European Urology

Simone G, Papalia R, Guaglianone S, et al.
Eur Urol 2009;56:520–6
Experts’ summary:
The authors reported their perioperative and oncologic results from a prospective randomised study following purely laparoscopic nephroureterectomy (LNU; group B) and open nephroureterectomy (ONU; group A) in 80 patients affected by nonmetastatic urothelial cancer of the upper urinary tract. After performing a standard transperitoneal laparoscopic nephrectomy, the ureter is dissected to the ureterovesical junction, and a bladder cuff is excised using a 10-mm LigaSure Atlas hand-switching instrument (Covidien, Boulder, CO, USA).

At a median follow-up of 44 mo, 12 cancer-related deaths occurred (4 in group A and 8 in group B). The 5-yr cancer-specific survival rate of group B (79.8%) was lower than that of group A (89.9%), although this difference was not statistically significant.

The 5-yr metastasis-free survival of group B (72.5%) also was lower than that of group A (77.4%), but this difference was not statistically significant. The bladder tumour–free survival rates of the two groups were similar: Subsequent bladder tumour occurred in 9 patients from group A and in 10 patients from group B. Neither metastasis nor cancer-related death was observed.

The authors concluded that LNU proved to be superior to ONU in terms of perioperative outcome, thanks to the advantages of minimal invasiveness and oncologic outcomes that were comparable to ONU in patients with organ-confined disease.
Experts’ comments:
Transitional cell carcinoma (TCC) of the upper urinary tract is relatively uncommon, accounting for 2–10% of all urothelial tumours and, unlike prostate and renal cell carcinomas, is unique because its cells may be shed via urine and become implanted in a raw wound. About 30% of these patients have tumours invading the musculature of the renal pelvis or the ureter, and an additional 30% have involvement of peripelvic or periureteral soft tissue, renal parenchyma, or regional lymph nodes at the time of initial diagnosis. The standard treatment for infiltrative TCC of the upper urinary tract consists of two different procedures: nephrectomy and removal of the lower end ureter with bladder cuff. The safety and efficacy of laparoscopy for upper urinary tract urothelial cancer have been discussed for many years, particularly with regard to oncologic outcome and the rate of tumour seeding. Discussion has focused on whether laparoscopy is associated with a higher risk of peritoneal dissemination and port-site metastases, the incidence of which is declining due to improvements in surgical technique [1].

The resection of the distal ureter with bladder cuff performed with a laparoscopic LigaSure system has been demonstrated to be safe with excellent oncologic results in two other studies [2] and [3].

The advantages of the LigaSure system are the absence of postoperative haemorrhages, lymphatic leakage, or lymphoceles. Moreover, no stones, which can be associated with a laparoscopic stapler, are described. With this technique it is possible to obtain a precise excision of the complete bladder cuff without breach of the urinary system, thus preventing spillage, and enabling the removal of the entire specimen en bloc.

Based on recent studies [2] and [3], radical LNU can become the new standard of care in surgical therapy for nonadvanced urothelial cancer of the upper urinary tract.

Conflicts of interest

The authors have nothing to disclose.