Dr. H.C. Klingler and colleagues from Vienna, Austria write in the October issue of European Urology about their experience with 19 patients who underwent modified laparoscopic nephroureterectomies (LNU) and compared them to 15 who had standard open nephroureterectomies (ONU).

Patient characteristics, tumor stages and body habitus were comparable.

They performed LNU trans-abdominally in 14 patients and retroperitoneally in 5. Kidney removal techniques were similar except for laparoscopic versus open approaches. They preserved Gerota's fascia, used "non-touch surgical technique" and did staging lymphadenectomy in 74% of LNU and 40% of ONU.

Their laparoscopic modification arose from ultimate removal of laparoscopic nephroureterectomy and open bladder cuff via a 10 cm. oblique muscle splitting supra-inguinal abdominal incision. They removed all specimens via "a cell tight organ bag". ONU techniques conformed to standard intercostal flank incision plus the same type of lower abdominal incision noted above.

Mean follow-up continued for 22 months (range 14-34). No patient recurred at any port or incisional site. Two patients, one from each group, recurred during follow-up. One LNU patient developed lung metastases after having positive lymph nodes found. One ONU patient recurred at the site of the bladder cuff. This was resected transurethrally, and the patient remains with no evidence of disease (NED).

Two other patients with lymph node micro-metastases received chemotherapy and remain NED.

The authors call our attention to significance peri-operative differences in the two groups: the LNU group recorded less mean operating time, significantly less blood loss, significantly shorter length of stay, significantly less need for pain medication and no severe complications. ONU patients developed one thromboembolism and three wound eventrations for a complication rate of 26.7%.

In discussion, they emphasize the above significant differences. They also note that overall results (NED) of the two different approaches remain similar at two years of follow-up. They believe that during LNU entrapment of the removed tissues in the cell tight organ bag may reduce the risk of metastatic spread. They also avoid use of harmonic scalpels. Finally, because of the lymph node metastases found in both groups, they now "routinely perform regional staging lymphadenectomy in all patients?." They conclude, "(further) results from long-term studies are still warranted?."

European Urology 2003;44:442-447