Removal of Kidney and Ureter
The kidney, ureter, and bladder are lined by tissue called transitional epithelium. When cancer occurs within this lining, it is referred to as transitional cell carcinoma. Symptoms may include pain, bleeding, or bladder irritation. The diagnosis is confirmed by performing ureteroscopy and obtaining tissue biopsy. If cancer is diagnosed, tests are performed to determine if the disease has spread. In patients with disease confined to the urinary tract, treatment includes removing both the kidney and the ureter. In the past this operation required two large incisions, one in the flank and a second in the lower abdomen. Using laparoscopy this same procedure may be performed using three to four small keyhole incisions.
The patient must undergo general anesthesia for this procedure. First, the ureter where it enters the bladder is freed using a specially designed cystoscope. Next, four to five small cylindrical tubes called trocars are placed into the abdominal cavity. The trocars allow entry of a video-telescope, called a laparoscope, for a view of the entire abdominal cavity and kidney. The video-telescope gives the surgeon a magnified view of the operating field and allows identification of vessels and structures with more clarity than is possible in open surgery. Small accessory trocars allow the introduction of fine instruments necessary to perform surgery. When all of the trocars and instruments are in place, the vessels that bring blood to and from the kidney are clipped. The kidney and ureter are now freed from their surrounding structures. The ureter is dissected all the way down to the bladder. The kidney and ureter are then removed as one by extending one of the trocar incisions two to three inches.
Several investigators, including ourselves, have compared laparoscopic nephroureterectomies with standard open nephroureterectomies in terms of operative time, estimated blood loss, pain medication required, length of hospital stay, time to return to normal activity, and complications. We have concluded that although the operative time appears longer, less pain medication is required and time in hospital and time off from work are significantly shorter. In addition there was no increase in complications, and blood loss was similar in both groups. After the operation the patient is required to have a tube draining the bladder (Foley catheter) for seven to ten days to insure proper healing of the bladder. This precaution also is required when the older open procedure is performed.