Biomedical subjects
Publications and source records attributed to Burkhard Ubrig.
We report a modified technique for laparoscopic nephroureterectomy that results in complete removal of the specimen, including a cuff of bladder mucosa, while avoiding tumor cell spillage. A modified lithotomy position allows simultaneous laparoscopic and transurethral access without repositioning. Contraindications are juxtavesical or intramural ureteral tumor.
BACKGROUND AND PURPOSE: Long ureteral defects can be reconstructed in humans with reconfigured short colonic or ileal segments. We undertook the present study to evaluate whether laparoscopy with completely intracorporal reconfiguration could replicate open surgery results. MATERIALS AND METHODS: In eight renoureteral units of six pigs, a ureteral defect of 4.5 to 8.0 cm (mean 6.6 cm) was created. Ileum was used for reconstruction in six renal units and colon in two. A 3-cm-long segment was isolated from the intestinal tract and transversely reconfigured into a long pedicled tubular graft, which was then interposed into the ureteral defect. Reconfiguration and all anastomoses were performed by freehand intracorporal suturing and knot-tying. RESULTS: Reconstruction was successful in all cases. No significant blood loss or open conversions occurred. The mean total surgical time was 296 minutes (range 234-353 minutes). CONCLUSIONS: Ureteral repair with intracorporally reconfigured intestinal segments is technically feasible. Clinical application will await survival studies.
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OBJECTIVES: We retrospectively compared two techniques of transurethral management of the lower ureter in nephroureterectomy. PATIENTS AND METHODS: From August 1992 to December 2003, 34 patients underwent either transurethral detachment of the intramural ureter and cephalad extraction ("pluck"; Group 1, N = 18) or transection of the ureter with subsequent transurethral extraction (Group 2, N = 16). Choice of technique was left to the operating surgeon. All patients with upper tract urothelial carcinoma (TCC) were regularly followed by cystoscopy and abdominal ultrasound. RESULTS: Of the 34 patients, 29 had upper tract TCC. Mean follow-up in these was 44 months (range: 1-129), with 24 (83.8%) over 24 months. On follow-up, 14 bladder tumors (all superficial) occurred in 7 patients (24.1%), but in no case on the scar of the excised ureteral orifice. No extravesical recurrences in the former ureteral bed were found. Of the 29 with upper tract TCC, 19 (65.5%) are alive without disease (median 45 months, range: 6-129), 5 (17.2%) have died with no evidence of disease (median 34 months, range: 20-58), and 4 (13.8%) have died from progressive disease (median 18 months, range: 1-33); 1 patient was lost to follow-up at 34 months with no evidence of disease. Differences between techniques with regard to blood loss, operative time, complications, and oncologic outcome were not significant. CONCLUSION: Both techniques proved technically and oncologically safe. Bladder tumor recurrence rate was in the range reported for classic nephroureterectomy. No extravesical tumor recurrence in the former ureteral bed or on the scar of the resected ureteral orifice occurred.
In a subset of patients with intractable symptoms from incurable pelvic cancer, palliative cystectomy and urinary diversion with intestinal segments may not be feasible. The described technique, in which a midline stoma was constructed and dissection was entirely extraperitoneal, resulted in symptom relief in 8 patients.
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Reconfigured colon was used as a ureteral substitute in seven selected patients. In four patients, a single reconfigured colon segment was interposed into an extensive defect of the upper ureter. In an additional three patients with solitary kidney, reconfigured colon segments were used for the construction of a conduit. At a mean follow-up of 23 months (range: 2-38 months), no complications related to the reconfigured colon segments were noted. Two patients died of progressive disease, but with no evidence of malfunction of the ureteral substitute. Surgical access is mainly retroperitoneal, and intraperitoneal surgery is minimal. The colonic segments are taken immediately proximal to the ureteral defect, necessitating little mobilization of the mesenteric pedicle. In patients with renal insufficiency or a history of irradiation, this technique may be superior to the use of ileum. Before wider use, long term follow-up data on the uretero-intestinal anastomosis will be necessary.
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