Laparoscopic nephroureterectomy was developed in an effort to reduce the morbidity of the surgical management. Indeed, several investigators have recently suggested their benefit for patient recovery with disease control comparable to that of traditional open surgery [2–4]. The mean oral diet day, urethral catheter time, and hospital stay were equivalent in the both groups in our series. However, the operative time was longer in the laparoscopic groups. On the other hand, the blood loss and the dosage of analgesia were lower after laparoscopic nephroureterectomy. In a literature review of 1365 nephroureterectomy patients, Rassweiler et al. reported the operative time (277 vs. 220 min) and the blood loss (241 vs. 463 ml.) comparing between the laparoscopic series and open series . These findings correspond to our results and support the effectiveness of laparoscopic procedure compared with the standard open procedure.
Laparoscopic nephroureterectomy can be performed via a transperitoneal or retroperitoneal access. We used the retroperitoneal approach. Although the operating space is smaller and a more skilled technique is required than with the transperitoneal approach, the advantage of retroperitoneal approach in avoiding intraabdominal injury and tumor spillage into intraabdominal cavity are our consideration. Rouprêt et al. reported the complications of colonic injury after transperitoneal LNU . We found no complication of intraabdominal injury and two minor complications after retroperitoneal LNU in our series. These finding confirmed the benefit of retroperitoneal approach and a feasible technique for LNU. Additionally, the technique of ureterectomy and bladder cuff excision has not been standardized yet. A number of minimal invasive approaches to the distal ureter such as endoscopic stripping or pluck-off techniques have been reported [8–11]. However, these endoscopic techniques have a greater risk of local recurrence and stone formation in the staple lines . We prefer open distal ureterectomy and bladder cuff excision. This method avoids the risk of urinary leakage and allows for intact specimen removal. We believed this will not adversely affect patient's recovery compared with the endoscopic approach. Furthermore, there are no contraindications such as ureteral tumors or periureteral fibrosis due to previous surgery, irradiation or inflammatory pelvic disease . The worldwide reported bladder recurrence rate was 9–48% with different methods for controlling the bladder cuff [2, 14, 15]. In our series, the bladder recurrence rate (29%) after RNU was within the reported range. In addition, the problem of port site metastasis in laparoscopic procedure is important. Rassweiler et al. reported that six port site metastasis in 377 (1.6%) analyzed patients following laparoscopy were recognized . Recently, Schatteman et al. reported another three cases of port metastasis after laparoscopy . In most cases, extraction of the specimen was performed without an organ or with a torn organ bag. In our series, no case of port site metastasis was observed during the follow up period. We routinely avoid the use of harmonic scalpel for tissue dissection which might be an origin of tumor cell spreading as previously described  and we retrieved the intact specimen via the open wound.
The indication for laparoscopic nephroureterectomy in upper tract TCC is not yet well defined. Although most authors still recommended that high stage and grade tumors should be contraindications to LNU [2, 3, 5]. Recently in 2007, Muntener et al. reported oncologic outcome after LNU with a median follow up time of 74 months and supported the LNU as the standard of care for high grade or high stage upper tract TCC . In our series, we found no statistically significant difference in recurrence free survival curve between both procedures in terms of tumor grade and stage (Fig. 1B–E). However, we believe that the indication tend to increase as surgical skill developed in laparoscopic treatment and we could have identified additional candidates with high grade or high stage tumor for LNU if accurate staging with preoperative imaging and biopsy had been done.
McNeill et al. reported favorable long term outcomes after LNU compared with ONU; however, information on nodal status was available in only 4% of cases . Klinger et al. found micrometastasis in 14.3% (2 of 14) of clinical No patients and advised to perform lymphadenectomy routinely for staging purpose . In our series, lymphadenectomy was performed in 48.3% (29/60) of cases. We had no definitive criteria for choosing the surgical procedure, including the indication for lymphadenectomy, which might affect the results of treatment. We found micrometastasis in 2 patients and these patients are still alive until the last follow up time. However, the prospective randomized study is needed to support the benefit and efficacy of routine laparoscopic regional lymphadenectomy.
In 2000 Gill et al. reported retroperitoneoscopic nephroureterectomy with bladder cuff excision through a transvesical approach and at a mean follow up of 11 months the cancer specific survival rate was 97% in the LNU group . Hsueh et al. reported Hand assisted RNU with open bladder cuff excision compare to ONU . The study showed no significant difference in terms of the disease specific and overall survival rate between the two groups. In 2007, Manabe et al. reported oncologic outcome of LNU with the same surgical approach as in our study. The study showed the 2 years disease specific survival rate were similar in both groups (85.2 vs 87%) . The worldwide reported disease survival was 72–95% with different methods for LNU and distal ureter management [16, 17, 22]. In the present series shows a 2 years disease specific survival of 86.3% which is comparable to literature data. No significant difference in disease specific and overall survival curve were found between both procedures. These results confirmed the oncologic safety of retroperitoneoscopic nephrectomy compared with the standard ONU.