A NOVEL ENDOSCOPIC APPROACH TOWARDS RESECTION OF THE DISTAL URETER WITH SURROUNDING BLADDER CUFF DURING HAND ASSISTED LAPAROSCOPIC NEPHROURETERECTOMY

The experience and use of hand assisted laparoscopic renal surgery continues to expand among urologists.1‐3 Hand assisted laparoscopic nephroureterectomy appears to be a safe, effective technique that provides intact specimen removal and appropriate pathological staging.4 However, as with the standard laporoscopic approach to nephroureterectomy, no consensus has been reached regarding the optimal technique for excising the distal intravesical ureter with an adequate bladder cuff. Classic oncological protocol requires resection o fa1c m. bladder cuff around the involved ureteral orifice to excise and remove completely the distal intravesical ureter. In an attempt to adhere to these oncological principles, a variety of endoscopic techniques have been used for complete resection of the distal intravesical ureter during laparoscopic nephroureterectomy. These approaches include transurethral unroofing of the ureteral orifice before laparoscopic nephrectomy, endoscopic extravesical clipping or stapling of the bladder cuff, combination bladder port/transurethral unroofing of the ureteral orifice, transurethral bladder cuff excision alone and the “pluck” technique with or without transurethral resection.1‐ 6 Since the most safe and effective method to complete distal intravesical ureteral resection has not been agreed upon by laparoscopic urologists, all of these techniques continue to be used, each with their own specific advantages and disadvantages. We describe an alternative approach to the removal of the distal ureter with a surrounding bladder cuff during hand assisted laparoscopic nephroureterectomy. The potential advantages of this approach may facilitate hand assisted laparoscopic nephroureterectomy. METHODS A 62-year-old man initially presented with gross hematuria. Computerized tomography and retrograde pyelography revealed a 3 3 3 3 5 cm. left renal pelvis mass. Left renal pelvic cytology and ureteroscopy confirmed the diagnosis of transitional cell carcinoma. Cystoscopy and cytology of the bladder revealed no evidence of carcinoma, and metastatic evaluation indicated no evidence of distant disease. After informed consent was obtained a general anesthetic was given and the patient was placed in the left lateral position without the use of the kidney rest. Hand assisted laparoscopic nephrectomy was performed through a 6.5 cm. midline, periumbilical incision using a pneumosleeve with 2, 5 to 12 mm. ports, 1 of which was in the midclavicular line