The gold-standard treatment of localized UTUC is radical nephroureterectomy with ipsilateral bladder cuff excision [1]. Nowadays, various techniques for RNU have been reported by surgeons all over the world. (Table 3)
Table 3
Summary of published techniques for radical nephroureterectomy with ipsilateral bladder cuff excision
| | Laparoscopic/robotic | operative approach | Patient's positioning |
| Tomoaki et al., (2007) | Laparoscopic + open | Retroperitoneal | Flank + supine |
| Seyed et al., (2012) | Laparoscopic + open | Transperitoneal | Flank + supine |
| Homayoun et al., (2014) | Robotic | Transperitoneal | Modified flank 60° |
| Zhang et al., (2017) | Pure laparoscopic | Retroperitoneal | Full flank |
| Song et al., (2019) | Pure laparoscopic | Retroperitoneal + transperitoneal | Full flank + flank 60° |
| Jun et al., (2020) | Pure laparoscopic | Extraperitoneal | Full supine |
| Xiao et al., (2021) | Pure laparoscopic | Transperitoneal | Flank |
| Present study | Laparoscopic + open | Retroperitoneal | Modified flank 60° |
Laparoscopy, a substituted procedure to the traditional open approach, was performed and played the key role in surgery for its minimally invasive injury which reduced intraoperative blood loss and the occurrence rate of perioperative complications [18, 19]. And oncological outcomes are also comparable to the open surgery in UTUC patients according to recent meta-analysis and multi-institutional studies [20, 21].
With the development of technology, robot-assisted nephroureterectomy has attracted increasingly higher attention for its advantages of reducing the difficulty of laparoscopic suturing and improving the comfort of surgeons, but the high cost of robotic consumables limited its popularity.
Consequently, many medical centers still attached priority to the pure laparoscopic nephroureterectomy with resection of bladder cuff (pLNU) or hybrid operations (laparoscopic nephroureterectomy plus open resection of bladder cuff) to treat UTUC.
And pLNU requires extra ports [11] and experienced surgeons with proficient skill, additionally the learning curve is longer. Additionally, not only the pure laparoscopic nephroureterectomy but also the robot-assisted radical nephroureterectomy faced a comparatively narrow operating space when it comes to the bladder cuff, which increased the risk of complications associated with surgery. And none of the techniques can avoid the abdominal incision which is inevitably required for specimen retrieval.
Therefore, huge amounts of patients achieved hybrid operations in centers without robotic equipment and a portion of surgeons preferred these even in front of idle robots.
Radical nephroureterectomy with ipsilateral bladder cuff excision was traditionally divided into two steps as its title suggests. And the commonly used hybrid surgical method in clinical practice is laparoscopic nephroureterectomy (step 1) plus ipsilateral bladder cuff excision (step 2) through a Gibson incision in lower abdomen.
The first step can be performed via the transperitoneal or retroperitoneal approach. And each is claimed to be superior to the other for laparoscopic nephroureterectomy.
The larger working space and familiar anatomical landmark gained advantages for the transperitoneal approach. While the retroperitoneal approach not only enabled an independent retroperitoneal space without requiring mobilization of bowel and other organs around the kidney and ureter which reduced the incidence of complications related to bowels and other internal organ but an easier management of the renal pedicle which is crucial for nephrectomy as well.
Wentao Liu et al. reported that although both the transperitoneal and retroperitoneal laparoscopic approaches are safe and effective methods for treatment of UTUC, retroperitoneal approach showed the advantage in terms of quicker bowel recovery and hospital discharge [22]. Tae Heon Kim et al. reviewed retrospectively 743 eligible patients with UTUC and discovered that patients who underwent retroperitoneal nephroureterectomy (rRNU) resulted in better oncologic control of disease progression than those who accepted transperitoneal nephroureterectomy (tRNU), and pointed that the surgical approach was a significant predictive factor of PFS [23]. Kazumasa Matsumoto et al. reported the association of body mass index (BMI) with perioperative outcomes in patients who underwent retroperitoneal laparoscopic or open radical nephroureterectomy and the former approach can be safely performed with significantly reduced EBL even in obese patients with UTUC [24].
The second step, however, all patients who achieved laparoscopic approach at step 1 faced the necessity of reposition, resterilization and draping during the operation, which potentially wasted about 30 mins.
In this study, we introduced a modified hybrid operation method without intraoperative patient repositioning.
Compared with the conventional procedure, our procedure included the following features:
(i).The angle between the long axis of the truncus and the operating table is 30 degrees with the patient's buttocks towards the surgeon, which met the ergonomics design for eliminating the distortion of the surgeon's lower back and improving the comfort level of the operation.
(ii).This modified hybrid operation simplified the surgical position by allowing the circuit nurse to turn the operating table to the patient's dorsal side when finished first step and the patient was placed in an approximated 60° flank position. With this position, the entire colon slid to the large extent towards the contralateral side, which brings a better view of the operation area and a short time of distal ureter and bladder cuff resection. Such a simple modification accelerated its popularization and application. And no difficulty was noted when using this technique.
(iii).The open excision of distal ureter and bladder cuff, which minimized tumor extravasation to the large extent and provided a solid repair of the bladder defect, strictly adheres to the oncologic principles and remains a highly safe and quick procedure. Hem-o-lock, Endo-GIA stapler [25] and bulldog clamp technique [26] were introduced for dealing with the bladder cuff. But when performed blindly as most of the approaches using laparoscope, it can result in an injury of the contralateral ureteric orifice, leaving behind a stump in situ [25], and potential bladder calculi as it is a foreign body irritation. Whereas, the open excision allowed us a standard partial bladder resection around the bladder cuff. And the 2-0 absorbable sutures were used to make running suture in closing the bladder wall without additional cost.
(iv).The whole procedure was performed through an extraperitoneal approach to avoid possible bowel complications and the abdominal cavity implantation metastasis. In our study, we did not find vascular injury or intestinal complications, and the drainage tubes were in place for 5 (4-7) days. The catheter duration was shorter in female patients without the effect of prostatic hyperplasia.
(v).Any kind of minimally invasive surgery aims to duplicate the gold standard open procedure, including the removal of a bladder cuff and a reliable closure of the bladder defect. Our research maximizes this principle.
Limitations of this study include its retrospective nature. In this study, we did not assess the status of neoadjuvant or adjuvant chemotherapy of each patient. And lymphadenectomy was just performed when observed visible lesion during the operation and only 2 were detected positive by pathology. The therapeutic benefits of nodal status and lymph node dissection for disease-free and cancer-free survival remain controversial and needed to be clarified. But from a technical point of view, performing lymphadenectomy with this position did not impose a significant surgical challenge.
Despite these limitations, our center provided comparable data relevant to the effect of surgical approach in patients with UTUC. This technique can be safely reproduced with surgical outcomes comparable to other established techniques.