title: A Novel and Simple Modification for Management of Distal Ureter During Laparoscopic Nephroureterectomy Without Patient Repositioning: A Bulldog Clamp Technique and Description of Modified Port Placement.
abstract: OBJECTIVE
  To describe a novel and pure laparoscopic approach using a custom-made bulldog clamp with modified port placement for management of distal ureter during laparoscopic nephroureterectomy.
  
  
  METHODS
  Between October 2013 and December 2014, 31 patients found to have upper tract urothelial carcinoma were treated using this technique. After finishing a standard laparoscopic transperitoneal nephrectomy in a 45° to 60° recumbent position, an additional 12-mm trocar was inserted at the lower abdomen to allow the surgeon to continue dissecting the ureter caudally toward the bladder wall without repositioning the patient. The intramural ureter was separated from the surrounding detrusor muscle and down to the bladder mucosa, until a tent-shaped bladder cuff and intramural ureter could be formed by retraction in the superior and lateral directions. Then, a custom-made laparoscopic bulldog clamp was placed at the bottom of the tent-shaped structure to prevent urine spillage, and the bladder was closed by two-layer running closure using a barbed suture.
  
  
  RESULTS
  All surgeries were completed uneventfully. The mean operative time and estimated blood loss were 146.6 minutes and 47.3 mL, respectively. The median duration of the postoperative hospital stay was 6 days. No complications were noted. There were no positive margins in any specimen. No patients experienced stone formation or local or bladder recurrence during the 10.5-month follow-up period.
  
  
  CONCLUSIONS
  Our novel technique fully replicates the open excision technique and conforms to the strictest oncologic principles while avoiding patient repositioning and the use of staplers (EndoGIA or Hemolock) to prevent stone formation.
authors.affiliation: 1 Department of Urology, Peking University First Hospital , Beijing, China .|2 Institute of Urology, Peking University , Beijing, China .|3 National Urological Cancer Center , Beijing, China .
authors.forename: Pei
authors.initials: P
authors.lastname: Liu
authors.affiliation: 1 Department of Urology, Peking University First Hospital , Beijing, China .|2 Institute of Urology, Peking University , Beijing, China .|3 National Urological Cancer Center , Beijing, China .
authors.forename: Dong
authors.initials: D
authors.lastname: Fang
authors.affiliation: 1 Department of Urology, Peking University First Hospital , Beijing, China .|2 Institute of Urology, Peking University , Beijing, China .|3 National Urological Cancer Center , Beijing, China .
authors.forename: Gengyan
authors.initials: G
authors.lastname: Xiong
authors.affiliation: 1 Department of Urology, Peking University First Hospital , Beijing, China .|2 Institute of Urology, Peking University , Beijing, China .|3 National Urological Cancer Center , Beijing, China .
authors.forename: Kaiwei
authors.initials: K
authors.lastname: Yang
authors.affiliation: 1 Department of Urology, Peking University First Hospital , Beijing, China .|2 Institute of Urology, Peking University , Beijing, China .|3 National Urological Cancer Center , Beijing, China .
authors.forename: Lei
authors.initials: L
authors.lastname: Zhang
authors.affiliation: 1 Department of Urology, Peking University First Hospital , Beijing, China .|2 Institute of Urology, Peking University , Beijing, China .|3 National Urological Cancer Center , Beijing, China .
authors.forename: Lin
authors.initials: L
authors.lastname: Yao
authors.affiliation: 1 Department of Urology, Peking University First Hospital , Beijing, China .|2 Institute of Urology, Peking University , Beijing, China .|3 National Urological Cancer Center , Beijing, China .
authors.forename: Cuijian
authors.initials: C
authors.lastname: Zhang
authors.affiliation: 1 Department of Urology, Peking University First Hospital , Beijing, China .|2 Institute of Urology, Peking University , Beijing, China .|3 National Urological Cancer Center , Beijing, China .
authors.forename: Xuesong
authors.initials: X
authors.lastname: Li
authors.affiliation: 1 Department of Urology, Peking University First Hospital , Beijing, China .|2 Institute of Urology, Peking University , Beijing, China .|3 National Urological Cancer Center , Beijing, China .
authors.forename: Zhisong
authors.initials: Z
authors.lastname: He
authors.affiliation: 1 Department of Urology, Peking University First Hospital , Beijing, China .|2 Institute of Urology, Peking University , Beijing, China .|3 National Urological Cancer Center , Beijing, China .
authors.forename: Liqun
authors.initials: L
authors.lastname: Zhou
mesh_terms: D000368:Aged; D002295:Carcinoma, Transitional Cell / Q000601:surgery*; D005260:Female; D006801:Humans; D007680:Kidney Neoplasms / Q000601:surgery*; D007682:Kidney Pelvis; D010535:Laparoscopy / Q000379:methods; D007902:Length of Stay; D008297:Male; D008875:Middle Aged; D055805:Moving and Lifting Patients; D009392:Nephrectomy / Q000379:methods*; D061646:Operative Time; D056888:Patient Positioning; D013525:Surgical Instruments; D014513:Ureter / Q000601:surgery*; D014516:Ureteral Neoplasms / Q000601:surgery*