the traditional treatment for upper tract urothelial tumors is total nephroureterectomy with excision of bladder cuff ( 1 , 2 ) .
this procedure involves one or two long abdominal incisions that causes significant postoperative discomfort and requires lengthy convalescence ( 3 ) .
recently , laparoscopic nephroureterectomy has emerged as an alternative treatment , due to its minimal invasiveness . however , despite its obvious advantages , this technique has certain inherent technical limitations , including a certain diminution of tactile feedback , long operative times and steep learning curves ( 4 , 5 ) .
hand assisted laparoscopy can overcome these disadvantages , without sacrificing the associated improvements in patient convalescence , which are the benefits of minimally invasive procedures ( 6 , 7 ) . however , the korean health insurance system is different from those in other countries .
for example , although most cost is covered by public or corporate health insurance , the hand assisted device is not covered by korean health insurance .
thus , we developed a modified approach to hand - assisted retroperitoneoscopic nephroureterectomy without consumption of hand - assisted device , for both direct resection of the distal ureter and bladder cuff , and nephroureterectomy without repositioning the patient .
the patient is placed in the standard 70 flank position and maintained this posture throughout the entire procedure .
the operating table can be rotated from side to side to facilitate exposure during the different steps of the procedure . a 7 cm ipsilateral lower pararectal skin incision
1 ) . the anterior and posterior fasciae of the rectus muscle are incised , but the peritoneum is left intact .
the left hand of the surgeon ( in left retroperitoneoscopic nephroureterectomy ) or of the assistant ( in right retroperitoneoscopic nephroureterectomy ) is inserted into the retroperitoneal space ( fig .
balloon dissection can be performed through the pararectal incision if more space is required . the first 10-mm port for the 30 laparoscope is inserted in the mid - axillary line at umbilicus level under the guidance of the left index finger .
the pararectal incision is closed in watertight manner with a running 1 - 0 vicryl suture .
a 10-mm and a 5-mm trocar are placed in the anterior and posterior axillary lines at the umbilicus level under direct laparoscopic vision .
initially , distal ureter and bladder cuff are identified , dissected from the fatty tissue and clipped at the level of the pelvic brim to prevent possible seeding of tumor cells .
after circumferentially mobilizing the kidney , except for the renal pedicle , the pararectal incision is reopened and the left hand of the surgeon or of the assistant is inserted into the retroperitoneal space without the use of a hand - assisted device . after renal pedicle
is identified by arterial pulsation , renal artery and vein are isolated . the renal artery is circumferentially mobilized , clipped , and divided , with 2 clips on the vascular stump and 1 on the renal side . the renal vein is then secured and simultaneously transected with a vascular endo - gastrointestinal anastomosis device ( united states surgical corp . ,
subsequently , the ureter is dissected as far as possible towards the pelvis with the aid of a manual blunt dissection to ensure that the cut edge of the distal ureter is removed . without repositioning ,
the operating table is tilted towards the ipsilateral side , for make 30 flank position to provide a better view of the distal ureter . in this position
, open distal ureterectomy and bladder cuff resection can be done in the usual manner . at the end of the laparoscopic procedure
, the entire nephroureterectomy specimen is removed en bloc via the hand assistance incision without opening the urinary tract .
we performed retroperitoneoscopic nephroureterectomies by using the described technique in 3 male patients with urothelial carcinoma of the distal ureter .
the lesions were on the right side in 2 cases and on the left side in 1 .
average operative time and estimated blood loss were 251 min ( range 235 to 280 ) and 250 ml ( range 200 to 300 ) , respectively .
complication did not occur and conversion to open surgery was not necessary in all cases .
postoperative analgesic requirements were moderate and the time to regular diet intake averaged 3 days ( range 2 to 4 ) .
two patients had transitional cell carcinoma , for which pathologic stage and grade of the tumors were pt2giii and pt3gii , respectively .
none of the patients had a positive margin on the final pathologic specimen . at the average follow - up of 8.1 months , no regional recurrence , port - site metastasis , bladder recurrence , or distant metastasis were noted in any of the patients .
laparoscopic nephroureterectomy is becoming the new standard for managing localized urothelial cell carcinomas of the upper urinary tract .
various laparoscopic nephroureterectomy techniques have been described in the urologic literature ( 8 - 11 ) .
some require trocar placement into the urinary bladder ( 8 , 11 ) and mid - procedural patient repositioning ( 8 - 11 ) , while others entail utilization of the endo - gia autosuture ( ethicon , cincinnati , oh , u.s.a . ) for excision of the distal ureter and bladder cuff ( 10 ) .
these techniques pose a risk of tumor cell seeding , need long operative time due to technical difficulties and require intraoperative repositioning while distal ureter and bladder cuff are retained ( 9 ) . to date , there is no universal agreement as to which method of performing distal intravesical ureteral resection is the most safe and effective ( 5 , 12 - 15 ) .
our method resembles retroperitoneoscopic nephroureterectomy in the sense that a small incision is made in the lower abdomen . however , our method has some merits in comparison with other laparoscopic nephroureterectomy techniques .
first , our method is safe and easy . because bladder cuff is identical to that obtained during open surgery .
second , the incision created at an early stage can create the working space required by blunt manual dissection , to guide safe insertion of the first 10 mm port in order to prevent peritoneal injuries or injuries to other organs , and to perform nephroureterectomy without opening the urinary tract and with intact specimen removal .
although the working space is smaller and more skilled technique is required than with the transperitoneal approach , the retroperitoneal approach has the advantage of not manipulating the bowel , thus leading to minimal paralytic ileus , and possibly shorter hospital stay , as suggested by gill et al .
our technique provides a method of performing this procedure , while respecting oncological principles and offering the advantage of minimal invasiveness . finally , our method is relatively inexpensive because no hand - assisted device has been consumed .
hand - assisted laparoscopic procedures have many benefits for both experienced and inexperienced surgeons in terms of expanding the indications for laparoscopic surgery due to technical simplicity .
however , korean urologists can not try hand - assisted laparoscopic surgeries because hand - assisted device is too expensive and not covered by korean health insurance .
our method can make the hand - assisted laparoscopic surgeries without hand - assisted device .
our procedure may be challenging for a novice laparoscopist , since there is possibility of air leaking through the pararectal incision , maintaining the pneumoperitoneum during the entire operation is somehow difficult . however , if the size of the incision is designed to correspond to that of the surgeon 's hand , air leakage is minimized , because redundant retroperitoneal fat helps to make the incision air - tight , and therefore maintaining the pneumoperitoneum for a short time during the hilar dissection becomes possible .
 various laparoscopic nephroureterectomy techniques for urothelial carcinoma of the upper urinary tract have been developed to minimize postoperative discomfort and the necessity for a lengthy convalescence . 
 we performed hand - assisted retroperitoneoscopic nephroureterectomy without hand - assisted device in 3 male patients with urothelial carcinoma of the distal ureter . 
 average operative time and estimated blood loss were 251 min ( range 235 to 280 ) and 250 ml ( range 200 to 300 ) , respectively . 
 complication did not occur and conversion to open surgery was not necessary in all cases . 
 postoperative analgesic requirements were moderate and the time to regular diet intake averaged 3 days ( range 2 to 4 ) . 
 none of the patients had a positive margin on the final pathologic specimen . at the average follow - up of 8.1 months , no regional recurrence , port - site metastasis , bladder recurrence , or distant metastasis were noted in any patient . 
 we described our initial experience with the described technique , which obviates the need for midprocedural patient repositioning . 
INTRODUCTION
CASE REPORT
DISCUSSION