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POSTOPERATIVE DIAGNOSIS:
1. Obstructing distal left ureteral mass with associated lymphadenopathy consistent with high-grade urothelial carcinoma.
2. Atrophic left kidney.
PROCEDURE PERFORMED: Hand assisted laparoscopic left nephroureterectomy, transurethral incision of left ureteral orifice and left salpingo-oophorectomy.
Surgeon: M***** ******, MD
ASSISTANT:
L****** MD
CO-SURGEON:
V**** ******, MD.
COMPLICATIONS:
None.
PATHOLOGY:
Left kidney and ureteral segment, left ovary, and fallopian tube.
INDICATIONS:
The patient is a female with an atrophic left kidney from chronic distal ureteral obstruction. She underwent ureteroscopy which revealed an obstructing left ureteral tumor consistent with urothelial carcinoma. Cytology obtained at that time was consistent with high-grade urothelial carcinoma. Subsequent CT scan revealed an apparent ureteral tumor and left pelvic lymphadenopathy consistent with urothelial carcinoma. Left nephroureterectomy was offered for definitive treatment of an apparent obstructive urothelial carcinoma and an atrophic poorly-functioning left kidney with possible lymphadenopathy. The indications, alternatives, and attendant risks were explained in details.
FINDINGS:
She had an atrophic left kidney with hydroureter down to an obstructing ureteral tumor at the level of the left iliac vessels. Unfortunately, the tumor was unable to be resected off the left external iliac vessels and uterine blood supply. Left salpingo-oophorectomy was performed to obtain exposure in an attempt to remove the tumor. Unfortunately, we were unsuccessful.
DETAILS OF PROCEDURE:
The patient was taken to the operating room and positively identified as well as the site and side of surgery during a time-out. After adequate general anesthesia, she was transferred into the modified dorsal lithotomy position and prepped and draped in the usual sterile fashion for cystoscopy. Urethral meatus was dilated up to 28-French and a 25-French continuous flow resectoscope sheath passed with the obturator in place. The working element was then passed and using the right angle electrode, the left ureteral orifice was incised circumferentially until perivesical fat was identified. The ureter was allowed to retract superiorly. Hemostasis was obtained with electrocautery. The bladder was left partially distended and scope removed. An 18-French Foley catheter was then inserted and balloon inflated to 10 mL. Effluent came back pink tinged. The patient was then repositioned into the modified left flank position over the break in the table and secured in place with a bean bag. All pressure points were appropriately padded. An incision was made with a 15 blade scalpel knife along the interior costal margin on the left-hand side for distance of approximately 8 cm. Dissection was then carried down through the subcutaneous fat and muscle layers to enter the peritoneal cavity. The rectus muscle was partially divided laterally. The remainder of the muscles were swept medially. The perineum was entered between hemostats through the posterior rectus sheath. There were no significant adhesions noted. The wound protector portion of the GelPort was placed. GelPort was then applied and a 10 mm port passed through the GelPort and the abdomen insufflated. Two 10 mm ports were placed through stab incision in the left lower quadrant under direct vision and guidance. Using the L-hook electrosurgical dissector and LigaSure, the colon was reflected by incising along the white line of Toldt. The colon was mobilized from the sigmoid to the splenic flexure. The kidney was then mobilized outside of Gerota fascia posteriorly and inferiorly. Upper pole was then mobilized inside Gerota fascia along the kidney capsule to free up the adrenal gland, which was left intact. A single renal artery was dissected posteriorly and clipped doubly proximally, singly, distally, and then transected with the LigaSure device. The renal vein was then dissected circumferentially with blunt sharp and dissection. It was then transected with the endovascular stapler. The remaining attachments of the upper pole were transected with the endovascular stapler, freeing the kidney. The gonadal vein and ureter were identified and traced down in the pelvis. Electrocautery was used to dissect out the dilated ureter down to an obstructing tumor adherent to the external left iliac vessels. The ureter was doubly clipped and transected at that level. An attempt was made to dissect the tumor off the vessels, but was tightly adherent and unable to be safely removed with blunt and sharp dissection. The ovary and fallopian tube were medially adjacent and were ultimately resected by Dr. V****, who was consulted intraoperatively for possible hysterectomy. Ultimately we decided against hysterectomy since we were unable to safely dissect the tumor off the iliac vessels. There is also a dense desmoplastic reaction overlying the lymph nodes. The dissection was further complicated with the uterus being adherent to the tumor and left pelvic sidewall. There was no evidence of malignancy within the uterus. I was able to dissect down to the distal ureter to expose the previously incised ureteral orifice. The distal ureteral segment was able to be delivered and transected. A clip was placed on the ureteral segment left behind. Unfortunately, approximately 6 cm of ureter were unable to be resected since they were densely adherent to the left pelvic sidewall. There did appear to be palpable lymphadenopathy along the pelvic sidewall. Formal lymph node dissection was not carried out due to the adherence to the overlying vessels. Clips were placed to mark the ureteral tumor. The wound was irrigated with copious amounts of water. Hemostasis was obtained with electrocautery and Arista powder. A Nu-Knit gauze was placed over the cut edge of the uterus and excellent hemostasis obtained. The renal fossa was then inspected and hemostasis noted to be adequate. She will be noted that a transverse incision was created during open dissection of the distal ureter and performing the salpingo-oophorectomy by Dr. V*****. Dissection of the distal ureter did not require a cystotomy. Vascular Surgery was consulted intraoperatively regarding possibility of resection of the tumor, which may have required resection of the left common iliac vessel. The patient has not had a proper consent likely to proceed with that aggressive resection and therefore we elected to stop at this point. All counts were correct. The muscle layer was then closed with 0 Vicryl running stitch. The Pfannenstiel incision was closed with a single layer of fascial closure. The hand port in the subcostal region was closed in 2 layers. Subcutaneous tissue was closed with interrupted Vicryl stitches. The skin for all incisions including the 10 mm ports were closed with subcuticular 4-0 Monocryl. No fascial stitches were placed in the 10 mm ports. The wounds were irrigated prior to closure. Sterile dressings were applied. All counts were correct. The patient tolerated the procedure well without complications. KJ 20220502
POSTOPERATIVE DIAGNOSIS:
1. Obstructing distal left ureteral mass with associated lymphadenopathy consistent with high-grade urothelial carcinoma.
2. Atrophic left kidney.
PROCEDURE PERFORMED: Hand assisted laparoscopic left nephroureterectomy, transurethral incision of left ureteral orifice and left salpingo-oophorectomy.
Surgeon: M***** ******, MD
ASSISTANT:
L****** MD
CO-SURGEON:
V**** ******, MD.
COMPLICATIONS:
None.
PATHOLOGY:
Left kidney and ureteral segment, left ovary, and fallopian tube.
INDICATIONS:
The patient is a female with an atrophic left kidney from chronic distal ureteral obstruction. She underwent ureteroscopy which revealed an obstructing left ureteral tumor consistent with urothelial carcinoma. Cytology obtained at that time was consistent with high-grade urothelial carcinoma. Subsequent CT scan revealed an apparent ureteral tumor and left pelvic lymphadenopathy consistent with urothelial carcinoma. Left nephroureterectomy was offered for definitive treatment of an apparent obstructive urothelial carcinoma and an atrophic poorly-functioning left kidney with possible lymphadenopathy. The indications, alternatives, and attendant risks were explained in details.
FINDINGS:
She had an atrophic left kidney with hydroureter down to an obstructing ureteral tumor at the level of the left iliac vessels. Unfortunately, the tumor was unable to be resected off the left external iliac vessels and uterine blood supply. Left salpingo-oophorectomy was performed to obtain exposure in an attempt to remove the tumor. Unfortunately, we were unsuccessful.
DETAILS OF PROCEDURE:
The patient was taken to the operating room and positively identified as well as the site and side of surgery during a time-out. After adequate general anesthesia, she was transferred into the modified dorsal lithotomy position and prepped and draped in the usual sterile fashion for cystoscopy. Urethral meatus was dilated up to 28-French and a 25-French continuous flow resectoscope sheath passed with the obturator in place. The working element was then passed and using the right angle electrode, the left ureteral orifice was incised circumferentially until perivesical fat was identified. The ureter was allowed to retract superiorly. Hemostasis was obtained with electrocautery. The bladder was left partially distended and scope removed. An 18-French Foley catheter was then inserted and balloon inflated to 10 mL. Effluent came back pink tinged. The patient was then repositioned into the modified left flank position over the break in the table and secured in place with a bean bag. All pressure points were appropriately padded. An incision was made with a 15 blade scalpel knife along the interior costal margin on the left-hand side for distance of approximately 8 cm. Dissection was then carried down through the subcutaneous fat and muscle layers to enter the peritoneal cavity. The rectus muscle was partially divided laterally. The remainder of the muscles were swept medially. The perineum was entered between hemostats through the posterior rectus sheath. There were no significant adhesions noted. The wound protector portion of the GelPort was placed. GelPort was then applied and a 10 mm port passed through the GelPort and the abdomen insufflated. Two 10 mm ports were placed through stab incision in the left lower quadrant under direct vision and guidance. Using the L-hook electrosurgical dissector and LigaSure, the colon was reflected by incising along the white line of Toldt. The colon was mobilized from the sigmoid to the splenic flexure. The kidney was then mobilized outside of Gerota fascia posteriorly and inferiorly. Upper pole was then mobilized inside Gerota fascia along the kidney capsule to free up the adrenal gland, which was left intact. A single renal artery was dissected posteriorly and clipped doubly proximally, singly, distally, and then transected with the LigaSure device. The renal vein was then dissected circumferentially with blunt sharp and dissection. It was then transected with the endovascular stapler. The remaining attachments of the upper pole were transected with the endovascular stapler, freeing the kidney. The gonadal vein and ureter were identified and traced down in the pelvis. Electrocautery was used to dissect out the dilated ureter down to an obstructing tumor adherent to the external left iliac vessels. The ureter was doubly clipped and transected at that level. An attempt was made to dissect the tumor off the vessels, but was tightly adherent and unable to be safely removed with blunt and sharp dissection. The ovary and fallopian tube were medially adjacent and were ultimately resected by Dr. V****, who was consulted intraoperatively for possible hysterectomy. Ultimately we decided against hysterectomy since we were unable to safely dissect the tumor off the iliac vessels. There is also a dense desmoplastic reaction overlying the lymph nodes. The dissection was further complicated with the uterus being adherent to the tumor and left pelvic sidewall. There was no evidence of malignancy within the uterus. I was able to dissect down to the distal ureter to expose the previously incised ureteral orifice. The distal ureteral segment was able to be delivered and transected. A clip was placed on the ureteral segment left behind. Unfortunately, approximately 6 cm of ureter were unable to be resected since they were densely adherent to the left pelvic sidewall. There did appear to be palpable lymphadenopathy along the pelvic sidewall. Formal lymph node dissection was not carried out due to the adherence to the overlying vessels. Clips were placed to mark the ureteral tumor. The wound was irrigated with copious amounts of water. Hemostasis was obtained with electrocautery and Arista powder. A Nu-Knit gauze was placed over the cut edge of the uterus and excellent hemostasis obtained. The renal fossa was then inspected and hemostasis noted to be adequate. She will be noted that a transverse incision was created during open dissection of the distal ureter and performing the salpingo-oophorectomy by Dr. V*****. Dissection of the distal ureter did not require a cystotomy. Vascular Surgery was consulted intraoperatively regarding possibility of resection of the tumor, which may have required resection of the left common iliac vessel. The patient has not had a proper consent likely to proceed with that aggressive resection and therefore we elected to stop at this point. All counts were correct. The muscle layer was then closed with 0 Vicryl running stitch. The Pfannenstiel incision was closed with a single layer of fascial closure. The hand port in the subcostal region was closed in 2 layers. Subcutaneous tissue was closed with interrupted Vicryl stitches. The skin for all incisions including the 10 mm ports were closed with subcuticular 4-0 Monocryl. No fascial stitches were placed in the 10 mm ports. The wounds were irrigated prior to closure. Sterile dressings were applied. All counts were correct. The patient tolerated the procedure well without complications. KJ 20220502