title: A sealed bladder cuff technique during laparoscopic nephroureterectomy utilizing the LigaSure electrosurgical device: laboratory and clinical experience.
abstract: BACKGROUND
  Laparoscopic nephroureterectomy (LNU) is a safe, minimally invasive approach for management of upper tract urothelial tumors. Controversy exists over the optimal technique for the distal ureter and bladder cuff (DUBC) excision. We examined the novel technique of using the LigaSure bipolar electrosurgical device in laboratory investigations and during clinical LNU to manage the DUBC.
  
  
  METHODS
  Initial investigations were undertaken in the porcine model. Areas of both normal porcine ureters and bladders, and ex vivo human ureters from radical nephrectomy specimens were sealed with the LigaSure and stained with nicotinamide adenine dinucleotide (NADH) and hematoxylin and eosin to examine the length of treatment effect and the viability of the ablated tissue. Clinically, we performed 22 LNU for proximal urothelial tumors using the LigaSure for the management of the DUBC. Intraoperative cystoscopy assessed cuff resection and bladder leakage. On postoperative day 10, a cystogram was performed.
  
  
  RESULTS
  In the porcine model, the technique sealed the bladder effectively with a mean burst pressure of 14 mm Hg. Cellular staining revealed no viable urothelial tissue in the seal area and an additional 2 mm outside this area. Eighteen patients had a successful seal/ablation intraoperatively. Cystoscopy revealed cautery artifact and blanching over the former position of the ureteral orifice.
  
  
  CONCLUSIONS
  The LigaSure device ablates and seals urothelial tissue with no viable cells in the clamped and adjacent blanched tissue. Our technique is technically feasible, removes an adequate bladder cuff, typically maintains a closed urinary system, and adheres to sound oncological principles. This procedure could be performed in both laparoscopic and open nephroureterectomy for proximal upper tract transitional cell tumors.
authors.affiliation: Department of Urology, Vanderbilt University Medical Center, Nashville, Tennessee 37232, USA. ehl2102@gmail.com
authors.forename: Erica H
authors.initials: EH
authors.lastname: Lambert
authors.forename: Lee R
authors.initials: LR
authors.lastname: Schachter
authors.forename: Hernan O
authors.initials: HO
authors.lastname: Altamar
authors.forename: Sergei
authors.initials: S
authors.lastname: Tikhonenkov
authors.forename: Gilbert
authors.initials: G
authors.lastname: Moeckel
authors.forename: Nicole L
authors.initials: NL
authors.lastname: Miller
authors.forename: S Duke
authors.initials: SD
authors.lastname: Herrell
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D000818:Animals; D004564:Electrocoagulation; D004598:Electrosurgery / Q000295:instrumentation*; D005260:Female; D006801:Humans; D010535:Laparoscopy / Q000379:methods*; D008297:Male; D008875:Middle Aged; D023421:Models, Animal; D009243:NAD / Q000378:metabolism; D009392:Nephrectomy / Q000379:methods*; D034421:Sus scrofa; D014513:Ureter / Q000601:surgery*; D001743:Urinary Bladder / Q000601:surgery*
chemical_list: D009243:NAD