Surgical Advances in Nephroureterectomy: Laparoscopic and Robotic Approaches

  • Jonathan Bloom
  • John L. PhillipsEmail author


Nephroureterecomy represents the gold standard in surgical treatment of upper urinary tract urothelial carcinoma (UUT-UC). UUT-UC represents a highly aggressive disease with poor survival once invasive and high recurrence rates if the distal ureter and bladder cuff remain in place. This necessitates the need for urologists to make every attempt to remove the diseased tissue. While the basic principle of the nephroureterectomy surgery have remained the same, advances in technology have allowed surgeons to develop new ways to deal with the most challenging aspect of performing this surgery, removal of the distal ureter and bladder cuff. Despite the multitude of techniques to remove the distal ureter, surgeon preference and patient specifics provide the best tools for surgical planning. Currently, minimally invasive techniques such as endoscopic resection of the ureteral orifice, laparoscopy, and robotic-assisted surgeries have been developed with the goal of reducing postoperative pain, hospitalizations, and perioperative complications while still providing excellent cancer control. Finally, new treatment modalities, such as preoperative chemotherapy, have shown promise in lower tract disease but current studies lack data from prospective trials to make it the standard of care.


Nephroureterectomy Upper urinary tract urothelial carcinoma (UUT-UC) Distal ureter Bladder cuff Transurethral resection ureteral orifice (TUR-UO) Lymphadenectomy Recurrence Survival Neoadjuvant chemotherapy 


  1. 1.
    Mitra AP, Alemozaffar M, Harris BN, et al. Outcomes after urothelial recurrence in bladder cancer patients undergoing radical cystectomy. Urology. 2014;84:1420.CrossRefPubMedGoogle Scholar
  2. 2.
    Raman JD, Messer J, Sielatycki JA, et al. Incidence and survival of patients with carcinoma of the ureter and renal pelvis in the USA, 1973–2005. BJU Int. 2011;107:1059.CrossRefPubMedGoogle Scholar
  3. 3.
    Makhoul B, De La Taille A, Vordos D, et al. Laparoscopic radical nephrectomy for T1 renal cancer: the gold standard? A comparison of laparoscopic vs open nephrectomy. BJU Int. 2004;93:67.CrossRefPubMedGoogle Scholar
  4. 4.
    Steinberg JR, Matin SF. Laparoscopic radical nephroureterectomy: dilemma of the distal ureter. Curr Opin Urol. 2004;14:61.CrossRefPubMedGoogle Scholar
  5. 5.
    Hung SY, Yang WC, Luo HL, et al. Segmental ureterectomy does not compromise the oncologic outcome compared with nephroureterectomy for pure ureter cancer. Int Urol Nephrol. 2014;46:921.CrossRefPubMedGoogle Scholar
  6. 6.
    Porten S, Siefker-Radtke AO, Xiao L, et al. Neoadjuvant chemotherapy improves survival of patients with upper tract urothelial carcinoma. Cancer. 2014;120:1794.CrossRefPubMedPubMedCentralGoogle Scholar
  7. 7.
    Lin YK, Kaag M, Raman JD. Rationale and timing of perioperative chemotherapy for upper-tract urothelial carcinoma. Expert Rev Anticancer Ther. 2014;14:543.CrossRefPubMedGoogle Scholar
  8. 8.
    Reservitz GB. A historic review of nephroureterectomy. Surg Gynecol Obstet. 1967;125:853.PubMedGoogle Scholar
  9. 9.
    McDonald HP, Upchurch WE, Sturdevant CE. Nephro-ureterectomy: a new technique. J Urol. 1952;67:804.CrossRefPubMedGoogle Scholar
  10. 10.
    Clayman RV, Kavoussi LR, Figenshau RS, et al. Laparoscopic nephroureterectomy: initial clinical case report. J Laparoendosc Surg. 1991;1:343.CrossRefPubMedGoogle Scholar
  11. 11.
    Guzzo TJ, Schaeffer EM, Allaf ME. Laparoscopic radical nephroureterectomy with en-bloc distal ureteral and bladder cuff excision using a single position pneumovesicum method. Urology. 2008;72:850.CrossRefPubMedGoogle Scholar
  12. 12.
    Kawauchi A, Fujito A, Soh J, et al. Hand-assisted retroperitoneoscopic radical nephrectomy and nephroureterectomy. J Endourol. 2004;18:365.CrossRefPubMedGoogle Scholar
  13. 13.
    Gill IS, Soble JJ, Miller SD, et al. A novel technique for management of the en bloc bladder cuff and distal ureter during laparoscopic nephroureterectomy. J Urol. 1999;161:430.CrossRefPubMedGoogle Scholar
  14. 14.
    Trudeau V, Gandaglia G, Shiffmann J, et al. Robot-assisted versus laparoscopic nephroureterectomy for upper-tract urothelial cancer: a population-based assessment of costs and perioperative outcomes. Can Urol Assoc J. 2014;8:E695.CrossRefPubMedPubMedCentralGoogle Scholar
  15. 15.
    Sugihara T, Yasunaga H, Yu C, et al. Perioperative outcome comparisons between open and laparoscopic nephroureterectomy among a population-based Cohort from 2010 to 2012. J Endourol. 2015;29:770.CrossRefPubMedGoogle Scholar
  16. 16.
    Arango O, Bielsa O, Carles J, et al. Massive tumor implantation in the endoscopic resected area in modified nephroureterectomy. J Urol. 1997;157:1839.CrossRefPubMedGoogle Scholar
  17. 17.
    Sammon J, Perry A, Beaule L, et al. Robot-assisted radical prostatectomy: learning rate analysis as an objective measure of the acquisition of surgical skill. BJU Int. 2010;106:855.CrossRefPubMedGoogle Scholar
  18. 18.
    Hall MC, Womack S, Sagalowsky AI, et al. Prognostic factors, recurrence, and survival in transitional cell carcinoma of the upper urinary tract: a 30-year experience in 252 patients. Urology. 1998;52:594.CrossRefPubMedGoogle Scholar
  19. 19.
    Muntener M, Nielsen ME, Romero FR, et al. Long-term oncologic outcome after laparoscopic radical nephroureterectomy for upper tract transitional cell carcinoma. Eur Urol. 2007;51:1639.CrossRefPubMedGoogle Scholar
  20. 20.
    Aboumohamed AA, Krane LS, Hemal AK. Oncologic outcomes following robot-assisted laparoscopic nephroureterectomy with bladder cuff excision for upper tract urothelial carcinoma. J Urol. 2015; 194:1561.CrossRefPubMedGoogle Scholar
  21. 21.
    Simone G, Papalia R, Guaglianone S, et al. Laparoscopic versus open nephroureterectomy: perioperative and oncologic outcomes from a randomised prospective study. Eur Urol. 2009;56:520.CrossRefPubMedGoogle Scholar
  22. 22.
    Roupret M, Babjuk M, Comperat E, et al. European association of urology guidelines on upper urinary tract urothelial cell carcinoma: 2015 update. Eur Urol. 2015;68:868.CrossRefPubMedGoogle Scholar
  23. 23.
    Bourdoumis A, Syed I, Soosay G, et al. Transitional cell carcinoma of the ureteric stump: a systematic review of the literature. Urol Int. 2013;91:170.CrossRefPubMedGoogle Scholar
  24. 24.
    Kang M, Jeong CW, Kwak C, et al. The characteristics of recurrent upper tract urothelial carcinoma after radical nephroureterectomy without bladder cuff excision. Yonsei Med J. 2015;56:375.CrossRefPubMedPubMedCentralGoogle Scholar
  25. 25.
    Tsivian A, Benjamin S, Sidi AA. A sealed laparoscopic nephroureterectomy: a new technique. Eur Urol. 2007;52:1015.CrossRefPubMedGoogle Scholar
  26. 26.
    Fang Z, Li L, Wang X, et al. Total retroperitoneal laparoscopic nephroureterectomy with bladder-cuff resection for upper urinary tract transitional cell carcinoma. J Invest Surg. 2014;27:354.CrossRefPubMedGoogle Scholar
  27. 27.
    Gill IS, Sung GT, Hobart MG, et al. Laparoscopic radical nephroureterectomy for upper tract transitional cell carcinoma: the Cleveland Clinic experience. J Urol. 2000;164:1513.CrossRefPubMedGoogle Scholar
  28. 28.
    Zargar H, Krishnan J, Autorino R, et al. Robotic nephroureterectomy: a simplified approach requiring no patient repositioning or robot redocking. Eur Urol. 2014;66:769.CrossRefPubMedGoogle Scholar
  29. 29.
    Darwiche F, Swain S, Kallingal G, et al. Operative technique and early experience for robotic-assisted laparoscopic nephroureterectomy (RALNU) using da Vinci Xi. Springerplus. 2015;4:298.CrossRefPubMedPubMedCentralGoogle Scholar
  30. 30.
    Patel MN, Aboumohamed A, Hemal A. Does transition from the da Vinci Si to Xi robotic platform impact single-docking technique for robot-assisted laparoscopic nephroureterectomy?. BJU Int. 2015;116:990.CrossRefPubMedGoogle Scholar
  31. 31.
    Matin SF, Sfakianos JP, Espiritu PN, et al. Patterns of lymphatic metastases in upper tract urothelial carcinoma and proposed dissection templates. J Urol. 2015;194:1567.CrossRefPubMedPubMedCentralGoogle Scholar
  32. 32.
    Kondo T, Nakazawa H, Ito F, et al. Impact of the extent of regional lymphadenectomy on the survival of patients with urothelial carcinoma of the upper urinary tract. J Urol. 2007;178:1212.CrossRefPubMedGoogle Scholar
  33. 33.
    Mason RJ, Kassouf W, Bell DG, et al. The contemporary role of lymph node dissection during nephroureterectomy in the management of upper urinary tract urothelial carcinoma: the Canadian experience. Urology. 2012;79:840.CrossRefPubMedGoogle Scholar
  34. 34.
    Yang D, Chen Q, Song X, et al. Effect of lymph node dissection on the outcomes of upper tract urothelial carcinomas: a meta-analysis. Expert Rev Anticancer Ther. 2014;14:667.CrossRefPubMedGoogle Scholar
  35. 35.
    Huang CY, Chung SD, Wang SM, et al. An audit of nephroureterectomy for upper tract urothelial carcinoma. Eur J Surg Oncol. 2009;35:1333.CrossRefPubMedGoogle Scholar
  36. 36.
    Stravodimos KG, Komninos C, Kural AR, et al. Distal ureterectomy techniques in laparoscopic and robot-assisted nephroureterectomy: Updated review. Urol Ann. 2015;7:8.CrossRefPubMedPubMedCentralGoogle Scholar
  37. 37.
    Li WM, Shen JT, Li CC, et al. Oncologic outcomes following three different approaches to the distal ureter and bladder cuff in nephroureterectomy for primary upper urinary tract urothelial carcinoma. Eur Urol. 2010;57:963.CrossRefPubMedGoogle Scholar
  38. 38.
    Macejko AM, Pazona JF, Loeb S, et al. Management of distal ureter in laparoscopic nephroureterectomy—a comprehensive review of techniques. Urology. 2008;72:974.CrossRefPubMedGoogle Scholar
  39. 39.
    Palou J, Caparros J, Orsola A, et al. Transurethral resection of the intramural ureter as the first step of nephroureterectomy. J Urol. 1995;154:43.CrossRefPubMedGoogle Scholar
  40. 40.
    Giovansili B, Peyromaure M, Saighi D, et al. Stripping technique for endoscopic management of distal ureter during nephroureterectomy: experience of 32 procedures. Urology. 2004;64:448.CrossRefPubMedGoogle Scholar
  41. 41.
    Strong DW, Pearse HD, Tank ES Jr, et al. The ureteral stump after nephroureterectomy. J Urol. 1976;115:654.CrossRefPubMedGoogle Scholar
  42. 42.
    Hetherington JW, Ewing R, Philp NH. Modified nephroureterectomy: a risk of tumour implantation. Br J Urol. 1986;58:368.CrossRefPubMedGoogle Scholar
  43. 43.
    Brown JA, Strup SE, Chenven E, et al. Hand-assisted laparoscopic nephroureterectomy: analysis of distal ureterectomy technique, margin status, and surgical outcomes. Urology. 2005;66:1192.CrossRefPubMedGoogle Scholar
  44. 44.
    Kurzer E, Leveillee RJ, Bird VG. Combining hand assisted laparoscopic nephroureterectomy with cystoscopic circumferential excision of the distal ureter without primary closure of the bladder cuff—is it safe? J Urol. 2006;175:63.CrossRefPubMedGoogle Scholar
  45. 45.
    Saika T, Nishiguchi J, Tsushima T, et al. Comparative study of ureteral stripping versus open ureterectomy for nephroureterectomy in patients with transitional carcinoma of the renal pelvis. Urology. 2004;63:848.CrossRefPubMedGoogle Scholar
  46. 46.
    Ubrig B, Boenig M, Waldner M, et al. Transurethral approach to the distal ureter in nephroureterectomy: transurethral extraction vs. “Pluck” technique with long-term follow-up; used with permission. Eur Urol. 2004;46:741.CrossRefPubMedGoogle Scholar
  47. 47.
    Walton TJ, Sherwood BT, Parkinson RJ, et al. Comparative outcomes following endoscopic ureteral detachment and formal bladder cuff excision in open nephroureterectomy for upper urinary tract transitional cell carcinoma. J Urol. 2009;181:532.CrossRefPubMedGoogle Scholar
  48. 48.
    Srirangam SJ, van Cleynenbreugel B, van Poppel H. Laparoscopic nephroureterectomy: the distal ureteral dilemma. Adv Urol. 2009;2009:1.CrossRefGoogle Scholar
  49. 49.
    Otsuka M, Taguchi S, Nakagawa T, et al. Lower ureteral lesion is an independent predictor of intravesical recurrence after radical nephroureterectomy for upper tract urothelial carcinoma. Urol Oncol. 2015;34:e9.Google Scholar
  50. 50.
    Lucca I, Klatte T, Roupret M, et al. Kidney-sparing surgery for upper tract urothelial cancer. Curr Opin Urol. 2015;25:100.CrossRefPubMedGoogle Scholar
  51. 51.
    Pedrosa JA, Masterson TA, Rice KR, et al. Oncologic outcomes and prognostic impact of urothelial recurrences in patients undergoing segmental and total ureterectomy for upper tract urothelial carcinoma. Can Urol Assoc J. 2015;9:E187.CrossRefPubMedPubMedCentralGoogle Scholar
  52. 52.
    Fifer GL, Raynor MC, Selph P, et al. Robotic ureteral reconstruction distal to the ureteropelvic junction: a large single institution clinical series with short-term follow up. J Endourol. 2014;28:1424.CrossRefPubMedGoogle Scholar
  53. 53.
    Rose TL, Deal AM, Basch E, et al. Neoadjuvant chemotherapy administration and time to cystectomy for muscle-invasive bladder cancer: an evaluation of transitions between academic and community settings. Urol Oncol. 2015;33(386):e1.Google Scholar
  54. 54.
    Witjes JA, Comperat E, Cowan NC, et al. EAU guidelines on muscle-invasive and metastatic bladder cancer: summary of the 2013 guidelines. Eur Urol. 2014;65:778.CrossRefPubMedGoogle Scholar
  55. 55.
    Secin FP, Jiborn T, Bjartell AS, et al. Multi-institutional study of symptomatic deep venous thrombosis and pulmonary embolism in prostate cancer patients undergoing laparoscopic or robot-assisted laparoscopic radical prostatectomy. Eur Urol. 2008;53:134.CrossRefPubMedGoogle Scholar
  56. 56.
    Yao L, Yang K, Li X. Comparison between completely and traditionally retroperitoneoscopic nephroureterectomy for upper tract urothelial cancer. World J Surg Oncol. 2016;14:171.CrossRefPubMedPubMedCentralGoogle Scholar
  57. 57.
    Khemees TA, Nasser SM, Abaza R. Clinical pathway after robotic nephroureterectomy: omission of pelvic drain with next-day catheter removal and discharge. Urology. 2014;83:818.CrossRefPubMedGoogle Scholar
  58. 58.
    Feicke A, Baumgartner M, Talimi S. Robotic-assisted laparoscopic extended pelvic lymph node dissection for prostate cancer: surgical technique and experience with the first 99 cases. Eur Urol. 2009;55:876.CrossRefPubMedGoogle Scholar

Copyright information

© Springer International Publishing AG, part of Springer Nature 2018

Authors and Affiliations

  1. 1.Department of UrologyWestchester Medical Health Network/New York Medical CollegeValhallaUSA
  2. 2.Urologic Oncology BranchNational Institute of HealthBethesdaUSA

Personalised recommendations