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Minimally invasive surgery (MIS) in pediatric population is becoming more and more popular among pediatric urologists and now it can be considered the best treatment for nephroureterectomy that is one of the most frequent urological procedures. The main indications to MIS ureteronephrectomy in children are congenital or acquired benign conditions such as nonfunctional and/or damaging kidney, renal dysplasia, and destroyed kidneys due to obstructive or refluxing uropathy. Since ever in open urological surgery, the lateral retroperitoneal approach represents the typical way to approach this kind of surgery. Although different surgical approaches can be chosen (i.e., posterior retroperitoneal, lateral retroperitoneal, laparoscopic transperitoneal, and robotic approach), the lateral retroperitoneal approach represents the typical way to perform this kind of surgery, also with minimally invasive techniques. In this article, we illustrate the technique of retroperitoneoscopic nephroureterectomy in infants and children, reporting our experience with this technique in the past 20 years.

Ureteral cancer in the retrocaval ureter is rare. We herein report a patient with this condition laparoscopically treated. A 69-year-old man was referred to us because of right ureteral cancer diagnosed during ureteroscopic surgery for a ureteral calculus. Histological diagnosis of the ureteroscopically biopsied material was non-invasive papillary urothelial carcinoma, low grade (G2). Computed tomography (CT) demonstrated a retrocaval ureter : a double J stent placed during ureteroscopy assisted the diagnosis. The patient underwent retroperitoneoscopic complete nephroureterectomy on the right side. Sufficient separation of the right ureter and the inferior vena cava under retroperitoneoscopic procedures facilitated en bloc extirpation of the kidney and ureter with a minimal lower abdominal incision. The surgical procedures for ureteral cancer in the retrocaval ureter, should be preoperatively considered with care.

Background The present study was designed to compare oncologic outcomes of T2 upper tract urothelial carcinoma patients treated with retroperitoneoscopic nephroureterectomy (RNU) or open radical nephroureterectomy (ONU). Patients and Methods T2 upper tract urothelial carcinoma patients were treated with RNU (n = 110) or ONU (n = 118) and followed-up for > 5 years. Demographic and clinical data, including preoperative indexes, intraoperative indexes, and oncological outcomes, were retrospectively compared to determine the efficacy of the 2 procedures. Results The RNU and ONU groups were statistically similar in age, sex, tumor location, and tumor pathologic grade. The original surgery time required for RNU and ONU was statistically similar, but RNU was associated with a significantly smaller volume of intraoperative estimated blood loss and shorter length of postoperative hospital stay. Follow-up (average: 43.2 months; range, 6-72 months) revealed that the estimated 5-year overall survival rate and the estimated 5-year disease-specific survival rate after RNU was slightly worse than after ONU (66.0% vs. 67.1%, and 80.8% vs. 83.8%, respectively), and the estimated 5-year recurrence-free survival rate and the estimated 5-year intravesical recurrence-free survival rates were slightly better than ONU (79.5% vs. 77.9%, and 68.3% vs. 65.6%, respectively). However, none of these differences were statistically significant. Conclusion The open surgery strategy and the RNU strategy are equally effective for treating T2 upper tract urothelial carcinoma. However, the RNU procedure is safer, less invasive, and requires a shorter duration of postoperative hospitalized care; thus, RNU is recommended as the preferred strategy.

Objective This study examined the efficacy of the intracorporeal one-hand tie technique for renal pedicle control during hand-assisted retroperitoneoscopic nephroureterectomy (HARN). Methods The intracorporeal one-hand tie technique was conducted in 32 consecutive patients with upper tract urothelial cancer that underwent HARN and open bladder cuff excision. Results All suture ligatures were successful in securing the renal vessels, except one minor venous bleeding that occurred during vessel transection, which was then controlled by additional clips. The process of controlling the renal pedicle took an average of 12.4 minutes (range, 8–30 minutes). No pedicle control related morbidities were noted. By sparing the usage of endovascular clips and staplers, operative costs were reduced and associated malfunctions eliminated. Conclusion The intracorporeal one-hand tie technique is an easy, reliable, and cost-effective method in controlling the renal pedicle during HARN. Its efficacy in pedicle control is beyond doubt.

Objectives: To explore the feasibility and safety of retroperitoneoscopic nephroureterectomy for kidney tuberculosis. Methods: Forty-eight retroperitoneoscopic nephroureterectomies and thirty-five nephroureterectomies for kidney tuberculosis procedures were performed from June 2008 to December 2014. The patients consisted of 53 males and 30 females with a mean age of 36 years (range: 26â51 years). The patients' data were reviewed and analyzed. Results: The retroperitoneoscopic nephroureterectomy procedures were completed successfully in 48 cases with no conversions to open surgery. The mean operating time was 170 minutes (range: 121â258 minutes), the mean blood loss was 110Â ml (range: 70â250Â ml), and the mean hospital stay was 5.70 days (range: 5â14 days); these were all much less than nephroureterectomy procedures (PÂ Â 0.05). Seventy-five patients were followed up, and the average follow-up time was 12.5 months (range: 6â20 months). All the patients recovered without any lesions remaining. Conclusions: The results of this study indicate that retroperitoneoscopic nephroureterectomy is a feasible, safe, effective, and less invasive treatment modality for treating renal tuberculosis. Keywords: Renal tuberculosis, Retroperitoneoscopic, Nephroureterectomy

Ureteral cancer in the retrocaval ureter is rare. We herein report a patient with this condition laparoscopically treated. A 69-year-old man was referred to us because of right ureteral cancer diagnosed during ureteroscopic surgery for a ureteral calculus. Histological diagnosis of the ureteroscopically biopsied material was non-invasive papillary urothelial carcinoma, low grade (G2). Computed tomography (CT) demonstrated a retrocaval ureter : a double J stent placed during ureteroscopy assisted the diagnosis. The patient underwent retroperitoneoscopic complete nephroureterectomy on the right side. Sufficient separation of the right ureter and the inferior vena cava under retroperitoneoscopic procedures facilitated en bloc extirpation of the kidney and ureter with a minimal lower abdominal incision. The surgical procedures for ureteral cancer in the retrocaval ureter, should be preoperatively considered with care.

To carry out hand-assisted retroperitoneoscopic nephroureterectomy (HARN) and open bladder cuff excision using a homemade hand-assist device.Twenty-four consecutive patients with upper tract transitional cell carcinoma received HARN and open bladder cuff excisions. The procedures were carried out using a homemade hand-assist device comprising a medium-sized Alexis wound retractor and surgical gloves. The Alexis wound retractor was positioned through a 7-8-cm Gibson incision ready for use. The surgeon inserted the double-gloved, nondominant hand into the retroperitoneal space via the wound retractor. During the procedure, the cuff of the surgeon's outer surgical glove was turned outside-in and snapped onto the external ring of the Alexis wound retractor to prevent carbon dioxide gas leakage. We successfully created pneumoretroperitoneum by insufflating with carbon dioxide at 15 mm Hg. The procedure was carried out through the 7-8-cm Gibson incision and two additional laparoscopic ports.All procedures were performed without complication. The mean estimated blood loss was 81 mL. The mean operation time was 103 minutes. Morphine (mean, 17.6 mg) was administered for pain relief for 1-3 days following surgery. The mean time for recommencing oral intake was 1.5 days, and that to ambulation was 2.0 days. There were no wound complications related to the homemade hand-assist device.Preliminary results show that carrying out HARN using a homemade hand-assist device is safe and feasible. Our homemade hand-assist device offers a cost reduction for the HARN procedure over using commercially available devices.

Background To evaluate the safety and efficacy of the completely retroperitoneoscopic nephroureterectomy (CRNU), a retrospectively comparative study between completely and traditionally retroperitoneoscopic nephroureterectomy (TRNU) was done in a single center. Methods From January 2014 to December 2014, 107 patients with upper tract urothelial cancer (UTUC) underwent CRNU. The kidney was retroperitoneoscopically dissected and the bladder cuff was cut by endoscopic gastrointestinal automatic stapler, and the specimen was removed from a 6-cm incision by posterior axillary line. Demographic, perioperative, and follow-up data were collected and compared retrospectively with 110 patients undergoing TRNU. Results The patients’ characteristics between the two groups were not statistically different (p > 0.05), and all patients successfully received the procedure. The mean operative time (106 ± 37.9 versus 199 ± 69.1 min, p

Introduction Retroperitoneal laparoscopic nephroureterectomy (RLNU) presents a therapeutic dilemma for the surgeon, especially in the case of upper urinary tract urothelial carcinoma (UUT-UC) with huge hydronephrosis (HH). The present study describes a specific technical modification for efficient and successful RLNU for UUT-UC with HH by using the SAND balloon catheter. Patient and Methods A 72-year-old female underwent RLNU. The SAND balloon catheter was directly inserted into the expanded hydronephrotic kidney, and the liquid was extracted appropriately. Urine leakage from the hydronephrotic kidney was avoided, because the puncture site was sealed firmly between the two adjacent balloons at the tip of the catheter. Disposal counter traction using the catheter facilitated the mobilization of the hydronephrotic kidney. Results RLNU with HH was completed without the need for open conversion by the use of the SAND (‘SAND’ derived from ‘sandwich’) balloon catheter. Virtually no spillage occurred during the procedure. The original HH sac could be extracted at its smallest possible size. Conclusion This method improves the surgeon's vision and facilitates the performance of a resection, without causing any spillage of the hydronephrotic kidney contents during RLNU.

To compare the perioperative and oncologic outcome between hand-assisted nephroureterectomy (HARNU) and transurethral bladder cuff incision-assisted nephroureterectomy (TUINU), which manage the bladder cuff with different methods.From January 2005 to December 2008, 325 patients with upper urinary tract urothelial carcinoma (UUT-UC) underwent nephroureterectomy at our institution. A total of 208 patients were enrolled in this retrospective study.A total of 208 patients, including 102 men and 106 women, were analyzed in this retrospective study. Ninety-eight patients underwent HARNU for UUT-UC, and110 patients underwent TUINU. The HARNU group has less operative time and hospital stay, and fewer postoperative ileus episodes. There were trends of less blood loss in the HARNU group. There were no statistical differences in the total bladder tumor recurrence, local recurrence, contralateral recurrence, distant metastasis, and cancer-specific survival between HARNU and TUINU. There was a significantly higher incidence of bladder tumor recurrence in TUINU group, however, than in the HARNU group (P=0.008) if the tumor was located at the low third of the ureter.There were more oncologic concerns about bladder tumor recurrence for the low third ureteral tumor in the TUINU group. In addition, the perioperative outcomes such as operative time, blood loss, hospital stay, and ileus rate were better in the HARNU group. Therefore, surgeons can manage UUT tumor with less oncologic concern and better perioperative results with HARNU.

Objective To evaluate the possible effects of peritoneal tears during hand-assisted retroperitoneoscopic nephroureterectomy (HARN). Materials and Methods Between October 2003 and June 2008, HARN and open bladder cuff excision were performed in 110 patients, 20 of whom had peritoneal tears during the operation. Our policy is not to close the peritoneal defect. We compared the intraoperative and postoperative criteria among the peritoneum-preserved or peritoneum-violated group to evaluate the impacts of peritoneal tears during and after HARN. Results All procedures were successful except 2 open conversions in cases without peritoneal tears because of vascular injuries. There was no significant difference in age, American Society of Anesthesiologists class, or body mass index between the 2 groups. Both groups were similar in terms of total operative time (166 vs 137 minutes, P = .06), estimated blood loss (196 vs 268 mL, P = .51), hospital stay (9.1 vs 12.1 days, P = .41), and postoperative analgesia requirements (28.6 vs 28.5 mg morphine equivalent, P = .51). Compared with the peritoneum-preserved group, peritoneal violation during HARN was associated with a heavier specimen weight (308 vs 193 g, P = .01), and 1 patient in the violation group developed small bowel obstruction 3 weeks after the surgery. Conclusions Most peritoneal tears during HARN may be safely managed without peritoneal closure. Bowel obstruction from internal herniation is rare but is too significant to be ignored. To prevent this morbidity, peritoneal tears of a selected size need either repair or enlargement.

Objectives To evaluate the feasibility of hand-assisted bilateral retroperitoneoscopic nephroureterectomy (HARN) in a completely supine position (spread-eagle position [SEP]) for dialysis patients with bilateral upper urinary tract tumors. Methods From October 2006 to May 2009, bilateral HARN with open bladder cuff excisions were performed in 13 dialysis patients with upper urinary tract tumors. The patient was placed supine with both legs extended and abducted at 45-60 degrees and both arms stretched out to the sides in a SEP. The operation was completed via a 7- to 8-cm lower midline incision and 4 laparoscopic ports (2 on each side). Results All procedures were successful. The mean operation time of bilateral HARN and open bladder cuff resection was 215 minutes, and the mean estimated blood loss was 216 mL. The time to oral intake was 2.5 days and to ambulation was 4.3 days. All patients recovered uneventfully to normal daily activity. No specific complication was related to the position. Conclusions Bilateral HARN in a completely supine, SEP position is feasible and safe. SEP has several advantages, including ease in patient positioning, and the feasibility to perform simultaneous bilateral nephroureterectomy without repositioning of the patient. It also avoids potential risks associated with the lateral decubitus position. Bowel interference of the visual field and mechanical bowel injury are not concerns in this approach. Our experience shows that a completely supine position is not only possible but also advantageous to bilateral HARN.

To compare the perioperative parameters, convalescence parameters, and oncologic outcomes of intermediate follow-up between hand-assisted laparoscopic nephroureterectomy (HALNU) and hand-assisted retroperitoneoscopic radical nephroureterectomy (HARNU) in treating upper urinary tract urothelial carcinoma.We analyzed the data from 48 patients who underwent HALNU and 25 patients who underwent hand-assisted retroperitoneoscopic nephroureterectomy in our institution between January 1999 and December 2003 for UC of the ureter, renal pelvis, or both. Clinical preoperative and perioperative data were collected retrospectively by reviewing medical records. All specimens were pathologically confirmed. The outcomes including bladder recurrence-free survival, metastasis-free survival, cancer-specific survival, and overall survival were compared between the 2 operative methods.The median follow-up period in the HALNU group was 47.5 months (range, 6 to 72 mo) and 32 months in the HARNU group (range, 21 to 43 mo). Patients' demographic data showed no significant difference between the 2 groups. The operation time was similar between the HALNU group and the HARNU group (223 min vs. 252 min; P=0.11). There was statistically less blood loss in the HALNU group compared with the HARNU group (164 mL vs. 212 mL; P=0.42). The complication rates between the HALNU group and the HARNU group were similar (10.4% and 12%, respectively, P=0.84). There was no open conversion or intraoperative mortality in both groups. The 3-year bladder recurrence-free survival, cancer-specific survival, metastasis-free survival, and overall survival rate were comparable in both groups.HALNU and HARNU have comparable perioperative parameters, convalescence results, and oncologic outcomes for the management of upper urinary tract urothelial carcinoma from an intermediate follow-up period.

To evaluate the oncologic results of our operative technique, hand-assisted retroperitoneoscopic nephroureterectomy (HRNU), for the treatment of upper-tract urothelial cancer, various perioperative parameters and oncologic outcomes were compared for HRNU and conventional open nephroureterectomy (CONU).Thirty-six patients with clinical stage T(1,2)N(0)M(0) renal-pelvic and ureteral tumors underwent HRNU. A retroperitoneoscopic nephrectomy was carried out with hand assistance via a lower-abdominal midline incision. The lower ureter was resected by open surgery through the same incision, and the operative specimen was extracted via the same incision. Thirty-seven cases of CONU were reviewed as historical controls. Various perioperative and parameters and oncologic results were compared for the two procedures.The HRNU was completed in all but one case, which was converted to CONU. The mean operating time (395 minutes) was longer than that for CONU (289 minutes), and the mean estimated blood loss with HRNU (497 g) was greater than that with CONU (296 g). The mean time to oral intake (1.4 days) was shorter than that after CONU (2.3 days), and the mean time to walking was shorter (2.1 days v 2.6 days). There were no statistical differences in the cause-specific survival rate, the disease-free survival rate, or the bladder recurrence-free survival rate between HRNU (median follow-up 23 months) and CONU (median follow-up 56 months).The HRNU, a combination of endoscopic and conventional open surgery, seems to be a reasonable surgical procedure, because the lower-abdominal incision can be utilized, not only as a route for hand assistance, but also as a window for open surgery when resecting the distal ureter as well as for extraction of surgical specimens. The procedure is a safe alternative to conventional open surgery for upper urinary-tract tumors from an oncologic viewpoint.

The goal of this study is to compare surgical and oncological outcomes of laparoscopic nephroureterectomy and the open surgery using the concept of systemic inflammatory response syndrome (SIRS) in addition to common variables. Thirty-six and 23 patients having upper urinary tract urothelial cancer who were operated on with retroperitoneoscopic hand-assisted nephroureterectomy (RHANU) or standard open nephroureterectomy (ONU) retrospectively, were analyzed. Median operation time was 140 (range 70-200) and 60 (range 45-85) minutes, respectively in the RHANU group and the ONU group. The median days to ambulation and hospital stay of the RHANU group were significantly shorter than those of the ONU group. There was no significant difference in the incidence of SIRS and other surgical results between the two groups. In oncological outcome, no significant difference was found in the bladder recurrence rate (RHANU vs. ONU; 52% vs. 45%), local recurrence (0% vs. 0%), distant metastasis (11% vs. 13%) or survival rate (94% vs. 91%) between the RHANU group and the ONU group at 2-year follow-up. There was no port site recurrence in the RHANU group. Although the RHANU may have an advantage in terms of earlier recovery, there were no significant differences in the incidence of SIRS and oncological outcomes between the RHANU group and the ONU group., 腎盂尿管腫瘍に対する体腔鏡下および開放腎尿管全摘除術につき手術成績、術後経過を比較検討する。全身的侵襲性の指標としてsystemic inflammatory response syndrome(SIRS)の発症頻度に関しても比較検討を行う。腎盂尿管腫瘍に対して腎尿管全摘除術を施行した体腔鏡下手術36例(2002年4月～2004年12月)開放手術(ONU)23例(1999年1月～2001年12月)を対象とした。体腔鏡下手術は後腹膜鏡下ハンドアシスト法(RHANU)を用いた。手術時間(中央値)はRHANU群140分、ONU群60分とONU群で有意に短かった。出血量は両群とも平均約150mlであった。RHANU群において歩行開始日が有意に短縮していた。SIRSの頻度はRHANU群17%、ONU群26%と有意差を認めなかった。膀胱再発率は52, 45%(以下RHANU群vsONU群)、遠隔転移11, 13%、局所再発は両群とも認めず2年での生存率は94, 91%であった。体腔鏡下手術では、歩行開始日が有意に短く早期の回復が示唆された。SIRSの頻度、再発・転移・生存率に有意な差を認めなかった。体腔鏡下手術のリスク、術式の患者への利点を充分考慮した手術方法の選択が重要と思われた。(著者抄録)

We report our experience with hand-assisted retroperitoneoscopic nephroureterectomy for upper urinary-tract urothelial cancer.Our initial 10 cases of clinical stage T(1)N(0)M(0) renal pelvic and ureteral tumors treated with hand-assisted retroperitoneoscopic nephroureterectomy are included in the present report. Nephrectomy was conducted retroperitoneoscopically with hand assistance via a lower-abdominal midline incision. Resection of the lower ureter together with the bladder cuff was performed as open surgery and the specimen was removed en bloc via the same incision.Hand-assisted retroperitoneoscopic nephroureterectomy was completed successfully in all 10 cases. The mean operating time was 456 +/- 90 minutes, and the mean estimated blood loss was 462 +/- 364 mL. The times to oral intake and walking were 1.5 +/- 0.5 days and 2.3 +/- 0.7 days, respectively. One case of renal vein injury, one case of pulmonary embolism, and three cases of wound infection were the complications.This is the first report of hand-assisted endoscopic nephroureterectomy using the retroperitoneal approach. The surgical technique seems quite reasonable because the lower-abdominal incision can be utilized, not only as a route for hand assistance, but also as a window for open surgery when resecting the distal ureter as well as for extracting the surgical specimen.

Post-operative chyloretroperitoneum is a rare complication in urological surgery. We experienced two cases of post-operative chyloretroperitoneum following retroperitoneoscopic left nephroureterectomy. Both cases were treated successfully with drainage, low fat diet, total parenteral nutrition (case 1 only), sclerotherapy and somatostatin analog. Laparoscopic procedures are supposed to have a higher risk of chylous complications, as CO2 pressure appears to make the operator overlook suppressing the lymphatic leakage from the resected lymphatic channels.

Robot-assisted renal surgery is usually performed transperitoneally due to more available space for excursion of the robotic arms. To our knowledge, we report the first experience with robotic retroperitoneoscopic nephroureterectomy using the Da Vinci Surgical System (Intuitive Surgical, Sunnyvale, CA, USA) and a hybrid port technique. Robotic retroperitoneal nephroureterectomy was performed on two male patients. One 37-year-old patient had a painful non-functioning hydronephrotic left kidney and megaureter; the other aged 76 had a muscle invasive lower left ureteric tumour. Both the procedures were successfully completed with the robot without conversion. Mean operative time was 182.5 min and estimated blood loss 75 ml. Histological examination confirmed the preoperative diagnoses; margins were clear in the patient with tumour. Postoperative recovery was uneventful. We report the technical feasibility of robotic retroperitoneoscopic nephroureterectomy. However, as with all new technology, the benefits need to be further evaluated and proven before this technique can be widely accepted.

Objective: We compared long-term clinical outcomes of upperurinary tract transitional cell carcinoma (TCC) patients treated byretroperitoneoscopic nephroureterectomy (RNU) or open radicalnephroureterectomy (ONU).Methods: Upper urinary tract TCC patients were treated with RNU(n = 86) or ONU (n = 72) and followed-up for more than threeyears. Demographic and clinical data, including preoperativeindexes, intraoperative indexes and long-term clinical outcomes,were retrospectively compared to determine long-term efficacy ofthe two procedures.Results: The RNU and ONU groups were statistically similar inage, gender, previous bladder cancer history, tumour location,pathologic tumour stage, pathologic node metastasis or tumourpathologic grade. The original surgery time required for both RNUand ONU was statistically similar, but RNU was associated witha significantly smaller volume of intraoperative estimated bloodloss and shorter length of postoperative hospital stay. Follow-up(average: 42.4 months, range: 3-57) revealed that the RNU 3-yearrecurrence-free survival rate was 62.8% and the 3-year cancerspecific survival rate was 80.7%. In the ONU group, the 3-yearrecurrence-free survival and the three-year cancer-specific survivalrates were 59.2% and 80.3%, respectively. Neither of the survivalrates were statistically different between the two groups. T stage,grade, lymph node metastasis and bladder tumour history wererisk factors for tumour recurrence; the operation mode and thebladder cuff incision mode had no correlation with the recurrencefreesurvival.Conclusion: The open surgery strategy and the retroperitoneoscopicnephroureterectomy strategy are equally effective for treating upperurinary tract TCC. However, the RNU procedure is less invasive,and requires a shorter duration of postoperative hospitalized care;thus, RNU is recommended as the preferred strategy.

We present the results of a pure retroperitoneoscopic/ extraperitoneal nephroureterectomy (RENU) for upper urinary tract transitional cell cancer (UT-TCC). After establishment of RENU in benign indications (n = 21 Patients), 14 patients (age range 51–92 years, mean 71.6) with UT-TCC have undergone the technique in our clinic from October 2005 to October 2008. This paper reports the operative procedure, clinical results and follow up. Total operative time was 110-240 minutes (median 154.5). Average blood loss was 132 mL. Tumor localization in oncology patients was renal pelvis (63.6%), ureter (18.2%) or both (18.2%). Postoperative tumor stages were Ta (n = 2), Tis (n = 2), T1 (n = 3), T2 (n = 3) and T3 (n = 4) without lymph node involvement. No perioperative complications were observed. Urethral catheters were removed on Day 6-8 post surgery (median Day 7). Recovery to normal life activity ranged from 8 to 30 days (mean 17.8). During the 4–36 month (median 23) follow-up period, there was one mortality due to cancer progression. Four patients had developed superficial bladder cancer disease requiring regular cystoscopic resections. One patient had coincidental Bellini duct renal tumor and developed psoas metastasis after eight months. The 2-year tumor specific survival rate is 91%. The retroperitoneoscopic/ extraperitoneal nephroureterectomy is a lowrisk and minimally invasive procedure to be used whenever nephroureterectomy is indicated. It is an attractive alternative to both laparoscopic and open techniques and adheres to the oncological principles of radical nephroureterectomy. Short-term follow-up data showed no increased risk of tumor recurrence. However, long-term results are needed before this technique can be established as standard UT-TCC therapy.

Objective To report our technique using a modified muscle-sparing Gibson incision for hand-assisted retroperitoneoscopic nephroureterectomy (HARN) and open bladder cuff excision. Materials and Methods Thirty-four patients with upper tract transitional cell carcinoma received HARN and open bladder cuff excision using the modified muscle-sparing Gibson incision—an approach through a window behind the rectus abdominis muscle with the patient in a supine position with the legs extended and abducted at 45-60° with the surgeon standing between the legs of the patient. The window behind the rectus muscle was identified with ease. HARN and open bladder cuff excision were performed uneventfully using this incision. Mean estimated blood loss was 119 mL. Mean operation time was 139 minutes. Morphine was required for pain relief for 1-3 days (mean 16.5 mg). Mean time to oral intake was 1.5 days and to ambulation was 2.1 days. No lower abdominal bulge was found during a 15.4-month follow-up. Conclusion This modified muscle-sparing Gibson incision for retroperitoneal hand-assisted laparoscopic nephrectomy has the benefit of easier retroperitoneal approach of the Gibson incision. Iliohypogastric nerves can be spared under direct vision. By merely retracting and not incising or splitting the rectus abdominis muscle, this incision may decrease wound-related morbidity. This window could be an important portal for hand-assisted laparoscopic surgeries.

PubMedID: 20879861 Background and Purpose: In children with end-stage reflux nephropathy, nephroureterectomy can be performed either open or laparoscopically. It is not common to use a three-trocar retroperitoneal approach for nephroureterectomy with complete ureteral excision in the pediatric age group. We report the results of pediatric retroperitoneoscopic nephroureterectomies by using three trocars only. Patients and Methods: Between August 2003 and November 2009, 13 children-seven boys and six girls-with end-stage reflux nephropathy underwent retroperitoneoscopic nephroureterectomy. The operations were performed by using three trocars with the patient in a flank position under general anesthesia. Renal blood vessels were individually dissected and divided followed by the transection of the ureter at the level of the ureterovesical junction. Results: The mean age of the patients was 6.5±4.4 years (15 months-14 years). Eight of the operations were performed on the left and five on the right side. Mean operative time was 137±47 minutes (75-230min). Estimated blood losses were minimal. Mean hospitalization time was 2.2±0.9 days (2-5 d). No major intraoperative complication was seen. Overall postoperative analgesic requirement was minimal. Cosmetic results were excellent at the initial postoperative visit. Conclusion: Retroperitoneoscopic nephroureterectomy by using three trocars is feasible and safe with excellent outcomes in pediatric patients with end-stage reflux nephropathy. Copyright 2010, Mary Ann Liebert, Inc.

We report our initial experiences with gasless, hand-assisted retroperitoneoscopic nephroureterectomy for the treatment of urothelial cancer of the upper urinary tract. One hand was inserted by way of the small incision made in the lower abdomen. This method provides easy maneuverability and an acceptable operative time without opening the upper urinary tract.

To assess the efficacy of gasless hand-assisted retroperitoneoscopic nephroureterectomy (HARNU).A total of 54 patients who underwent HARNU were enrolled in the study. Patients were divided into two groups: Retroperitoneoscopic nephroureterectomy with hand port (traditional HARNU) and without hand port (gasless HARNU). Each group was then divided further based on whether body mass index (BMI) value was greater or less than 24 kg/m(2). Operative times, blood loss, and hospital stay were recorded and compared between traditional HARNU and gasless HARNU groups by two-paired Student t test and Wilcoxon sign rank test. These results were also compared between different BMI groups.There were no open surgery conversions in this study. Only one patient needed repeated surgery because of urine leakage from the bladder cuff into the peritoneal space. No statistically significant differences existed in operative times, blood loss, and hospital stay between the hand port and no hand port groups in retroperitoneoscopic nephroureterectomy. Notably, no statistically significant differences existed regardless of whether BMI exceeded 24 kg/m(2) in each group.Gasless retroperitoneoscopic nephroureterectomy proved that the surgery can be performed without a hand port. Obesity did not cause an increase in operative time and blood loss in this study. Therefore, gasless retroperitoneoscopic nephroureterectomy is safe and provides the alternative choice for nephroureterectomy.

To compare the outcomes of retroperitoneoscopic nephroureterectomy (RNU) with those of open retroperitoneal nephroureterectomy (ORNU) for upper urinary tract cancer.This study included 240 consecutive patients who received a clinical diagnosis of localized upper urinary tract cancer and underwent nephroureterectomy by a retroperitoneal approach. Of these, 120 patients underwent RNU and 120 patients underwent ORNU.The mean operative time for RNU (346 min) was significantly longer than that for ONU (209 min), despite the lack of a significant difference in the estimated blood loss between these two groups. Significant differences were observed in parameters related to postoperative recovery between the groups, including the time to walk (1.8 versus 2.3 days), the time to oral intake (1.8 versus 2.7 days), and the time until permission for discharge (9.9 versus 13.4 days). There were no significant differences in the major pathologic factors between the groups. Furthermore, the incidences of intravesical as well as extravesical recurrence between the RNU and ORNU groups were similar, and there were no significant differences in cause-specific and overall survivals between the groups. Among patients with grade 3 disease, cause-specific survivals in patients undergoing RNU were significantly poorer than those in patients undergoing ORNU, while there was no significant difference in the overall survival between the groups. Multivariate analysis, however, indicated that the surgical procedure (RNU versus ORNU) could not be an independent predictor of both overall and cancer-specific survivals irrespective of tumor grade.RNU represents an effective, safe, and less invasive management option for upper urinary tract cancer and achieves a cancer control rate similar to that of ORNU; however, it is necessary to perform further investigations to determine the optimal indications for RNU for patients with high-grade disease.

An 84-year-old man was referred to our hospital with gross hematuria. Abdominal computed tomography demonstrated a well-circumscribed enhanced mass in the right pelviureteral junction. Retroperitoneoscopic nephroureterectomy was performed because of a clinical diagnosis of renal pelvic carcinoma. Pathologic examination led to a final diagnosis of an adult Wilms tumor arising from the renal pelvis. This is the first report of a Wilms tumor in the renal pelvis of an adult patient.

Retroiliac ureter is a rare congenital anomaly. In this paper, we present a case in which retroiliac double ureters were incidentally found during a retroperitoneoscopic nephroureterectomy procedure in a 5-year-old boy with dysplastic right kidney in duplex system and ureterocele. Ureters were both in the retroiliac artery position. The nephroureterectomy procedure was completed retroperitoneoscopically. After a literature review, this case appeared to be the first report of retroiliac double ureters in a duplex system. © Mary Ann Liebert, Inc.

In laparoscopic operations for upper urinary tract transitional cell carcinoma (TCC), three kinds of approach, the transperitoneal, retroperitoneal, and hand-assisted transperitoneal, have been reported. We have performed hand-assisted retroperitoneoscopic nephroureterectomy (HALS) since 2000. The surgical techniques and the operative results of 61 cases of HALS are described and analyzed. These procedures were effective and safe for upper urinary tract TCC.

Various laparoscopic nephroureterectomy techniques for urothelial carcinoma of the upper urinary tract have been developed to minimize postoperative discomfort and the necessity for a lengthy convalescence. We performed hand-assisted retroperitoneoscopic nephroureterectomy without hand-assisted device in 3 male patients with urothelial carcinoma of the distal ureter. Average operative time and estimated blood loss were 251 min (range 235 to 280) and 250 mL (range 200 to 300), respectively. Complication did not occur and conversion to open surgery was not necessary in all cases. Postoperative analgesic requirements were moderate and the time to regular diet intake averaged 3 days (range 2 to 4). None of the patients had a positive margin on the final pathologic specimen. At the average follow-up of 8.1 months, no regional recurrence, port-site metastasis, bladder recurrence, or distant metastasis were noted in any patient. We described our initial experience with the described technique, which obviates the need for midprocedural patient repositioning.

Retroperitoneoscopic heminephrectomy used to manage a horseshoe kidney in a 15-month-old boy is reported. The surgery was decided after a progressive increase of arterial blood pressure in the patient followed for poor kidney functioning resulting from vesicoureteral reflux in both ureters of the left duplex moiety of a horseshoe kidney. The retroperitoneoscopy was conducted with three trocars: a 10-mm port inserted under direct vision at the extremity of the left 12th rib and two 5-mm operating trocars. Division of the isthmus was performed using an ultrasonic scalpel. Duration of the pneumoretroperitoneum was 115 min. The patient was discharged on postoperative day 4. At 2 years postoperatively, the patient’s arterial blood pressure was normal without treatment. The authors conclude that retroperitoneoscopic nephrectomy for horseshoe kidney is safe and feasible in children, offering all the advantages of minimally invasive surgical procedures.