol>
	</li>
	<li>Postoperative care.
	<ol>
		<li>Let the patient lay in bed for approximately 1 h postoperatively in the care unit until he or she completely wakes up from anesthesia.</li>
		<li>Meanwhile, monitor the patient and ensure that oxygen is available during this time.</li>
		<li>When the patient completely wakes up, return the patient to the ward. Pay attention to the color and volume of the urine and abdominal drainage. Pay attention to the presence of any abdominal signs and symptoms (e.g., stomachache and peritoneal irritation).</li>
	</ol>
	</li>
</ol>

<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>

The authors have nothing to disclose.

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 of ureteral cancer are not the same in all medical centers. The main differences are in the approach and the distal ureteral treatment. At present, hospitals in China have adopted open surgery or transurethral distal ureterectomy. In recent years, complete laparoscopic techniques have been used to treat upper urinary tract urothelial tumors9. The biggest advantage of the method used in this study is that it does not require position changes or complete removal of the upper urinary tract urothelial cells. This tumor treatment technique reduces the overall time needed for surgery and anesthesia10, reduces the risk of local tumor implantation11, simplifies the operation, reduces the difficulty of the surgery, and facilitates promotion of this technique12.
Compared with other treatments for upper urinary tract urothelial tumors, the techniques used in this study have the following characteristics: Traditional laparoscopic surgery is mainly used to treat the renal and upper ureter. During distal ureter and bladder sleeve resection, an incision in the lower abdominal oblique muscles is made, or transurethral distal ureterectomy is used. Transurethral ureteral resection first requires that the patient be placed in the lateral position, thus, the ureteral opening is not clearly visible once the entire layer of the bladder is cut open. Before blocking the affected ureter, the continued outflow of urine with tumor cells may increase the chance of extra bladder implantation, which is not ideal to prevent tumors13. A complete laparoscopic kidney, ureter, and bladder sleeve resection was performed. After completely freeing the kidney, we continued to free the distal end of the ureter to the level of the external iliac vessels. The medial umbilical artery travels from the outside of the surgical field to view to the inside, like a curtain obstructing the end of the ureter and the outside of the bladder. After cutting the medial iliac crest, the artery can reach the outside of the bladder. Then, the end of the ureter falls towards the inner side, increasing the operation space. The nondominant hand of the surgeon does not need to be used to retract the medial iliac crest. Before the distal ureter and bladder were treated, the umbilical artery was disconnected, and the curtain blocking the visual field was opened and fully exposed to increase the operation space, which helps the surgeon and reduces the risk of injury to the surrounding tissues14. The technique in this study was superior to traditional laparoscopic kidney, ureter, and bladder sleeve resection in terms of operative time, intraoperative blood loss, urinary catheter indwelling time, length of postoperative hospital stay, and postoperative complications15.
In summary, this complete laparoscopic renal ureteral bladder resection and modified ureteral endpoint treatment is a safe and effective minimally invasive treatment method for upper urinary tract urothelial tumors compared to other ureteral treatment methods. The surgical procedure is simpler, the end of the ureter is treated under direct vision of the laparoscope, and the bladder incision is sutured reliably.

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 3.24 &#177; 1.47 cm, and the average operation time was 162.50 &#177; 45.64 min. The volume of intraoperative blood loss was 113.33 &#177; 59.74 mL. No patients required perioperative blood transfusions. On average, the drainage tubes were in place for 4.56 &#177; 1.12 days, and the catheters were in place for 5.63 &#177; 2.17 days. The surgical specimens were positive. The postoperative pathological stages ranged from T1N0M0 to T4N0M0 (T1 = 24 cases, T2 = 19 cases, T3 = 37 cases, T4 = 7 cases). No complications occurred during the operation, although two patients had complications after the operation (i.e., infection). After treatment, the patients were discharged. All patients underwent routine intravesical instillation. Urinary pathology tests, cystoscopy and imaging examinations were performed in regular outpatient clinics. The follow-up time was 1&#8211;44 months, and the median follow-up time was 13 months. Eight patients had postoperative tumor recurrence, all of which were bladder recurrence (Table 1 and Table 2).
<img alt="Figure 1" class="xfigimg" src="/files/ftp_upload/60662/60662fig01.jpg" /> 
Figure 1: Trocar position. (A) Position of the trocar on the right side. (B) Position of the trocar on the left side. (a) The umbilical level of the affected side, close to the lateral edge of the rectus abdominis (viewed with a mirror). (b) Under the affected part of the midline of the clavicle (operating hole). (c) The front side of the affected side intersects with the umbilical level. The operator uses his or her hand to treat the kidney. The operator uses his or her hand to treat the lower part of the ureter. (d) The midline of the clavicle and the midpoint of the inguinal ligament are on the same longitudinal line as the clavicle. A triangular relationship exists with the umbilical level and cannula A when treating the lower segment of the ureter. (e) Under the xiphoid while lifting the liver. <a href="https://www-jove-com.bdigitaluss.remotexs.co/files/ftp_upload/60662/60662fig01large.jpg" target="_blank">Please click here to view a larger version of this figure.</a>
<img alt="Figure 2" class="xfigimg" src="/files/ftp_upload/60662/60662fig02.jpg" /> 
Figure 2: Treatment of the umbilical ligament (exposure). Diagram (A) and image (B). <a href="https://www-jove-com.bdigitaluss.remotexs.co/files/ftp_upload/60662/60662fig02large.jpg" target="_blank">Please click here to view a larger version of this figure.</a>
<img alt="Figure 3" class="xfigimg" src="/files/ftp_upload/60662/60662fig03.jpg" /> 
Figure 3: Treatment of the umbilical ligament (cut). The umbilical ligament is like a curtain that completely blocks the end of the ureter and the side of the bladder. After the peritoneum of the free umbilical ligament is cut, the umbilical ligament can be well exposed and directly treated. Diagram (A) and image (B). <a href="https://www-jove-com.bdigitaluss.remotexs.co/files/ftp_upload/60662/60662fig03large.jpg" target="_blank">Please click here to view a larger version of this figure.</a>
<img alt="Figure 4" class="xfigimg" src="/files/ftp_upload/60662/60662fig04.jpg" /> 
Figure 4: Treatment of the lower ureter. After the end of the ureter is closed, the entire layer of the bladder was cut, and the full layer of the bladder was sutured with 3-0 absorbable thread as an indicator and for traction. If the ureteral end and the bladder sleeve mucosa are not completely disconnected, the bladder incision is exactly sutured under direct vision. Diagram (A) and image (B). <a href="https://www-jove-com.bdigitaluss.remotexs.co/files/ftp_upload/60662/60662fig04large.jpg" target="_blank">Please click here to view a larger version of this figure.</a>
<table border="1" fo:keep-together.within-page="1" fo:keep-with-next.within-page="always">
	<tbody>
		<tr>
			<td>Parameters</td>
			<td>Data</td>
		</tr>
		<tr>
			<td>Age (years)</td>
			<td>67.25 &#177; 9.90</td>
		</tr>
		<tr>
			<td>Renal pelvic carcinoma</td>
			<td>47</td>
		</tr>
		<tr>
			<td>Renal pelvic carcinoma and ureteral cancer</td>
			<td>10</td>
		</tr>
		<tr>
			<td>Ureteral cancer</td>
			<td>30</td>
		</tr>
		<tr>
			<td>Upper ureteral cancer</td>
			<td>10</td>
		</tr>
		<tr>
			<td>Middle ureteral cancer</td>
			<td>9</td>
		</tr>
		<tr>
			<td>Terminal ureteral cancer</td>
			<td>11</td>
		</tr>
		<tr>
			<td>Left tumors</td>
			<td>49</td>
		</tr>
		<tr>
			<td>Right tumors</td>
			<td>38</td>
		</tr>
		<tr>
			<td>Tumor diameter</td>
			<td>3.24 &#177; 1.47</td>
		</tr>
		<tr>
			<td>Operative time (min)</td>
			<td>162.50 &#177; 45.64</td>
		</tr>
		<tr>
			<td>Bleeding (mL)</td>
			<td>113.33 &#177; 59.74</td>
		</tr>
		<tr>
			<td>Blood transfusion rate (%)</td>
			<td>0</td>
		</tr>
		<tr>
			<td>Drainage duration (days)</td>
			<td>4.56 &#177; 1.12</td>
		</tr>
		<tr>
			<td>Catheter duration (days)</td>
			<td>5.63 &#177; 2.17</td>
		</tr>
		<tr>
			<td>Intraoperative complications</td>
			<td>0</td>
		</tr>
		<tr>
			<td>Postoperative complications</td>
			<td>2</td>
		</tr>
		<tr>
			<td>Positive rate of surgical margin(%)</td>
			<td>0</td>
		</tr>
		<tr>
			<td>Median follow-up time (months)</td>
			<td>13</td>
		</tr>
		<tr>
			<td>Tumor recurrence</td>
			<td>8</td>
		</tr>
	</tbody>
</table>
Table 1: Perioperative data of 87 patients with UTUC who underwent total transperitoneal laparoscopic nephroureterectomy. Data are shown as mean &#177; SD; UTUC = upper tract urothelial carcinoma; SD = Standard deviation.
<table border="1" fo:keep-together.within-page="1" fo:keep-with-next.within-page="always">
	<tbody>
		<tr>
			<td>T</td>
			<td>N</td>
			<td>M</td>
			<td>Number</td>
		</tr>
		<tr>
			<td>1</td>
			<td>0</td>
			<td>0</td>
			<td>24</td>
		</tr>
		<tr>
			<td>2</td>
			<td>0</td>
			<td>0</td>
			<td>19</td>
		</tr>
		<tr>
			<td>3</td>
			<td>0</td>
			<td>0</td>
			<td>37</td>
		</tr>
		<tr>
			<td>4</td>
			<td>0</td>
			<td>0</td>
			<td>7</td>
		</tr>
	</tbody>
</table>
Table 2: Postoperative pathological stage.

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 ...

technical-modification-terminal-ureter-during-total-transperitoneal

Universidad San Sebastian

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7.6K Views.  The Joint Unit of the Chinese Academy of Medical Sciences. 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.

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

Surgical Techniques for Catheter Placement and 5/6 Nephrectomy in Murine Models of Peritoneal Dialysis

Peritoneal dialysis (PD) is a renal replacement therapy consistent on the administration and posterior recovery of a hyperosmotic fluid in the peritoneal cavity to drain water and toxic metabolites that functionally-insufficient kidneys are not able to eliminate. Unfortunately, this procedure deteriorates the peritoneum. Tissue damage triggers the onset of inflammation to heal the injury. If the injury persists and inflammation becomes chronic, it may lead to fibrosis, which is a common occurrence in many diseases. In PD, chronic inflammation and fibrosis, along with other specific processes related to these ones, lead to ultrafiltration capacity deterioration, which means the failure and subsequent cessation of the technique. Working with human samples provides information about this deterioration but presents technical and ethical limitations to obtain biopsies. Animal models are essential to study this deterioration since they overcome these shortcomings.
A chronic mouse infusion model was developed in 2008, which benefits from the wide range of genetically modified mice, opening up the possibility of studying the mechanisms involved. This model employs a customized device designed for mice, consisting of a catheter attached to an access port that is placed subcutaneously at the back of the animal. This procedure avoids continuous puncture of the peritoneum during long-term experiments, reducing infections and inflammation due to injections. Thanks to this model, peritoneal damage induced by chronic PD fluid exposure has been characterized and modulated. This technique allows the infusion of large volumes of fluids and could be used for the study of other diseases in which inoculation of drugs or other substances over extended periods of time is necessary.
This article shows the method for the surgical placement of the catheter in mice. Moreover, it explains the procedure for a 5/6 nephrectomy to mimic the state of renal insufficiency present in PD patients.

This article shows the method for the surgical placement in mice of an intraperitoneal catheter attached to an access port that is positioned at the back of the animal. Moreover, it explains the procedure for a 5/6 nephrectomy to resemble the uremic state of PD patients.

Peritoneal dialysis (PD) is a renal replacement therapy consistent on the administration and posterior recovery of a hyperosmotic fluid in the peritoneal ...

Engineering

A Murine Model of Irreversible and Reversible Unilateral Ureteric Obstruction

Obstruction of the kidney may affect native or transplanted kidneys and results in kidney injury and scarring. Presented here is a model of obstructive nephropathy induced by unilateral ureteric obstruction (UUO), which can either be irreversible (UUO) or reversible (R-UUO). In the irreversible UUO model, the ureter may be obstructed for variable periods of time in order to induce increasingly severe renal inflammation and interstitial fibrotic scarring. In the reversible R-UUO model the ureter is obstructed to induce hydronephrosis, tubular dilation and inflammation. After a suitable period of time the ureteric obstruction is then surgically reversed by anastomosis of the severed previously obstructed ureter to the bladder in order to allow complete decompression of the kidney and restoration of urinary flow to the bladder. The irreversible UUO model has been used to investigate various aspects of renal inflammation and scarring including the pathogenesis of disease and the testing of potential anti-inflammatory or anti-fibrotic therapies. The more challenging model of R-UUO has been used by some investigators and does offer significant research potential as it allows the study of inflammatory and immune processes and tissue remodeling in an injured and scarred kidney following the removal of the injurious stimulus. As a result, the R-UUO model offers investigators the opportunity to explore the resolution of kidney inflammation together with key aspects of tissue repair. These experimental models are of relevance to human disease as patients often present with obstruction of the renal tract that requires decompression and are commonly left with significant residual kidney impairment that has no current treatment options and may lead to eventual end stage kidney failure.

The murine model of irreversible unilateral ureteric obstruction (UUO) is presented together with the model of reversible UUO in which the ureteric obstruction is relieved by anastomosis of the severed ureter into the bladder. These models enable the study of renal inflammation and scarring as well as tissue remodeling.

Obstruction of the kidney may affect native or transplanted kidneys and results in kidney injury and scarring. Presented here is a model of obstructive ...

Murine Kidney Transplant Technique

The first mouse kidney transplant technique was published in 19731 by the Russell laboratory. Although it took some years for other labs to become proficient in and utilize this technique, it is now widely used by many laboratories around the world. A significant refinement to the original technique using the donor aorta to form the arterial anastomosis instead of the renal artery was developed and reported in 1993 by Kalina and Mottram 2 with a further advancement coming from the same laboratory in 1999 3. While one can become proficient in this model, a search of the literature reveals that many labs still experience a high proportion of graft loss due to arterial thrombosis. We describe here a technique that was devised in our laboratory that vastly reduces the arterial thrombus reported by others 4,5. This is achieved by forming a heel-and-toe cuff of the donor infra-renal aorta that facilitates a larger anastomosis and straighter blood flow into the kidney.

The goal of this manuscript is to describe the steps required to perform a kidney transplant in a mouse, paying particular attention to the details of the arterial anastomosis.

The first mouse kidney transplant technique was published in 19731 by the Russell laboratory. Although it took some years for other labs to become ...

A Modified Surgical Technique for Kidney Transplantation in Mice

Kidney transplantation in mice is a complicated and challenging surgery procedure. There are very few publications demonstrating the key steps of this operation. Therefore, this article introduces the technique and points out the surgical caveats associated with this operation. In addition, important modifications in comparison to the conventional procedure are demonstrated. Firstly, a patch of the abdominal aorta is cut and prepared so that the proximal bifurcations of the renal artery, including the ureteral artery are transected together with the donor kidney en bloc. This reduces the risk of a ureter necrosis and avoids the development of a urinary tract occlusion. Secondly, a new method of the vascular anastomosis is demonstrated that allows the operator to flexibly increase or decrease the size of the anastomosis after renal transplant reperfusion has already been initiated. This avoids the development of vessel strictures and intraabdominal bleeding. Thirdly, a technique that enables the anastomosis of the delicate donor ureter and the recipient bladder that does not cause a trauma is shown. Adopting this protocol can shorten the operation time and reduces the damage to the recipient's bladder, thereby significantly increasing the operation success rate for the recipient mice.

This protocol presents a new surgical technique of mouse kidney transplantation focusing on a modified arterial anastomosis strategy. A vascular suture technique including a simple and safer ureter-bladder anastomosis method is also presented. These modifications shorten the operation time and improve the success rate of the mouse kidney transplantation procedure.

Kidney transplantation in mice is a complicated and challenging surgery procedure. There are very few publications demonstrating the key steps of this ...

Immunology and Infection

Accessing Collagen Scaffold for Single-Stage Urinary Diversion Surgery in Pigs

Surgical Model for Single-Staged Tissue-Engineered Urothelial Tubes in Minipigs

Reconstructive surgeries are often challenged by a lack of grafting tissue. In the treatment of urogenital malformations, the conventional solution has been harvesting gastrointestinal tissue for non-orthotopic reconstruction due to its abundance to reestablish normal function in the patient. The clinical outcomes after rearranging native tissues within the body are often associated with significant morbidity; thus, tissue engineering holds specific potential within this field of surgery. Despite substantial advances, tissue-engineered scaffolds have not yet been established as a valid surgical treatment alternative, mainly due to the costly and complex requirements of materials, production, and implantation. In this protocol, we present a simple and accessible collagen-based tubular scaffold embedded with autologous organ-specific tissue particles, designed as a conduit for urinary diversion. The scaffold is constructed during the primary surgical procedure, comprises commonly available surgical materials, and requires conventional surgical skills. Secondly, the protocol describes an animal model designed to evaluate the short-term in vivo outcomes post-implantation, with the possibility of additional variations to the procedure. This publication aims to demonstrate the procedure step-by-step, with special attention to the use of autologous tissue and a tubular form.

Tissue-engineered implants for reconstructive surgery rarely progress beyond preclinical trials due to laborious ex vivo culturing, which includes complex and expensive scaffold components. Here, we present a single-staged procedure designed for urinary diversion with an accessible collagen-based tubular scaffold containing autologous micrografts.

Reconstructive surgeries are often challenged by a lack of grafting tissue. In the treatment of urogenital malformations, the conventional solution has ...

Bioengineering

Robotic Radical Cystectomy, Pelvic Lymph Node Dissection, and Intracorporeal Ileal Conduit Urinary Diversion

The robotic approach to radical cystectomy is compelling because of its oncologic equivalence to open radical cystectomy (ORC), its association with lower surgical blood loss, its potential association with shorter hospital stay after surgery. These factors suggest that the robotic approach to radical cystectomy may be an important component of enhanced recovery programs aimed at reducing surgical morbidity. This paper describes the importance of the cranial placement of robotic trocars, the use of Cadiere forceps for atraumatic bowel grasping, pelvic lymph node dissection (PLND), and utero-enteric anastomoses. Also discussed are steps that are critical for the successful outcome of RARC. In spite of the increased operating times and associated costs and the costs of robotic surgical platforms and equipment, adoption of the robotic technique by bladder cancer surgeons has increased. This paper describes a systematic and reproducible method that details robotic extended pelvic lymph node dissection, cystectomy/cystoprostatectomy, and intracorporeal ileal conduit urinary diversion.

This paper describes robotic radical cystectomy, pelvic lymph node dissection, and intracorporeal ileal conduit urinary diversion.

The robotic approach to radical cystectomy is compelling because of its oncologic equivalence to open radical cystectomy (ORC), its association with lower ...

Robot-Assisted Kidney Transplantation

This paper describes robot-assisted kidney transplantation (RAKT) from a living donor. The robot is docked between the parted legs of the patient, placed in the supine Trendelenburg position. Kidney allografts are provided by a living donor. Before vascular anastomosis, the kidney allograft is prepared by inserting a double-J stent in the ureter, and the temperature for the anastomosis is lowered by wrapping it in an ice-packed gauze. A 12 mm or 8 mm port for the robotic camera and three 8 mm ports for robotic arms are placed. A peritoneal pouch is created for the kidney allograft by raising the peritoneal flaps on both sides over the psoas muscle before dissecting the iliac vessels and bladder. A 6 cm Pfannenstiel incision is made to insert the kidney into the peritoneal pouch, lateral to the right iliac vessels. 
After clamping the external iliac vein with Bulldogs clamps, a venotomy is performed, and the graft renal vein is anastomosed to the external iliac vein in an end-to-side continuous manner with a 6/0 polytetrafluoroethylene suture. After clamping the graft renal vein, the iliac vein is declamped. This is followed by clamping of the external iliac artery, arteriotomy, arterial anastomosis with a 6/0 polytetrafluoroethylene suture, clamping of the graft renal artery, and declamping of the external iliac artery. Reperfusion is then carried out, and ureteroneocystostomy is performed using the Lich-Gregoir technique. The peritoneum is closed at a few locations with polymer locking clips, and a closed-suction drain is placed through one of the working ports. After deflating the pneumoperitoneum, all incisions are closed.

This paper provides technical details for robot-assisted kidney transplantation from a living donor.

This paper describes robot-assisted kidney transplantation (RAKT) from a living donor. The robot is docked between the parted legs of the patient, placed ...

Robot-assisted Total Mesorectal Excision and Lateral Pelvic Lymph Node Dissection for Locally Advanced Middle-low Rectal Cancer

Since their approval for clinical use, da Vinci surgical robots have shown great advantages in gastrointestinal surgical operations, especially in complex procedures. The high-quality 3-D visual, multijoint arm and natural tremor filtration allow the surgeon to expose and dissect more accurately with minimal invasion. Total mesorectal excision is the standard surgical technique for the treatment of resectable rectal cancer. To reduce the lateral recurrence rate, lateral pelvic lymph node dissection can be performed, as it is a safe and feasible procedure for locally advanced middle-low rectal cancer with a high possibility of metastasis to the lateral lymph nodes. However, the complexity of the anatomic structures and the high postoperative complication rate limit its application. Recently, several surgeons have increasingly used robotic techniques for total mesorectal excision and lateral pelvic lymph node dissection. Compared with open and laparoscopic surgery, the robotic technique has several advantages, such as less blood loss, fewer blood transfusions, minimal trauma, shorter postoperative hospitalization, and quicker recovery. A robotic approach is generally regarded as a reasonable alternative for complicated procedures such as lateral pelvic lymph node dissection, although there are a limited number of high-quality prospective randomized controlled studies reporting direct evidence. Here, we provide the detailed steps of robot-assisted total mesorectal excision and lateral pelvic lymph node dissection performed at the First Affiliated Hospital of Xi&#39;an Jiaotong University.

The robotic technique described herein aims to detail a stepwise approach to robot-assisted total mesorectal excision and lateral pelvic lymph node dissection for locally advanced (T3/T4) rectal cancer located below the peritoneal reflection.

Since their approval for clinical use, da Vinci surgical robots have shown great advantages in gastrointestinal surgical operations, especially in complex ...

Retzius-Sparing Robot-Assisted Radical Prostatectomy

The technique of Retzius-sparing robot-assisted radical prostatectomy (RS-RARP) and initial experience with it at a single center are provided. The technique is described step-by-step and further illustrated by a video to enhance reproducibility. Early oncological and functional results were evaluated. In total, 77 patients were included with a median follow-up of 11 months (range: 3-21 months). Fifty-one percent of patients had local high-risk or locally advanced prostate cancer. There were no intra-operative complications, and all high-grade complications (2.6%) were related to pelvic lymph node dissection performed concomitant with RS-RARP. Median operation time was 160 min (range: 122-265 min) and median hospital stay was 3 (range: 3-8) days. A positive surgical margin was reported in 42.9%. One-year biochemical recurrence-free survival was 90.1%. After 6 months, all patients were socially continent and after 1 year, 94.3% were fully continent. Of sexually active patients who underwent at least unilateral nerve-sparing, 43.3% were able to have sexual intercourse. This series underlines the surgical safety of performing RS-RARP by a standardized technique and confirms the beneficial effect on the early return of continence. The patient needs to be informed about the risk of a positive surgical margin.

Robot-assisted Retzius-sparing radical prostatectomy is a technique that enables to preserve urinary continence or facilitates recovery of urinary continence in the majority of patients. Patients must be informed about the risk of a positive surgical margin.

The technique of Retzius-sparing robot-assisted radical prostatectomy (RS-RARP) and initial experience with it at a single center are provided. The ...

Transcorporal Artificial Urinary Sphincter Cuff Placement in a Case Requiring Revision for Urethral Atrophy

Artificial urethral sphincter (AUS) implantation is the definitive management of male stress urinary incontinence (SUI). Under the long-term pressure of the cuff, recurrence of incontinence caused by urethral atrophy can always be observed in patients. In this situation, distal cuff locations are needed, and new cuff sites should be sought in patients who need to undergo AUS reimplantations. Meanwhile, the circumference of the more distal urethra is often too small to fit with a 4.0 cm cuff. This means that the bulk of the urethra should be added not only for a sufficient urethral circumference but also for better protection. Here, we report a case that required AUS reimplantation because of urethral atrophy. This 73-year-old man had undergone AUS implantation 7 years ago and developed incontinence in the past 3 months. Physical examination and ultrasonography determined that the device still worked, and no obstruction or injury was observed through cystoscopy. Surgery for revision of the AUS was needed. In this operation, a new cuff was implanted transcorporally, which was 2 to 3 cm distal to the original cuff site. During a 6 month short-term follow-up, no stress incontinence, urethral injury, or dysuria was observed. The transcorporal technique offers significant advantages in patients with urethral atrophy: corporal tunica albuginea is added to the urethra, allowing a suitable cuff size and lower risk of erosion. It is worth recommending in the reoperation of AUS implantation.

Here we describe the application of transcorporal artificial urethral sphincter (AUS) placement in a case requiring revision of an artificial urinary sphincter for urethral atrophy.

Artificial urethral sphincter (AUS) implantation is the definitive management of male stress urinary incontinence (SUI). Under the long-term pressure of ...