title: Suprapubic transvesical single-port technique for control of lower end of ureter during laparoscopic nephroureterectomy for upper tract transitional cell carcinoma.
abstract: BACKGROUND
  Various minimally invasive techniques - laparoscopic, endoscopic or combinations of both - have been described to handle the lower ureter during laparoscopic nephroureterectomy but none has received wide acceptance.
  
  
  OBJECTIVE
  We describe an endoscopic technique for the management of lower end of ureter during laparoscopic nephroureterectomy using a single suprapubic laparoscopic port.
  
  
  METHODS
  Transurethral resectoscope is used to make a full thickness incision in the bladder cuff around the ureteric orifice from 1 o'clock to 11 o'clock. A grasper inserted through the transvesical suprapubic port is used to retract the ureter to complete the incision in the bladder cuff overlying the anterior aspect of the ureteric orifice. The lower end of ureter is subsequently sealed with a clip applied through the port. This is followed by a laparoscopic nephrectomy and the specimen is removed by extending the suprapubic port incision. Our technique enables dissection and control of lower end of ureter under direct vision. Moreover, surgical occlusion of the lower end of the ureter prior to dissection of the kidney may decrease cell spillage. The clip also serves as a marker for complete removal of the specimen.
  
  
  RESULTS
  Three patients have undergone this procedure with an average follow up of 19 months. Operative time for the management of lower ureter has been 35, 55 and 40 minutes respectively. A single recurrence was detected on the opposite bladder wall after 9 months via a surveillance cystoscopy. There has been no residual disease or any other locoregional recurrence.
  
  
  CONCLUSIONS
  The described technique for management of lower end of ureter during laparoscopic nephroureterectomy adheres to strict oncologic principles while providing the benefit of a minimally invasive approach.
authors.affiliation: Division of Urology and Renal Transplantation, Medanta Kidney and Urology Institute, Medanta, the Medicity, Gurgaon, India.
authors.forename: Rajesh K
authors.initials: RK
authors.lastname: Ahlawat
authors.forename: Gagan
authors.initials: G
authors.lastname: Gautam