Flexible cystoscopy-assisted distal ureter and bladder cuff excision in single-position transperitoneal laparoscopic radical nephroureterectomy: techniques and clinical outcomes

The human urinary system is a network of tubes and filters designed to move waste from the kidneys to the bladder and out of the body. Sometimes, cells lining the upper part of this system, specifically the tubes connecting the kidney to the bladder, begin to grow out of control, forming a cancer known as upper tract urothelial carcinoma. Because these tumors can spread easily along the lining of the tubes, the standard treatment involves removing the entire affected kidney, the full length of the ureter, and a small section of the bladder where the tube enters. This procedure, called a radical nephroureterectomy, is critical for preventing the cancer from returning, but it presents a significant surgical challenge at the very end of the operation. The surgeon must remove the tiny opening where the ureter meets the bladder without leaving any cancer behind, while also ensuring the bladder heals tightly so urine does not leak into the body. Traditional methods often require the patient to be moved from one position to another during the surgery, or involve cutting into the bladder directly, which carries risks of leakage and tumor spread.

A team of surgeons at Peking University People's Hospital recently explored a refined way to handle this difficult step. They developed a technique that keeps the patient in a single position throughout the entire operation and uses a flexible, camera-equipped scope inserted through the urethra to guide the removal of the bladder section. In a study of 29 patients with localized cancer, the researchers found that this approach allowed them to complete the surgery entirely through small incisions in the abdomen, without ever needing to convert to a large open cut. By using the camera to watch the bladder from the inside while they worked from the outside, the surgeons could see exactly where to cut and verify that the entire tumor was gone before closing the wound. The results showed that every patient had clean margins, meaning no cancer cells were left at the edges of the removed tissue, and the procedure was completed with minimal blood loss and a short recovery time in the hospital.

The core of this new method lies in how the surgeons manage the transition from the kidney to the bladder. In the past, removing the distal ureter and the bladder cuff often required the patient to be repositioned, which interrupts the flow of the surgery and adds time. Alternatively, surgeons might cut directly into the bladder to see the area clearly, but this creates a risk of urine leaking into the abdominal cavity or causing tumor cells to spread within the bladder. The team's modified technique eliminates the need for repositioning by performing the entire procedure with the patient lying on their side. To solve the problem of seeing inside the bladder without cutting it open, they inserted a flexible cystoscope through the urethra. This device acts like a thin, bendable flashlight with a camera, allowing the surgical team to view the inside of the bladder in real time while they work on the outside.

During the operation, the surgeons first removed the kidney and the upper part of the ureter using standard laparoscopic tools. Once they reached the lower section near the bladder, they paused to insert the flexible scope. This allowed them to confirm that there were no other tumors hiding in the bladder and to pinpoint the exact location of the ureteral opening. Guided by the live video feed from inside the bladder, the surgeons used laparoscopic scissors to carefully excise the bladder cuff and the end of the ureter. Immediately after cutting, they used the scope again to check that the entire opening had been removed and that the edges were clear of cancer. Finally, they stitched the bladder wall closed and used the scope one last time to ensure the seal was watertight and no bleeding was occurring. This step-by-step visual confirmation replaced the guesswork often associated with blind removal techniques.

The study included 29 patients who underwent this modified procedure between January 2023 and December 2025. The results demonstrated that the surgery was highly effective and safe. The median time for the entire operation was 170 minutes, and the amount of blood lost was minimal, with a median of 100 milliliters. Most importantly, all 29 patients achieved negative surgical margins, meaning the pathologists found no cancer cells at the edges of the removed tissue. This is a crucial indicator that the tumor was completely removed. The patients recovered quickly, with a median hospital stay of just five days. Postoperative complications were rare and mild; only three patients experienced minor issues, and there were no severe complications such as major bleeding or organ injury. Over the short term, the cancer did not return in the vast majority of patients, with only three cases of recurrence observed during the follow-up period.

The researchers noted that this approach offers a distinct advantage over traditional methods by combining the efficiency of a single-position surgery with the precision of direct visualization. By avoiding the need to move the patient or cut into the bladder, the technique reduces the time the patient spends under anesthesia and lowers the risk of complications related to urine leakage. The use of the flexible scope provided a level of certainty that blind techniques could not match, ensuring that the surgeon knew exactly what had been removed before closing the patient up. While the study was limited to a single center and a relatively small group of patients, the findings suggest that this method is a viable and effective option for treating localized upper tract urothelial carcinoma. The authors concluded that this technique simplifies the surgical workflow while maintaining high standards for tumor removal and patient safety, offering a promising alternative for future treatments.