Laparoscopic radical nephroureterectomy for upper tract transitional cell carcinoma: the Cleveland Clinic experience

We report our single institutional experience with retroperitoneal laparoscopic radical nephroureterectomy in patients with upper tract transitional cell carcinoma and compare results to those achieved by the open technique.

A total of 77 patients underwent radical nephroureterectomy for pathologically confirmed upper tract transitional cell carcinoma. Of these patients 42 underwent laparoscopic nephroureterectomy from September 1997 through January 2000 and 35 underwent open surgery. All specimens were extracted intact. Of the laparoscopic group the juxtavesical ureter and bladder cuff were excised by our novel transvesical needlescopic technique in 27 and radical nephrectomy was performed retroperitoneoscopically in all 42. Data were compared retrospectively with 35 patients undergoing open radical nephroureterectomy from February 1991 through December 1999.

Laparoscopy was superior in regard to surgical time (3.7 versus 4.7 hours, p = 0.003), blood loss (242 versus 696 cc, p <0. 0001), specimen weight (559 versus 388 gm., p = 0.04), resumption of oral intake (1.6 versus 3.2 days, p = 0.0004), narcotic analgesia requirements (26 versus 228 mg., p <0.0001), hospital stay (2.3 versus 6.6 days, p <0.0001), normal activities (4.7 versus 8.2 weeks, p = 0.002) and convalescence (8 versus 14.1 weeks, p = 0.007). Complications occurred in 5 patients (12%) in the laparoscopic group, including open conversions in 2, and in 10 (29%) in the open group (p = 0.07). Followup was shorter in the laparoscopic group (11.1 versus 34.4 months, p <0.0001). The 2 groups were similar in regard to bladder recurrence (23% versus 37%, p = 0.42), local retroperitoneal or port site recurrence (0% versus 0%) and metastatic disease (8.6% versus 13%, p = 1.00). Mortality occurred in 2 patients (6%) in the laparoscopic group and 9 (30%) in the open group. Cancer specific survival (97% versus 87%) and crude survival (97% versus 94%) were similar between both groups (p = 0.59).

In patients with upper tract transitional cell carcinoma who are candidates for radical nephroureterectomy the retroperitoneal laparoscopic approach satisfactorily duplicates established technical principles of traditional open oncological surgery, while significantly decreasing morbidity from this major procedure. Short-term oncological and survival data of the laparoscopic technique are comparable to open surgery. Although long-term followup data are not yet available, it appears that laparoscopic radical nephroureterectomy may supplant open surgery as the standard of care in patients with muscle invasive or high grade upper tract transitional cell carcinoma.