RESUMO
OBJECTIVES: We describe a series of surgical manoeuvres to perform a completely laparoscopic nephroureterectomy. METHODS/RESULTS: We set the patient in the lateral position. The trocars are placed in a rhombus shape, with an accessory trocar for liver retraction on the right side. Once the parietal peritoneum is open the ureter and gonadal vein are localized. We clip and section the gonadal vein. The renal pedicle is localized and dissected. We divide separately the renal artery and vein. We complete the dissection of the kidney. We start the caudal dissection of the ureter from the iliac vessels level down to the pelvis. We clip the ureter. Due to the trocar deployment we reach a point in which ureteral dissection becomes difficult. Then we perform 3 manoeuvres: 1) We change the camera from the lower trocar to the right side one. 2) We move the monitor to the feet of the patient. 3) The surgeon moves to the other side of the patient to work with the superior and inferior trocars. We introduce a retractor through the remaining trocar. With these changes the ureter is in line with the camera and we may have a good access to the pelvis, making the distal dissection of the ureter easier. The dissection ends when the classic image of tent of the vesicoureteral junction is seen. The bladder patch is resected and the bladder is sutured closed with a continuous suture. The specimen is bagged and extracted opening the orifice of the iliac fossa trocar. CONCLUSIONS: With this technique, a completely laparoscopic nephroureterectomy may be performed following the oncological principles of open surgery.
