Laparoscopic Complete Urinary Tract Exenteration for a Patient with Bilateral Synchronous Renal Pelvic Carcinomas

Abstract

Background: Bilateral synchronous renal pelvic carcinomas are rare diseases. Complete urinary exenteration or kidney-preserving procedures are two different options that confer different benefits to the patient depending on the clinical situation.

Case Presentation: A 69-year-old woman with bilateral synchronous renal pelvic carcinomas underwent laparoscopic complete urinary tract exenteration. Although dissection was difficult because of postoperative adhesions, the surgery was completed with minimal blood loss.

Conclusion: Laparoscopic complete urinary tract exenteration allows minimally invasive surgery with minimal blood loss.

Introduction

Bilateral synchronous renal pelvic carcinomas are rare diseases. Standard treatment for renal pelvic carcinomas is nephroureterectomy. Therefore, standard treatment for a patient with bilateral synchronous renal pelvic carcinomas is thought to be complete urinary tract exenteration. In contrast, kidney-preserving procedures (KPPs) may be offered to selected low-grade tumor cases; however, follow-up after KPPs is difficult. We report a case of laparoscopic complete urinary tract exenteration for bilateral synchronous renal pelvic carcinomas.

Case Report

A 69-year-old woman underwent hysterectomy for uterine cancer at the age of 40 years and ileocecal resection for ileocecal cancer at 60. She suffered from left lower abdominal pain and visited a previous doctor in April 2017. CT scan revealed left ureter stone and left renal pelvic tumor with hydronephrosis. For the diagnosis and the treatment, transurethral left ureteral lithotripsy and left renal pelvic tumor biopsy were performed. Pathological findings showed urothelial carcinoma. Further extensive CT examination revealed bilateral renal pelvic tumors (Fig. 1). At a later date she underwent transurethral right ureterorenoscopy and right renal pelvic tumor biopsy. Pathological findings also showed urothelial carcinoma. CT findings revealed no lymph node and distant metastasis were detected. She was diagnosed with bilateral synchronous renal pelvic cancer without metastasis. She visited a certain hospital for a second opinion and was recommended open bilateral nephroureterectomy and cystectomy. She desired more minimal invasive treatment and visited our hospital for further opinion in June 2017. We recommended laparoscopic complete urinary tract exenteration and subsequent dialysis management for her bilateral synchronous renal pelvic carcinomas. She chose our therapeutic strategy. She underwent laparoscopic complete urinary tract exenteration in August 2017. First of all, we performed left nephroureterectomy in the right decubitus position (Fig. 2a). Second, we performed right nephroureterectomy in the left decubitus position (Fig. 2b). Finally, we performed cystourethrectomy in the lithotomy position (Fig. 2c). Owing to the influence of the previous surgeries, adhesion between the pelvic wall and the lower ureters on both sides and the dorsal side of the bladder were observed. The patient's vaginal space was too narrow to remove the extirpating organs from vagina. Therefore, we performed a 6 cm incision in the lower abdomen and removed the extirpating organs through the incision (Figs. 2c and 3). The operating time was 9 hours 26 minutes and bleeding volume was 100 mL. Pathological findings were noninvasive papillary urothelial carcinomas that were low grade in bilateral renal pelvic tumors (Fig. 4), and there was no lymph nodes metastasis. Maintenance dialysis was started on the third postoperative day. On the 16th postoperative day, we performed inner shunt construction. After that, because of the obstruction of the shunt, we performed the second shunt construction on the other forearm. On the 50th postoperative day, she started dialysis using the inner shunt.

FIG. 1.

CT image at the time of pointing out bilateral renal pelvic tumors. (a) Contrast-enhanced CT image. (b) CT urography image.

FIG. 2.

The placements of the trocar port and an incision for removal of the extirpating organs. ● operator's port. ▲:camera port. ■:assistant's port.:6 cm incision for removal of extirpating organs. (a) Right decubitus position. (b) Left decubitus position. (c) Lithotomy position.

FIG. 3.

Resected specimens of the complete urinary tract.

FIG. 4.

Pathological findings of the renal pelvic tumors. (a) The right renal pelvic tumor that was noninvasive low-grade papillary urothelial carcinoma. (b) The left renal pelvic tumor that was also noninvasive low-grade papillary urothelial carcinoma.

Discussion

Standard treatment for upper tract urothelial carcinoma (UTUC) is nephroureterectomy.¹ In contrast, KPPs such as endoscopic management, partial nephrectomy has been offered to selected low-grade tumor cases in those with renal insufficiency, bilateral UTUC, solitary kidney, and associated severe morbid conditions that preclude the indication of radical surgery.² In this case, complete urinary tract exenteration and KPP were also considered as a treatment option. Each option has benefits depending on the clinical situation. Complete urinary tract exenteration is a good option for cancer control; however, subsequent dialysis management for the patient is required. KPPs have the benefit for the preservation of renal function and the patients may avoid from maintaining blood dialysis; however, the recurrence rate is considered to be high. Most of the data provided from small retrospective cohort series were 65% and 40% recurrence of UTUC, with 33% and 6%–50% progressing toward radical surgery after endoscopic management and percutaneous management, respectively.² In the management of UTUC, there have been no prospective randomized studies comparing the endoscopic management with nephroureterectomy. Strict surveillance is prerequisite after KPPs; however, follow-up after KPPs is difficult despite improvement of the endourologic management. Repeated endoscopic procedures are thought to be necessary; however, surveillance method is not established.¹ In the management of UTUC, there have been no prospective randomized studies comparing endoscopic management with nephroureterectomy. We informed the patient the treatment options, including KPPs; however, she chose complete urinary exenteration from her experience of medical history of uterine cancer and ileocecal cancer. As a result of discussion with the patient, we prioritized cancer control and performed laparoscopic complete urinary tract exenteration. Laparoscopic surgery is considered to allow minimally invasive surgery. Laparoscopic complete urinary tract exenteration was reported to have significantly less blood loss than open surgery.³ In our case, the ureters and bladder adhered firmly to pelvic wall because of influence of previous surgeries and the decortication was difficult; however, total bleeding volume was as small as 100 mL.

Abbreviations Used

CT

computed tomography

KPP

kidney-preserving procedure

UTUC

upper tract urothelial carcinoma

Disclosure Statement

No competing financial interests exist.

Cite this article as: Inui K, Murata M, Sato Y, Hasegawa G, Ikeda Y, Nakagawa Y, Nishiyama T (2019) Laparoscopic complete urinary tract exenteration for a patient with bilateral synchronous renal pelvic carcinomas, Journal of Endourology Case Reports 5:3, 107–109, DOI: 10.1089/cren.2019.0045.