Radical nephroureterectomy

Radical Nephroureterectomy is a surgical procedure that involves the removal of a kidney (nephrectomy) and the entire ureter (ureterectomy), often along with the bladder cuff (the part of the bladder where the ureter connects) and surrounding tissues. This procedure is typically performed to treat upper urinary tract tumors, such as renal pelvic cancer or ureteral cancer. It is considered a standard treatment for cancers involving both the kidney and the ureter.

Indications

Radical nephroureterectomy is primarily indicated for:

1. Upper Urinary Tract Urothelial Carcinoma (UTUC):
   • Cancer of the kidney, renal pelvis, or ureter.
2. Recurrent or High-Risk Urothelial Tumors:
   • In cases where the cancer has recurred or is deemed high-risk for metastasis.
3. Invasive Tumors:
   • Tumors that have invaded the renal parenchyma or the surrounding structures.
4. Non-functional Kidney:
   • Due to obstructive uropathy or damage from chronic disease, in the presence of a tumor.
5. Tissue Removal for Staging or Diagnosis:
   • If a biopsy is insufficient for confirming cancer or assessing its extent.

Preoperative Preparation

1. Diagnostic Workup:

   • CT Scan/MRI: To evaluate the extent of the tumor and any involvement of surrounding structures.
   • Urinary Cytology: To detect cancer cells in the urine.
   • Cystoscopy: In cases where there is suspected bladder involvement.
   • Blood Tests: To assess kidney function, general health, and hemoglobin levels.
   • Urinalysis: To check for signs of infection or other urinary tract issues.

2. Patient Counseling:

   • Discuss the risks, benefits, and postoperative care, including the need for urinary diversion (if applicable).
   • Talk about possible lifestyle changes after kidney and ureter removal.

3. Preoperative Imaging:

   • Full assessment of the urinary tract to ensure there are no metastases or other hidden tumors.

4. Bowel Preparation:

   • Sometimes required for better visualization of the urinary tract during surgery.

5. Smoking Cessation:

   • Encouraged to reduce complications and improve healing.

Surgical Procedure

Radical nephroureterectomy can be performed through:

1. Open Surgery:
   • A traditional abdominal or flank incision is made.
2. Laparoscopic or Robot-Assisted Surgery:
   • A minimally invasive approach using small incisions and robotic assistance for improved precision and recovery.

Steps of the Procedure:

1. Incision and Exposure:
   • An abdominal or flank incision is made to access the kidney and ureter.
2. Kidney and Ureter Removal:
   • The entire kidney and ureter, along with the surrounding fatty tissue, are removed. In some cases, the affected part of the bladder is also removed.
3. Bladder Cuff Removal:
   • The surgeon may remove a portion of the bladder where the ureter attaches to prevent cancer recurrence at the bladder connection.
4. Lymph Node Dissection:
   • Lymph nodes in the area may be removed to check for signs of cancer spread.
5. Hemostasis:
   • Ensuring that all blood vessels are sealed to prevent bleeding.
6. Urinary Diversion:
   • After removal, a urinary diversion is created if the bladder cuff is taken. The most common diversions are:
     • Ileal Conduit: Urine is diverted to an external stoma using a segment of the small intestine.
     • Continent Cutaneous Reservoir: A pouch is created inside the abdomen, which requires catheterization to drain urine.
     • Neobladder: Creation of a new bladder from a segment of the intestine (less common after nephroureterectomy).

Postoperative Care

1. Hospital Stay:

   • Typically 5-7 days, depending on the surgical approach and recovery.

2. Pain Management:

   • Analgesics are administered to manage pain after surgery.

3. Urinary Diversion Management:

   • Education on how to manage the stoma (for ileal conduit) or catheterization (for continent reservoirs).

4. Fluid and Nutrition:

   • Gradual reintroduction of fluids and food as tolerated.

5. Wound Care:

   • The surgical site is monitored for signs of infection or complications.

6. Activity Restrictions:

   • Avoid heavy lifting and strenuous activity for 6-8 weeks.

Follow-Up Care

1. Imaging:
   • Regular CT scans, MRIs, or ultrasounds to monitor for recurrence of cancer.
2. Urine Cytology:
   • To monitor for signs of recurrence or metastasis.
3. Kidney Function Tests:
   • Blood and urine tests to monitor kidney function, especially if one kidney remains.
4. Lifestyle and Dietary Adjustments:
   • Continue monitoring for any issues related to urinary diversion or kidney function.

Benefits

• Effective treatment for upper urinary tract cancers, improving survival outcomes and quality of life.
• Provides relief from symptoms like hematuria, obstruction, and pain caused by tumors.
• Can be curative for localized tumors.