title: Complete urinary tract exenteration for a dialysis patient with urothelial cancer: lower midline and extraperitoneal approach in a supine position.
abstract: OBJECTIVE
  To report a novel technique of extraperitoneal complete urinary tract exenteration (CUTE) for dialysis patients with multifocal urothelial cancer via a lower midline approach in a supine position (the spread-eagle position [SEP]).
  
  
  METHODS
  From October 2006 to May 2009, extraperitoneal CUTE was performed in 10 dialysis patients with multifocal urothelial cancer. Patients were placed supine with both legs extended and abducted at 45 to 60 degrees and both arms stretched out to the sides (SEP). CUTE involves simultaneous bilateral hand-assisted retroperitoneoscopic nephroureterectomy (HARN) and cystectomy or cystoprostatectomy. Bilateral HARN was completed via a 7- to 8-cm lower midline incision and 4 laparoscopic ports (2 on each side). Infraumbilical incision was extended to 12 cm and then extraperitoneal cystectomy was performed under direct vision using standard open surgical techniques.
  
  
  RESULTS
  All procedures were successful. The mean operation time of extraperitoneal CUTE was 328 minutes. The time to oral intake was 2.6 days and to ambulation was 4.6 days. The mean parenteral narcotic requirement (morphine) was 43.6 mg (range, 12-88.6). No patient had recurrent transitional cell carcinoma at a mean follow-up of 29.8 months.
  
  
  CONCLUSIONS
  Extraperitoneal CUTE via a lower midline incision in a completely supine position is feasible and safe. This technique has the benefit of easy supine positioning, eliminates the need for interprocedural repositioning, avoids bowel interference of the visual field, and reduces the risk of possible mechanical bowel injury of a retroperitoneal approach. This approach is a rational option when CUTE is considered.
authors.affiliation: Department of Urology, Medical College and Hospital, National Cheng-Kung University, Tainan, Taiwan.
authors.forename: Chien-Hui
authors.initials: CH
authors.lastname: Ou
authors.forename: Wen-Horng
authors.initials: WH
authors.lastname: Yang
mesh_terms: D000328:Adult; D000368:Aged; D002295:Carcinoma, Transitional Cell / Q000601:surgery*; D015653:Cystectomy; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D009392:Nephrectomy; D056888:Patient Positioning; D010385:Pelvic Exenteration / Q000379:methods; D006435:Renal Dialysis; D014571:Urologic Neoplasms / Q000601:surgery*; D013520:Urologic Surgical Procedures / Q000379:methods