Nephroureterectomy

Radical nephroureterectomy (RNU) with complete bladder cuff excision is the standard of care for high-risk upper tract urothelial carcinoma (UTUC). Its oncologic principles are en-bloc removal of the entire ipsilateral upper-tract urothelium — kidney, the whole ureter including the intramural portion and ureteral orifice, and a cuff of bladder — with negative margins, and avoidance of urinary spillage (early low ligation of the ureter) to prevent extra-urinary tumour seeding. Patient selection, risk stratification, and the kidney-sparing alternatives are covered in the Upper Tract Urothelial Carcinoma topic; this page is the operative reference.

Indications and Patient Selection

• RNU with bladder cuff and lymphadenectomy is the standard for high-risk UTUC (high-grade biopsy, larger or multifocal tumours, urinary obstruction, or invasive imaging features).
• Kidney-sparing surgery (ureteroscopic/percutaneous ablation, intraluminal therapy, or segmental ureterectomy) is preferred for low-risk disease, and distal ureterectomy with reimplantation is favoured for high-risk or unfavourable low-risk disease confined to the lower ureter in a functional renal unit.
• Rarely, a benign destroyed kidney (chronic infection, severe reflux) warrants nephroureterectomy; technique is unchanged.

Preoperative Workup

• Diagnosis — CT urography is the preferred study; a collecting-system/ureteral filling defect detects 50–75% of UTUC, and adding ureteroscopy with biopsy and cytology raises the yield to ~90%. Urine cytology is positive in ~20% of low-grade and up to ~75% of high-grade tumours.
• Staging — cystoscopy to exclude a synchronous bladder tumour, chest imaging, and a triple-phase CT of the abdomen/pelvis for nodes and metastases; treat positive cultures preoperatively.
• Neoadjuvant chemotherapy — cisplatin-based NAC should be considered for high-risk disease, especially when the post-operative eGFR is expected to fall below 60 (RNU worsens renal function and cisplatin eligibility), giving a pathologic complete response in ~11%.
• Peri-operative — hold/bridge anticoagulation, antibiotic prophylaxis (2 g cefazolin; TMP-SMX if penicillin-allergic), and VTE prophylaxis (compression devices + heparin).

Choosing the Approach

Open, laparoscopic, hand-assisted, robotic, and hybrid lap-then-robotic approaches are all used — nephroureterectomy arguably has more technical diversity than any other urologic cancer operation. Most UTUC are not bulky, so a minimally invasive approach is favoured (at least for the renal portion) with comparable oncologic efficacy, shorter stays, and fewer complications; the robot eases pelvic dissection and the bladder-cuff suturing. Reserve open surgery for large, bulky, or locally invasive tumours and marked lymphadenopathy. The operation divides into two parts — the nephrectomy with proximal ureter, and the distal ureterectomy with bladder cuff — which can be mixed and matched.

Nephrectomy and Proximal Ureter

The kidney and proximal ureter are removed exactly as in radical nephrectomy (see Radical Nephrectomy) — but the ureter is never divided at the lower pole; it is dissected in continuity toward the bladder, and clipped below the tumour early to stop tumour-cell migration. Spare the adrenal unless directly involved.

• Open (two-incision technique) — the popular open approach: a flank/miniflank incision for an adrenal-sparing radical nephrectomy, dissecting the ureter as far as the common iliac artery (clip below the tumour; do not avulse it), then reposition supine for a Gibson or low-midline incision to complete the bladder cuff. A single-incision (midline) approach exists but adds morbidity without better exposure.
• Laparoscopic — a transperitoneal four-trocar approach in a modified flank position (75–90° off the bed, table flexed 10–15°), kidney rest just cranial to the iliac crest so both stages can be done without repositioning. Incise the white line of Toldt, medialize the colon (leave lateral Gerota attachments so the kidney does not flop medially), control the hilum (artery then vein, or en-bloc stapler), and dissect the ureter distally — the superior vesical artery crosses just before the bladder and is a useful landmark (control it to avoid troublesome bleeding); divide the vas deferens or round ligament if needed for distal exposure.
• Hand-assisted (HALNU) — a hand incision (Gibson or midline) doubles as the extraction site and, with caudal extension, as access for an open distal ureterectomy; deep Trendelenburg rotates the hand into the pelvis for the distal dissection.
• Robotic — a single docking can complete the whole abdominopelvic case. da Vinci Si: a camera port lateral to the rectus at the umbilicus, three 8-mm arms, and a supraumbilical 12-mm assistant port; Xi: an 8-mm camera 2 fingerbreadths above the umbilicus with the arms along the lateral rectus line. Add a 5-mm subxiphoid liver-retractor port on the right.

Managing the Distal Ureter and Bladder Cuff

This is the oncologically critical step — a retained ureteral stump recurs in 30–75%, so the entire intramural ureter and orifice must come out with a bladder cuff. Endoscopic methods carry higher intravesical-recurrence rates, and an extravesical stapled transection without a cuff raises positive-margin rates (it leaves urothelium in the staple line and prevents margin assessment) — so it is not used for distal ureteral tumours.

Technique	Advantages	Disadvantages
Open intravesical	Ensures complete intramural-ureter excision; most reliable for bulky distal tumours	Cystotomy; prolonged catheterization; potential urine leak
Open extravesical	Quick, no formal cystotomy	Complete intramural removal can be difficult
Laparoscopic extravesical, with cuff	Minimally invasive, removes a true cuff	Technically demanding suturing (eased robotically)
Extravesical transection, no cuff	Quickest, no cystotomy	Higher positive margins / recurrence; contraindicated for distal tumours
Transvesical (cystoscopic) ligation	No abdominal cystotomy	Intramural tunnel may remain
Endoscopic (pluck / intussusception / unroofing)	Avoids a second incision	Tumour seeding and higher recurrence; pluck largely abandoned

Open intravesical (the most reliable): through a low-midline incision and the space of Retzius, fill the bladder, place stay sutures, and open it; pass a ureteral catheter into the orifice and fix it with a 3-0 silk figure-of-eight for traction, incise a 5–10 mm mucosal cuff around the orifice, dissect the intramural ureter free, remove the specimen en bloc, and close the bladder in two layers (2-0 muscle/serosa, 3-0 mucosa).

Open extravesical: develop the space of Retzius, rotate the bladder to expose the posterolateral ureteric insertion (ligating the superior vesical artery improves access), dissect the ureter through Waldeyer's sheath until a rim of bladder mucosa bulges around it, excise a 5–10 mm cuff, and close (3-0 mucosa running, 2-0 detrusor running).

Laparoscopic extravesical with cuff: dissect distally, incise the bladder just anterior to the ureter, dissect circumferentially around the orifice (avoid the contralateral orifice), detach the ureter once the cuff is fully excised, and close with a running barbed locking double-layer closure (or 3-0 Vicryl).

Endoscopic methods (pluck, intussusception/stripping, ureteral unroofing) are reserved for large-volume low-grade renal-pelvis tumours not amenable to endoscopic ablation, and must not be used for distal or mid-ureteral tumours.

Lymph Node Dissection

Considered for high-grade, ≥ T2/T3, or bulky disease and for radiographically suspicious nodes; a survival benefit is suggested for pT2–T4. Templates follow tumour location (renal hilum to the aortic bifurcation for upper-tract tumours):

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

Submit nodal packets separately and labelled; for distal tumours, dissection often follows bladder-cuff excision (the cuff bagged to avoid organ contact).

Intravesical Chemotherapy

• Intra-operative — some instill a cytotoxic (mitomycin C or Adriamycin) or sterile water into the bladder for a 15–30 minute dwell before the cystotomy to lyse free-floating tumour cells; drain the bladder before incising it to avoid spilling the agent into the field.
• Peri-operative single dose — a single intravesical instillation after RNU reduces bladder recurrence: ODMIT-C (single post-op mitomycin 40 mg in 40 mL at catheter removal) cut the first-year bladder-tumour rate to 16% vs 27%. Gemcitabine is often preferred over mitomycin (lower risk of chemical peritonitis on extravasation).

Postoperative Care

• A perivesical closed-suction drain for 1–3 days until drainage is minimal.
• The Foley catheter stays 7–14 days regardless of cuff technique; obtain a cystogram before removal to confirm no extravasation.
• Reassess blood pressure, eGFR, and proteinuria early and at 3–6 months — RNU reduces renal function and hyperfiltration can damage the remaining nephrons; refer to nephrology for progressive insufficiency.
• Bladder surveillance is essential — a metachronous bladder tumour develops in ~30% after RNU (mostly within 2 years), so schedule lifelong surveillance cystoscopy.

Complications

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

• Intraoperative — bleeding; injury to an adjacent organ (bowel, liver, or spleen); ureteral avulsion with tumour spillage if the ureter is pulled too hard.
• Early postoperative — infection; urine leak; reoperation for bleeding or wound dehiscence.
• Late — incisional hernia; post-RNU CKD; intravesical recurrence in ~30%, mostly within 2 years.