BERKELEY, CA (UroToday.com) - The dilemma of treating the distal ureteral cuff during laparoscopic nephroureterectomy continues. In this article, 12 patients undergoing laparoscopic nephroureterectomy with stapling of the distal cuff of bladder were compared to 12 patients undergoing open nephroureterectomy; of importance, all patients had only a primary upper tract renal transitional cell cancer and no history of lower tract transitional cell cancer. The incidence of carcinoma-in-situ, multifocality and high grade disease was similar and identical in the two groups, respectively. The local recurrence rate (17% vs. 0%) and the bladder recurrence rate (50% vs. 33%) were higher in the laparoscopic stapled group (p = 0.090). However, follow-up in the open group was briefer (39 vs. 55 months). Of note there were 3 patients (25%) with a positive margin in the laparoscopic group vs. none in the open group. There were no pelvic recurrences or recurrences in the scar of the excised ipsilateral ureteral orifice. The authors sagely recommend consideration of frozen section at the time of laparoscopic excision of the distal ureteral cuff, if it is done with a stapler; if the frozen section is positive then an open resection of the bladder cuff should ensue. One wonders if this had been done whether 3 of the recurrences would have been precluded thereby making the two approaches completely similar with regard to recurrence. To be sure, as a frequent user of the stapler to remove the ureteral cuff, I have over the years altered my technique in order to improve removal of a larger cuff of bladder along with the entire ureteral tunnel: a. Dissection is continued, as suggested to me by Dr. Yohsinari Ono, using the Ligasure or harmonic shears, distally along the ureter through the bladder adventitia and detrusor, thereby pulling the intact ureteral tunnel cephalad. b. Cystoscopic surveillance is done during the stapling procedure to be certain that the stapler is applied distal to the ureteral orifice.

Based on this article, I will now also include a frozen section of the bladder cuff.

Romero FR, Schaefer EM, Muntener M, Trock B, Kavoussi LR, Jarrett TW

J Endourol. 21(9):1025 – 1027, September 2007

PubMed Abstract
PMID: 17941780

UroToday.com Bladder Cancer Section

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