In general, laparoscopic extravesical Ganetespib cancer stapling of the distal ureter and bladder cuff is an attractive approach because the urinary tract is not opened, and tumor spillage is minimized. Additionally, this technique is rapid, especially in the hands of experienced laparoscopists. The disadvantages include the potential for positive surgical margins, the failure to remove the ipsilateral orifice, and a small but nonnegligible risk of compromising the contralateral orifice. Matin and Gill [12] evaluated the patterns of recurrence and survival for the various forms of bladder cuff control in a retrospective study. They demonstrated that positive margins were more frequently associated with a laparoscopic stapling approach than with either the transvesical or open techniques.
Most importantly, the laparoscopic stapling approach was also associated with poorer recurrence-free survival. Tsivian et al. [13] have described a purely laparoscopic nephroureterectomy technique that utilizes two additional trocars in the ipsilateral lower abdomen after a standard transperitoneal nephrectomy. Caudal ureteral dissection continues until the detrusor muscle fibers at the ureterovesical junction are identified. The ureter is then retracted upward, tenting up the bladder wall. The bladder cuff is excised using a 10mm LigaSure Atlas device, which seals the bladder defect. This method does avoid some of the disadvantages associated with the extravesical stapling technique. However, at least theoretically, this method does not address the issue of possible incomplete distal ureteral resection.
Another group of techniques based on the transvesical approach was also introduced in an effort to mimic the reliable open transvesical excision technique. Gill et al. [14] have described a novel laparoscopic technique that involves the use of two 2mm transvesical suprapubic trocars and a ureteral stent in the ipsilateral ureter. The ureter is tented upward; a loop ligature is placed around the stent, creating a closed system, and a Collin’s knife is then used to excise the ureteral orifice. A technique resembling this technique has been reported by Ahlawat and Gautam [15], in which only one transvesical suprapubic 5mm port is used. A transurethral resectoscope is used to make a full-thickness incision in the bladder cuff around the ureteric orifice from 1 o’clock to 11 o’clock.
A grasper inserted through the transvesical suprapubic port is then used to retract the ureter to complete the incision in the bladder cuff overlying the anterior aspect of the ureteric orifice. The ureter is subsequently sealed with a clip applied through the port. Recently, a very similar technique was described for a series of six patients by Zou et al. [16]. Instead of a 5mm port, Drug_discovery they utilized a 10mm port placed transvesically after pneumovesicum had been established [16].