Background:
In this presentation we describe a laparoscopic solution to an infrequent surgical dilemma. Extraperitoneal transvesical resection of a distal ureteral remnant is described in a patient who had a recurrence of transitional cell carcinoma posterior to the bladder in the area of the previously resected ureter. Recurrence of transitional cell carcinoma in the retroperitoneum or in the distal ureteral remnant after a complete nephroureterectomy is an infrequent complication. The treatment of recurrent local disease in the absence of metastasis includes aggressive surgical excision. Transurethral resection, segmental resection, radiation therapy, and cystectomy have all been described as treatment options. This video demonstrates a novel laparoscopic approach to the management of this problem.
The Patient:
One year prior to referral, a 51 year old male underwent a hand assisted laparoscopic nephroureterectomy for grade 3/3 transitional cell carcinoma of the renal pelvis. The distal ureter was managed with an endoscopic and laparoscopic technique but was complicated by avulsion of the ureter during the abdominal dissection. At one year follow up a submucosal mass was seen in the expected location of the right ureteral orifice. CT scan confirmed the presence of a 2.3x2x1 cm mass. He elected surgical excision and we performed this with a laparoscopic extraperitoneal transvesical technique. The video demonstrates the technique.
Results:
The surgery was performed with minimal blood loss and no immediate or delayed complications. The drain was removed and the patient was discharged on post-operative day one. The pathology demonstrated transitional cell carcinoma with negative margins. Follow up at 8 months with cystoscopy, urine cytology, and CT scan revealed no evidence of residual or recurrent mass.

Conclusions:
In the setting of a recurrence of transitional cell carcinoma in the distal ureteral remnant, a laparoscopic extraperitoneal transvesical approach is feasible and morbidity is minimal.

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