Figure 3The ureter is completely dissected and freed from the bladder wall.Figure 4The mobilized distal sellckchem ureter is placed outside the bladder. The bladder defect will be closed with running suture.The patient was then placed in a 90�� lateral decubitus position, and either an open nephrectomy via a standard flank incision or a transperitoneal laparoscopic nephrectomy was performed. In both approaches, after mobilizing the ureter caudally, the previously detached juxtavesical ureter and bladder cuff were easily removed. In the open approach, the entire specimen was extracted through the flank incision. In the laparoscopic approach, the en bloc specimen was placed in a specimen retrieval bag. The incision at one of the port sites was extended appropriately, and the bag was removed.3.

Results The distal ureter and bladder cuff excision procedure was completed uneventfully in all cases. The operating time for distal ureter excision ranged from 55 to 120 minutes (median 82.5 minutes). This time was calculated from the insertion of the cystoscope to the removal of the transvesical trocars. The operating time decreased from case 1 through case 10 due to increased experience. Blood loss related to the excision of the distal ureter was minimal in all cases (<50mL). Open nephrectomy via a standard flank approach was performed in the first two cases, whereas laparoscopic transperitoneal nephrectomy was performed in the last eight cases. No complications directly related to the pneumovesicum method were recorded. In one patient (case 2), a postoperative fever >38��C was recorded on the 2nd postoperative day.

This fever resolved spontaneously. Cystography before catheter removal (on the 7th postoperative day) was performed in the first two cases without evidence of extravasation. This examination was not performed in the last eight patients, and no complications were recorded. The mucosal margins of the bladder cuff were negative in all ten cases.The median follow-up duration for this series was 31 months (range 12�C55 months). During the follow-up period, two patients died from the disease. Patient number 2 had a T3 renal pelvic tumor and presented with both nodal and distant metastases 6 months postoperatively. Patient number 8 had a T2 renal pelvic tumor and initially developed metastases at the paraaortic lymph nodes 12 months postoperatively.

Both patients received chemotherapy but died 13 and 22 months after surgery, respectively. Noticeably none of the patients in this series developed local pelvic recurrences or pelvic lymph node metastases. A bladder tumor developed in three patients (30%) during the follow-up Cilengitide period. The tumors were found on the lateral bladder wall on the contralateral side with respect to the excised orifice in two patients and on the bladder dome in one patient. The intra- and postoperative data are summarized in Table 2.