title: A novel approach for a complete laparoscopic nephroureterectomy with bladder cuff excision.
abstract: OBJECTIVE
  The dilemma in management of the distal ureter and bladder cuff during nephroureterectomy (NU) for transitional-cell carcinoma (TCC) of the upper urinary tract has delayed the development of a completely minimally invasive approach to NU in cases of TCC. Our aim is to present our technique of a purely laparoscopic nephroureterectomy performed entirely through laparoscopic ports, which mimics established principles of open surgical nephroureterectomy with bladder cuff excision. Precluding the needed for patient repositioning, complex endoscopic procedures either before or after nephrectomy and leaving the bladder cuff defect to heal spontaneously.
  
  
  METHODS
  Patient positioning and trocar arrangement are similar to those of radical nephrectomy. The simple addition of a 5 mm trocar in the lower abdomen (midline or lateral to the rectus muscle, according to patient build) allows the surgeon to adequately dissect the distal ureter, excise an adequate bladder cuff, and suture the bladder defect in a watertight manner without the need for transurethral and intraureteral instrumentation as well as intraoperative repositioning of the patient.
  
  
  RESULTS
  Eight cases were successfully treated. The operative time ranged from 110 to 200 minutes (mean 157 min). The median time for catheter removal was 7 days; in one patient, catheter removal was delayed to 15 days because of bladder extravasation. Average hospital stay was 10.2 days. During a mean follow-up of 12.1 months, three patients had Ta bladder recurrence, and one patient had local recurrence.
  
  
  CONCLUSIONS
  A complete NU with bladder cuff excision can be accomplished using this approach, with early results comparable to the gold standard of open surgery with the simple addition of a trocar.
authors.affiliation: Urology Department, Krankenhaus Elisabethinen, Linz, Austria. ahmed_ghazimd@yahoo.com
authors.forename: Ahmed
authors.initials: A
authors.lastname: Ghazi
authors.forename: Alexander
authors.initials: A
authors.lastname: Shefler
authors.forename: Martin
authors.initials: M
authors.lastname: Gruell
authors.forename: Reinhold
authors.initials: R
authors.lastname: Zimmermann
authors.forename: Gunter
authors.initials: G
authors.lastname: Janetschek
mesh_terms: D000368:Aged; D005260:Female; D006801:Humans; D007430:Intraoperative Care; D010535:Laparoscopy / Q000379:methods*; D008297:Male; D008875:Middle Aged; D009392:Nephrectomy / Q000379:methods*; D019990:Perioperative Care; D013525:Surgical Instruments; D014513:Ureter / Q000601:surgery*; D001743:Urinary Bladder / Q000601:surgery*