multi-institutional

Article of the week: LESS nephroureterectomy: is it a good alternative?

September 18, 2013/by admin Z.9

Every week the Editor-in-Chief selects the Article of the Week from the current issue of BJUI. The abstract is reproduced below and you can click on the button to read the full article, which is freely available to all readers for at least 30 days from the time of this post.

In addition to the article itself, there is an accompanying editorial written by a prominent member of the urological community. This blog is intended to provoke comment and discussion and we invite you to use the comment tools at the bottom of each post to join the conversation.

Finally, the third post under the Article of the Week heading on the homepage will consist of additional material or media. This week we feature a video by Prof. Rha and colleagues of LESS nephroureterectomy.

If you only have time to read one article this week, it should be this one.

Laparoendoscopic single-site nephroureterectomy for upper urinary tract urothelial carcinoma: outcomes of an international multi-institutional study of 101 patients

Sung Yul Park, Koon Ho Rha¹, Riccardo Autorino², Ithaar Derweesh³, Evangelos Liastikos⁴, Yao Chou Tsai⁵, Ill Young Seo⁶, Ugo Nagele⁷, Aly M. Abdel-Karim⁸, Thomas Herrmann⁹, Deok Hyun Han¹⁰, Soroush Rais-Bahrami¹¹, Seung Wook Lee, Kyu Shik Kim, Paolo Fornara¹², Panagiotis Kallidonis⁴, Christopher Springer¹², Salah Élsalmy⁸, Shih-Chieh Jeff Chueh¹³, Chen-Hsun Ho¹⁴, Kamol Panumatrassamee², Ryan Kopp³, Jens-Uwe Stolzenburg¹⁵, Lee Richstone¹¹, Jae Hoon Chung, Tae Young Shin¹, Francesco Greco¹² and Jihad H. Kaouk²

Department of Urology, Hanyang University College of Medicine, Seoul, Korea, ¹Department of Urology, Yonsei University College of Medicine, Seoul, Korea, ²Glickman Urological & Kidney Institute, Cleveland Clinic, Cleveland, OH, USA, ³Division of Urology, University of California San Diego, La Jolla, CA, USA, ⁴Department of Urology, School of Medicine, University of Patras, Patras, Greece, ⁵Division of Urology, Buddhist Tzu Chi General Hospital, TaipeiBranch, Taipei, Taiwan, ⁶Department of Urology, Wonkwang University School of Medicine and Hospital, Iksan, Korea, ⁷Department of Urology, LKH, Hall in Tirol, Austria, ⁸Department of Urology, Alexandria University, Alexandria, Egypt, ⁹Department of Urology, Hannover Medical School, Hannover, Germany, ¹⁰Department of Urology, Samsung Medical Center, Sungkyunkwan University, Seoul, Korea, ¹¹The Arthur Smith Institute for Urology, Hofstra North Shore-LIJ School of Medicine, New Hyde Park, NY, USA, ¹²Department of Urology and Kidney Transplantation, Martin-Luther-University, Halle/Saale, Germany, ¹³Cleveland Clinic Urology Charleston Office, Charleston, WV, USA, ¹⁴Division of Urology, National Taiwan University Hospital, Taipei, Taiwan, ¹⁵Department of Urology, University of Leipzig, Leipzig, Germany

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OBJECTIVE

• To report a large multi-institutional series of laparoendoscopic single-site (LESS) nephroureterectomy (NU).

MATERIALS AND METHODS

• Data on all cases of LESS-NU performed between 2008 and 2012 at 15 institutions were retrospectively gathered.

• The main demographic data and perioperative outcomes were analysed.

RESULTS

• The study included 101 patients whose mean (sd) age was 66.4 (9.9) years and mean (sd) body mass index was 24.8 (4) kg/m², and of whom 29.7% had undergone previous abdominal/pelvic surgery.

• The mean (sd) operating time was 221.4 (73.7) min, estimated blood loss 231.7 (348.0) mL.

• A robot-assisted LESS technique was applied in 25.7% of cases. An extra trocar was inserted in 28.7% of cases to complete the procedure. Conversion to open surgery was necessary in three cases (3.0%). There was no bladder cuff excision in 20.8% of cases, and excision was carried out using a variety of techniques in the remaining cases.

• Six intra-operative complications occurred (5.9%). The mean (sd) length of hospital stay was 6.3 (3.5) days. The overall postoperative complication rate was 10.0%, and most of the complications were low grade (Clavien grades 1 and 2).

• The mean tumour size was 3.1 (1.9) cm. Pathological staging was pTis in two patients, pTa in 12 patients, pT1 in 42 patients, pT2 in 20 patients, pT3 in 23 patients and pT4 in two patients. Pathological grade was high in 71 and low in 30 patients.

• At a mean follow-up of 14 months, six patients (5.9%) had died. Disease recurrence (including distant and bladder recurrence) was detected in 22.8% of patients, with a mean time to recurrence of 11.5 months.

CONCLUSIONS

• This study reports the largest multi-institutional experience of LESS-NU to date.

• Peri-operative outcomes mirror those of published standard laparoscopy series.

• Despite encouraging early findings, longer follow-up is needed to determine the oncological efficacy of the procedure.

Read Previous Articles of the Week

Editorial: LESS versus laparoscopic nephroureterectomy: the winner is…

September 18, 2013/1 Comment/by Francesco Porpiglia

In this international multi-institutional study, Park et al. [1] have retrospectively collected and analysed data about 101 patients who underwent laparoendoscopic single-site (LESS) nephroureterectomy (NU) for upper urinary tract (UUT) urothelial carcinoma.

Nowadays, NU represents the standard of care for the surgical treatment of UUT urothelial carcinoma in the majority of patients [2]. Outcomes of such an intervention are strongly improved when lymph node dissection (LND) is performed according to a well-defined template [3].

In recent years, laparoscopy has become an important new approach to reduce the invasiveness of the surgical treatment of UUT urothelial carcinoma. In a multicentre Italian study Porpiglia et al. [4] showed that laparoscopic NU with open ureterectomy was a feasible and safe technique. Oncological results seemed to be similar to those of the traditional open approach, but the laparoscopic approach still has some disadvantages. First, patients who undergo a laparoscopic procedure receive LND with lower frequency. Moreover, the template during a laparoscopic procedure is rarely respected and the number of lymph nodes removed is often suboptimal [3]. Second, there is no consensus in the literature about the pathological stages that could potentially benefit from the bladder-cuff excision step of this procedure [5]. Bladder-cuff excision omission does not seem to undermine survival in patients with low-stage (pT1-2) disease, nevertheless confirmatory recurrence data are required before a NU without bladder-cuff excision may be considered as an option for this patient category.

The present paper shows that advances in surgical technology are being made, but it also underlines the fact that the above-mentioned disadvantages of NU are still under discussion, and these disadvantages are expanded when introducing a newer and challenging technique such as the LESS approach.

In the present study, different devices and instruments were used. Furthermore, the rate of LND reported was very low (27%), as the number of lymph nodes removed (approximately five). LND was often ‘formally’ performed, and no specific template was reported to be used. Bladder-cuff excision was not performed in 20% of cases and, when performed, the technique used was not clearly defined. With regard to oncological efficacy, the recurrence rate of 22% at 11 months is not sufficient to clarify if the LESS approach is oncologically effective [6].

In summary, there are evident limitations to the present paper; some are methodological, such as its retrospective nature and the non-homogeneous datasheets used to collect data, and some are technical and oncological. These limitations are justified by the fact that the technique is in its embryonic stages. Nevertheless, the authors deserve praise for having collected such a large number of cases for their study on LESS NU. Their paper underlines the fact that this technique is feasible and safe, and each surgeon who contributed by insisting on such a challenging and novel approach to NU should be congratulated for their efforts.

Now that the feasibility of the LESS NU technique has been demonstrated, the authors have the task of clarifying whether introducing a LESS approach would or would not compromise oncological outcomes. In any case, it is recommended that surgical oncological principles be respected when a new technique is introduced, especially when dealing with a high-risk cell-seeding tumour such as urothelial carcinoma.

Francesco Porpiglia and Riccardo Bertolo
Department of Clinical and Biological Sciences, San Luigi Hospital, Division of Urology, University of Turin, Orbassano-Turin, Italy

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REFERENCES

Park SY, Rha KH, Autorino R et al. Laparoendoscopic single-site nephroureterectomy for upper urinary tract urothelial carcinoma: outcomes of an international multi-institutional study of 101 patients. BJU Int 2013; 112: 610–615
Rouprêt M, Zigeuner R, Palou J et al. European guidelines for the diagnosis and management of upper urinary tract urothelial cell carcinomas: 2011 update. Eur Urol 2011; 59: 584–594
Roscigno M, Brausi M, Heidenreich A et al. Lymphadenectomy at the time of nephroureterectomy for upper tract urothelial cancer.Eur Urol 2011; 60: 776–783
Porpiglia F, Celia A, Luciani L, Terrone C, Guazzoni G, Parma P. Laparoscopic radical nephroureterectomy: results of a multicentric italian study. J Endourol 2009; 23 (Suppl. 1): A109
Lughezzani G, Sun M, Perrotte P et al. Should bladder cuff excision remain the standard of care at nephroureterectomy in patients with urothelial carcinoma of the renal pelvis? A population-based study. Eur Urol 2010; 57: 956–962
Walton TJ, Novara G, Matsumoto K et al. Oncological outcomes after laparoscopic and open radical nephroureterectomy: results from an international cohort. BJU Int 2010; 108: 406–412

Video: Is LESS more when it comes to nephroureterectomy?

September 18, 2013/by admin Z.9

Laparoendoscopic single-site nephroureterectomy for upper urinary tract urothelial carcinoma: outcomes of an international multi-institutional study of 101 patients

Sung Yul Park, Koon Ho Rha¹, Riccardo Autorino², Ithaar Derweesh³, Evangelos Liastikos⁴, Yao Chou Tsai⁵, Ill Young Seo⁶, Ugo Nagele⁷, Aly M. Abdel-Karim⁸, Thomas Herrmann⁹, Deok Hyun Han¹⁰, Soroush Rais-Bahrami¹¹, Seung Wook Lee, Kyu Shik Kim, Paolo Fornara¹², Panagiotis Kallidonis⁴, Christopher Springer¹², Salah Élsalmy⁸, Shih-Chieh Jeff Chueh¹³, Chen-Hsun Ho¹⁴, Kamol Panumatrassamee², Ryan Kopp³, Jens-Uwe Stolzenburg¹⁵, Lee Richstone¹¹, Jae Hoon Chung, Tae Young Shin¹, Francesco Greco¹² and Jihad H. Kaouk²

Department of Urology, Hanyang University College of Medicine, Seoul, Korea, ¹Department of Urology, Yonsei University College of Medicine, Seoul, Korea, ²Glickman Urological & Kidney Institute, Cleveland Clinic, Cleveland, OH, USA, ³Division of Urology, University of California San Diego, La Jolla, CA, USA, ⁴Department of Urology, School of Medicine, University of Patras, Patras, Greece, ⁵Division of Urology, Buddhist Tzu Chi General Hospital, TaipeiBranch, Taipei, Taiwan, ⁶Department of Urology, Wonkwang University School of Medicine and Hospital, Iksan, Korea, ⁷Department of Urology, LKH, Hall in Tirol, Austria, ⁸Department of Urology, Alexandria University, Alexandria, Egypt, ⁹Department of Urology, Hannover Medical School, Hannover, Germany, ¹⁰Department of Urology, Samsung Medical Center, Sungkyunkwan University, Seoul, Korea, ¹¹The Arthur Smith Institute for Urology, Hofstra North Shore-LIJ School of Medicine, New Hyde Park, NY, USA, ¹²Department of Urology and Kidney Transplantation, Martin-Luther-University, Halle/Saale, Germany, ¹³Cleveland Clinic Urology Charleston Office, Charleston, WV, USA, ¹⁴Division of Urology, National Taiwan University Hospital, Taipei, Taiwan, ¹⁵Department of Urology, University of Leipzig, Leipzig, Germany

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