Hand-assisted laparoscopic nephroureterectomy with open cystotomy for removal of the distal ureter and bladder cuff

While performing laparoscopic nephroureterectomy, different techniques are used for removal of the distal ureter and bladder cuff. We present a series of patients with urothelial carcinoma of the renal pelvis or ureter who underwent hand-assisted laparoscopic nephroureterectomy (HALNU) with open cystotomy for removal of the distal ureter and bladder cuff. From January 2000 to August 2004, 34 patients underwent HALNU. The hand-port device was placed in a lower-midline infraumbilical incision in all cases. After laparoscopic removal of the kidney and ureter down to the bladder, the hand port incision was extended caudally to allow open cystotomy. Intravesical dissection was performed at the ureteral orifice, and the bladder cuff and distal ureter were removed in a traditional open fashion. The mean operative time was 317 +/- 150 (SD) minutes, but the median operative time was 247 minutes. The mean estimated blood loss was 252 +/- 146 mL. The mean length of stay was 7.6 +/- 6.0 days, but the median stay was 5 days postoperatively (range 3-25). The mean morphine equivalent required postoperatively was 33 +/- 22 mg. The time of Foley catheter removal ranged from 3 to 15 days (mean 6.1 +/- 3.8 days), with no cases of extravasation by cystography at removal. Within a mean follow-up of 13.9 months, no recurrence of urothelial carcinoma was seen at the site of the excised ureteral orifice. A HALNU utilizing an open cystotomy for removal of the entire distal ureter with a bladder cuff provides excellent oncologic control while not adding significantly to the operative time or the morbidity of the procedure.