EAU 2019: Total Retroperitoneoscopic Nephroureterectomy with Modified Pluck Technique: Initial Experience

Barcelona, Spain (UroToday.com) One of the challenges of nephroureterectomy, regardless of the surgical approach, is the management of the distal ureter and excision of an adequate bladder cuff. Bladder cuff excision has been shown to improve oncologic control and decrease bladder recurrences, however, can be technically difficult in some patient populations.  Multiple techniques have been utilized for excision of the distal ureter, including open cystotomy with intravesical resection of the cuff, extravesical dissection of the ureter either open, laparoscopically, or robotically with subsequent intravesical tunneling and cuff resection, or endoscopic resection.

As part of the video session on urothelial carcinoma and bladder reconstruction at the 2019 European Association of Urology (EAU) 2019 Annual meeting in Barcelona, Spain, Dr. K Izumi from the Takamatsu Red Cross Hospital in Takamatsu, Japan discussed his group’s experience performing total retroperitoneoscopic nephroureterectomy with a modified “pluck” technique that involves initial cystoscopic excision of the ureteral orifice (UO) and distal ureter. He showed a video of two cases of patients with upper tract urothelial carcinoma undergoing nephroureterectomy using their technique. 

They begin by using a Collin’s knife to excise the UO on the affected side.  Care is taken to circumferentially dissect around the UO and into the intramural tunnel without visualizing retroperitoneal.  This is to avoid any irrigant and urine spillage into the retroperitoneum, which could theoretically cause tumor seeding.  After endoscopic excision of the distal ureter, he proceeds to dissect the distal ureter using a standard laparoscopic retroperitoneal technique.  The ureter is clipped to avoid tumor spillage, and care is taken to “pluck” the ureter out from within the bladder while keeping the ureter in-tact. After the ureter is fully dissected out from the bladder, the cystotomy is closed in 2 layers using a 3-0 V-Lock™ suture.  The repair is tested to ensure it is water-tight.  He then proceeds to dissect the renal hilum and the lateral attachments of the kidney to complete the procedure.  A 6cm muscle-splitting incision is extended from one of the laparoscopic ports for extraction of the specimen.

Moderators then discussed the duration of indwelling catheter placement post-operatively.  The author and colleagues leave a catheter for approximately 3 days after surgery, however, admit that this length is arbitrary.  Moderator J.D. Kelly, a urologic oncologist from London suggested that if a water-tight closure is achieved, a catheter may be unnecessary post-operatively. There was additional discussion regarding the necessity of leaving a surgical drain, however, most of the audience agreed that if the cystotomy closure is felt to be adequate, a drain is largely unnecessary.

Izumi’s group has now performed an initial 10 cases utilizing this technique and believe they have had good success with it.  There have been no significant post-operative complications such as urinoma or retroperitoneal seeding of urothelial carcinoma, though follow-up duration has not been significant.  Izumi concluded that this technique has a short learning curve, is technically feasible, and has provided good outcomes for his patients.  An additional benefit of the retroperitoneoscopic technique includes avoidance of the peritoneum, which can be very helpful in patients with prior intra-abdominal surgery.

Presented by: Kazuyoshi Izumi, Takamatsu Red Cross Hospital, Department of Urology, Takamatsu, Japan 

Written by: Brian Kadow, MD. Society of Urologic Oncology Fellow, Fox Chase Cancer Center at the 34th European Association of Urology (EAU 2019) #EAU19 conference in Barcelona, Spain, March 15-19, 2019.