RE: LAPAROSCOPIC-ASSISTED NEPHROURETERECTOMY AFTER RADICAL CYSTECTOMY FOR TRANSITIONAL CELL CARCINOMA
( Download pdf )

FREDERICO R. ROMERO, MICHAEL MUNTENER, SOMPOL PERMPONGKOSOL, LOUIS R. KAVOUSSI, THOMAS W. JARRETT

The James Buchanan Brady Urological Institute (FRR, MM), Baltimore, Maryland, Department of Urology, North Shore-LIJ Health System (LRK), Long Island, New York and Department of Urology, The George Washington University Medical Center (TWJ), Washington, DC, USA

Int Braz J Urol, 32: 631-9, 2006

To the Editor:

     To the best of my knowledge, this is the first extensive report on the outcome of laparoscopic nephroureterectomy in patients with a prior radical cystectomy. While the authors were successful in performing the procedure with laparoscopic assistance in 6 of 7 patients, the procedures were lengthy, associated with intraoperative complications in 28% of patients, postoperative complications in 28% of patients, and the need for an open incision through the prior cystectomy site in all cases in order to remove the distal cuff of bladder. It is of note that 3 of the 4 complications that occurred were associated with the opening of the old incision in all patients to deal with the distal ureter. The overall difficulty of the dissection is reflected in the 10.8 days of hospital stay. Unfortunately, there was no comparison made to an open cohort treated in a similar manner.
     This report is reminiscent of the initial articles on laparoscopic surgery for xanthogranulomatous pyelonephritis. In those early studies, no benefit to the laparoscopic approach could be found; however, with time and experience, the results have improved to the point where the laparoscopic approach is today the justifiably preferred method at most laparoscopic centers. I would anticipate a similar scenario would evolve for this difficult type of nephroureterectomy.
     What will make the difference? I would opine that other laparoscopic surgeons might elect to begin the procedure with a retroperitoneoscopic approach to the kidney as has been championed by several investigators such as Drs. Ono, Gill, and others. This would preclude dealing with many of the intra-abdominal adhesions and could possibly result in a shorter period of ileus. Secondly, it might be helpful to place a large external ureteral catheter via the conduit prior to embarking on the procedure. This could help with identification and dissection of the ureter especially at the level of the diversion.
     In sum, I congratulate the authors on providing an honest sobering report of their initial experience with postcystectomy nephroureterectomy. It is obvious that this approach is in its earliest stages. While the authors have shown that this procedure is feasible, it, at this point in time, does not appear to be better than the standard open approach.

Dr. Ralph V. Clayman
Professor and Chair, Department of Urology
University of California, Irvine Medical Center
Orange, California, USA
E-mail: rclayman@uci.edu