Open Nephroureterectomy

Abstract

Upper tract urothelial carcinoma (UTUC) represents 5% of all urothelial tumors, with a peak incidence of occurring in the eighth decade of life. Patients with UTUC are at high risk of developing intravesical concurrence and recurrence. Because of this downstream phenomenon of tumor seeding, the entire length of the ureter from the level of the lesion to the bladder cuff surrounding the ureteral orifice is removed at the time of radical nephroureterectomy (RNU). Open radical nephroureterectomy (ONU) with resection of the ipsilateral bladder cuff is the gold-standard treatment for UTUC. In ONU, the ureter ande ureteral orifice are removed en bloc with the kidney and perinephric fat. The surgery can be performed through a long midline transabdominal incision, or, preferably, through a subcostal or flank incision, along with a lower midline, Gibson, or Pfannenstiel incision for excision of the bladder cuff. A third option is combining the upper flank approach with a Gibson-like lower extension in a continuous, single retroperitoneal incision. Nephron-sparing surgery (NSS) for management of UTUC may be considered in individuals with low grade and low stage disease who have synchronous bilateral tumors, actual or functional solitary kidney, or those predisposed to recurrence of disease. All measures to minimize the risk of tumor cell spillage should be considered at all times. The distal ureter and the bladder cuff can be managed by several different techniques; however, if not managed appropriately, cancer cell spillage and recurrence rate can spoil a good cancer operation. Although lymphadenectomy improves cancer staging, its therapeutic role in management of UTUC remains controversial, particularly in low risk cases.