Nephroureterectomy

Radical nephroureterectomy (RNU) with complete bladder cuff excision is the standard of care for high-risk upper tract urothelial carcinoma. Its oncologic principles are complete en-bloc removal of the ipsilateral upper-tract urothelium — kidney, entire ureter including the intramural portion and ureteral orifice — with negative margins, and avoidance of urinary spillage (early low ligation of the ureter) to prevent extra-urinary tumour seeding.

Approach

Open, laparoscopic, and robotic approaches are all suitable. Most UTUC are not bulky, so a minimally invasive approach is ideal — at least for the renal portion — and is associated with shorter stays and fewer complications. Reserve open surgery for large, bulky tumours with clinical evidence of invasion into adjacent structures.

Preoperative Preparation

• Hold/bridge anticoagulation before surgery.
• Consider a bowel preparation to decompress the bowel.
• Antibiotic prophylaxis: 2 g cefazolin (TMP-SMX if penicillin allergic).
• Venous thromboembolism prophylaxis: compression stockings and heparin.

Management of the Distal Ureter and Bladder Cuff

This is the oncologically critical step. The risk of tumour recurrence in a retained ureteral stump is 30–75%, so the entire distal ureter — including the intramural portion and ureteral orifice — must be removed; complete excision improves oncologic outcomes versus incomplete resection. Simple extravesical "tenting up" of the ureter leaves distal ureter behind.

• Extravesical — free the distal ureter to the intramural portion; ligate and divide the bladder's lateral pedicle (obliterated artery; superior, middle, inferior vesical arteries) to reach the entire intramural ureter, then excise a bladder cuff en bloc, staying away from the contralateral orifice.
• Transvesical — make an anterior cystotomy and dissect the ureter intravesically with a ~1 cm mucosal cuff (wider if gross tumour protrudes; en-bloc partial cystectomy if invasive intramural tumour). Close the cystotomy in two layers (mucosa, then detrusor/adventitia), with a Foley for 5–7 days and a perivesical suction drain.
• Transvesical ligation — with the patient in low lithotomy, a cystoscope incises the bladder cuff with a Collins knife, carried into the extravesical space before the nephrectomy.
• Transurethral resection of the orifice ("pluck" technique) — for proximal tumours without bladder disease; aggressive TUR of the orifice and intramural ureter to perivesical fat facilitates later plucking. Largely abandoned because of concerns about extravesical seeding and incomplete resection.
• Intussusception technique — contraindicated with ureteral tumours; risks bladder-urothelium exposure to ureteral mucosa and incomplete intramural excision.
• Total laparoscopic (stapled) technique — contraindicated with distal ureteral tumours; an endovascular stapler placed as distally as possible may leave ureteral mucosa in the staple line and prevents pathologic margin assessment, and has been associated with higher positive-margin rates (which markedly reduce survival).

A formal bladder cuff excision with watertight closure avoids urinary extravasation, allows faster catheter removal, and permits perioperative intravesical chemotherapy.

Open Nephroureterectomy with Bladder Cuff Excision

Position — supine or modified flank; in males, include the genitalia in the field for catheter access. Incision — a midline incision gives the best access to the retroperitoneal nodes and bladder but may limit exposure of the left upper pole in obese patients; flank/subcostal/thoracoabdominal incisions require an additional Gibson, midline, or Pfannenstiel incision for the bladder cuff.

Steps:

1. Mobilize the ipsilateral colon along the white line of Toldt to expose Gerota's fascia.
2. Control the hilum before excessive manipulation (reflect the duodenum medially on the right; avoid the pancreatic tail and spleen on the left). Secure and divide the renal artery and vein; ligate the ureter early to prevent tumour-fragment migration to the bladder.
3. Mobilize the kidney outside Gerota's fascia. Routine adrenalectomy is unnecessary — the adrenal is removed only if directly involved on imaging or inspection.
4. Excise the distal ureter and bladder cuff (see above).

Laparoscopic Radical Nephroureterectomy

A transperitoneal approach with the patient rotated ~20° (movable between flank and modified supine by rotating the table); the flank and urethra are prepped and a Foley placed before insufflation. After incising the white line of Toldt and medializing the colon (leaving lateral Gerota attachments to prevent the kidney flopping medially), the proximal ureter is identified medial to the lower pole and dissected toward the renal pelvis, preserving periureteral fat over any tumour. The hilar vessels are controlled (artery then vein), the ureter clipped, and the kidney freed outside Gerota's fascia (adrenal spared). Note the ureteral blood supply: anteromedial in the proximal third, medial in the middle third, and lateral in the distal third. If the distal dissection reaches below the iliac vessels, the bladder cuff is completed through a lower-abdominal incision.

Robotic-Assisted Laparoscopic Nephroureterectomy

Contraindications — those of laparoscopy, extensive prior abdominopelvic surgery, morbid obesity, or an extremely large tumour. Advantages — reduced blood loss, less pain, shorter stay.

Setup — 60° ipsilateral (tumour-side-up) flank with ~15° Trendelenburg; typically 5 ports (6 if right-sided): four 8 mm robotic ports plus a 12 mm assistant port, with a subxiphoid 5 mm port for liver retraction on the right. Keep ports >8 cm apart and (if not midline) ≥6 cm lateral to the midline to avoid the inferior epigastric vessels. Equipment includes a vascular stapler (2.5 mm closed staple height) or Hem-o-Lok clips and an Endo Catch specimen pouch.

Key operative sequence:

1. Medialize the bowel along the white line of Toldt to expose the retroperitoneum (repair any mesocolon hole; on the right, identify the IVC and protect the duodenum with minimal cautery).
2. Mobilize the upper pole and identify the adrenal (spared); on the left, fully mobilize the spleen.
3. Identify the ureter and gonadal vein at the lower pole along the psoas (look for peristalsis to avoid confusing it with the psoas tendon or iliac artery); trace the gonadal vein to the renal vein (left) or IVC (right). Clip the ureter below the tumour early to prevent distal seeding.
4. Dissect the ureter distally toward the bladder, incising detrusor until the urothelial mucosa tents; partially then fully transect the ureter with the bladder cuff, place stay sutures, and close the cystotomy (pressure-test with ~250 mL saline). Optionally instill intravesical gemcitabine (clamp the Foley ~1 hour).
5. Dissect to and control the renal hilum (artery posterior to vein; beware early arterial branching, more common on the right); ligate vessels (artery/arteries first, then vein). If vessels are hard to isolate, en-bloc stapling is acceptable — a meta-analysis of 595 patients found no arteriovenous fistulae at ~26 months, shorter operative time, and no difference in blood loss or complications.
6. Complete kidney dissection (adrenal sparing), bag the en-bloc specimen (kidney + ureter + bladder cuff), reduce insufflation to ~5 mm Hg to confirm hemostasis, and perform lymphadenectomy if indicated.
7. Deliver the specimen through a Gibson (3 cm above and parallel to the inguinal ligament) or the more cosmetic Pfannenstiel incision, large enough to keep the specimen intact for pathology; close in layers and leave a drain.

Lymph Node Dissection

Considered for high-grade and T2/T3 or bulky disease, or radiographically suspicious nodes. Templates by tumour location:

• Right renal pelvis / proximal ureter — hilar, paracaval, and interaortocaval nodes.
• Left renal pelvis / proximal ureter — hilar, para-aortic, and interaortocaval nodes.
• Distal ureter — ipsilateral pelvic dissection (obturator, external iliac, internal iliac, common iliac packets).

Submit nodal packets separately and labeled. For proximal/pelvic tumours, LND is usually done after nephrectomy; for distal tumours, some perform it after bladder-cuff excision and closure (with the cuff bagged to avoid contact with other organs).

Complications

Overall adverse-event rates range 15–50%, with a ~1% 30-day mortality.

• Intraoperative — bleeding; injury to an adjacent organ (bowel, diaphragm, liver, spleen, pancreas).
• Early postoperative — infection; urine leak; reoperation for bleeding or wound dehiscence.
• Late — incisional hernia.

Key Exam Points

• A retained ureteral stump recurs in 30–75% of cases — excise the entire distal ureter, intramural portion, and ureteral orifice with a bladder cuff.
• Routine adrenalectomy is unnecessary; spare the adrenal unless directly involved.
• Ligate the ureter early (below the tumour) to prevent distal tumour seeding.
• Ureteral blood supply: anteromedial (proximal third), medial (middle third), lateral (distal third).
• The "pluck"/TUR and intussusception and total-laparoscopic-stapled cuff techniques have margin/seeding concerns; the pluck technique is largely abandoned, and stapled distal techniques are contraindicated with distal ureteral tumours.
• A single perioperative intravesical chemotherapy dose reduces bladder recurrence after nephroureterectomy.