Laparoscopic Distal Ureterectomy with Ureteroneocystostomy and Psoas Hitch

Abstract

Introduction:

In upper urinary tract carcinoma (UUTC), kidney-sparing surgery could represent a valid alternative ^1,2 to radical nephroureterectomy, even if long-term results remain a matter of debate. In this video (video running time: 9′ 37″), we show the technical aspects of laparoscopic distal ureterectomy with ureteroneocystostomy and psoas hitch for the conservative management of a distal ureteral tumor. The video shows some tips and tricks. First, it is imperative to exclude, by means of cystoscopy and ureteroscopy, the presence of further UUTC and to measure, by means of ureteroscopy, the length of a diseased ureter, thus identifying the proximal extent of the lesions. Secondly, it is important an early ureteral clipping above the lesion, thus reducing tumor seeding. Third, the ureteroneocystostomy, after the psoas anchorage, is totally extravesical by using a modified Lich-Gregoir technique. Finally, the video shows that, although laparoscopy needs surgical skill, the conventional laparoscopic approach is a feasible surgery.

Materials and Methods:

We report here a case of a 68-year-old female patient presenting with a high-grade, T1 urothelial carcinoma involving the last 4 cm of right ureter, detected at CT scan during evaluation of painful hematuria. The patient was accurately informed on the nature of the lesion and preferred a conservative treatment with laparoscopic distal ureterectomy and ureteroneocystostomy. Before surgery, cystoscopy and right ureteroscopy were performed to rule out the possibility of other site of urothelial cancer. For laparoscopy, the patient is in a supine position, with 30° Trendelenburg. The optical trocar is in the umbilical position; a 10-mm trocar is introduced in the right lateral position, 2 cm medial to the anterior superior iliac spine; the other 5- or 10-mm trocar is placed in the left lateral position, 2 cm medial to the anterior superior iliac spine. The dissection started by opening of the retroperitoneal space and with an extensive mobilization of the ureter. The distal ureter is carefully prepared and removed together with bladder cuff excision. The bladder is mobilized by freeing the peritoneal attachments; the right bladder dome is then anchored to the psoas major muscle with absorbable sutures, taking care to prevent injury to the genitofemoral nerve. The new ureteral hiatus is created superior to the original orifice by opening the bladder. The ureteroneocystostomy is shaped by using sutures and contemporary insertion of a Double-J catheter.

Results:

The operative time was 184 minutes. No intraoperative or postoperative complications were detected, with a low estimate blood loss. The urethral catheter was removed after a cystogram showing no evidence of an anastomotic leakage on day 8, and the patient was discharged uneventfully from the hospital on day 9. The pigtails were removed after 4 weeks and the patient was asymptomatic after 2 years of follow-up; at 2 years, the CT scan was negative for upper urinary tract relapse.

Conclusions:

Laparoscopic ureterectomy may be easily performed for the management of UUTC of the distal ureter ^3,4 ; the ureteral defect may be easily fixed by using a psoas hitch technique. Laparoscopy is associated with reduced hospital stay, minimal scar, and reduced cost with respect to robotic surgery.

No competing financial interests exist.

Runtime of video: 9 mins 37 secs