Template-based pelvic lymph node dissection during lateral decubitus-positioned total retroperitoneal laparoscopic radical nephroureterectomy: a step-by-step description of a surgical technique

Introduction

Radical nephroureterectomy (RNU) with the excision of the distal ureter and bladder cuff (DUBC) is the standard surgical treatment for patients with high-risk upper tract urothelial cancer (UTUC) (1); inadequate excision of the DUBC leads to inferior oncologic outcomes (2). However, the management of DUBC excision in the implementation of laparoscopic RNU remains challenging (3). Various methods have been applied to realize DUBC resection (4,5) and can be categorized into intravesical, transvesical, and extravesical approaches (6). In addition to en bloc excision of DUBC, optimal management should involve primary suturing of the bladder incision and the avoidance of urine spillage (7). The transperitoneal approach damages the integrity of peritoneum and is associated with worse prognosis as compared to the retroperitoneal approach (8,9). Therefore, we attempted to establish a single-position (single group of skin incisions) total retroperitoneal laparoscopic RNU approach.

Pelvic lymph node dissection (PLND) is critical to successful RNU (10,11). Indeed, the technique for treating distal UTUC without PLND could not truly be considered RNU. A PubMed search for “nephroureterectomy” and “lymph node dissection” or “lymphadenectomy” identified only two articles on retroperitoneal laparoscopic PLND technique: one reported a procedure in the supine position (two groups of skin incisions) (12), and the other, our preliminary work, reported a procedure in the decubitus position (9). However, no descriptions of lateral decubitus-positioned retroperitoneal laparoscopic PLND (LRL-PLND) have been reported to date.

Here, we present our experience with the LRL-PLND method in which an average of only 0–1 additional trocars were needed during lateral decubitus-positioned total retroperitoneal laparoscopic RNU (LTRL-RNU). This novel technique might provide substantial benefits for patients with UTUC. We present this article in accordance with the SUPER reporting checklist (available at https://tau.amegroups.com/article/view/10.21037/tau-2026-0332/rc).

Methods

Patient selection

We retrospectively enrolled 11 patients with distal UTUC who underwent PLND via the LTRL-RNU approach performed by the same surgeon with rich experience of laparoscopic surgeries at the Department of Urology, Ruijin Hospital, from July 2022 to September 2024. The study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments. The study protocol was approved by the Ruijin Hospital Ethics Committee (approval No. 144; year: 2021), and all patients provided written informed consent.

Statistical analysis

The basic information of patients such as age, gender, body mass index (BMI), tumoral location, and special circumstances were all collected. The surgical outcomes and follow-up data, including operation time, trocar number, estimated blood loss, conversion to open approach, complications (according to Clavien-Dindo grading system), postoperative hospital stay, pathological results, and follow-up duration, were also recorded.

SPSS 23.0 (IBM Corp., Armonk, NY, USA) was used to retrospectively analyze the data. The statistical results were presented as counts and percentages or mean ± standard deviation.

Description of the LTRL-RNU technique

The LTRL-RNU technique was performed as follows: the patients were placed in lateral decubitus position at 90°, with the waist elevated to separate the costal margin and the iliac crest as much as possible. Ultrasonic Scalpel (HARMONIC™, Ethicon, Johnson & Johnson MedTech, USA) and 3-0 V-Loc™ (Medtronic, USA) were utilized. Pneumoperitoneum pressure was 12 mmHg. The LTRL-RNU technique consisted of three procedures: nephrectomy, ureterectomy, and PLND. Nephrectomy and ureterectomy were performed in routine fashion (7). One patient also underwent template-based lumbar lymph node dissection (LLND) in the same operation.

PLND

PLND was performed under a caudal view during the ureterectomy procedure, with trocar 3 or 4 typically being used as an observation port and trocar 1 being used only in patients with favorable anatomical conditions (Figure 1). The scope of the dissection included the para-common iliac artery (para-CIA), para-external iliac artery (para-EIA) and para-obturator nerve field and was bounded by the deep iliac circumflex vein, EIA, and Cloquet lymph node. The obturator vessels and the uterine artery (in females) were often preserved.

Figure 1 Three-dimensional schematic diagram for the distribution of trocars during lateral decubitus-positioned total retroperitoneal laparoscopic radical nephroureterectomy.

The first step of PLND was the exposure of the obturator nerve. Separation was performed along the psoas muscle on the dorsal side of the EIA and external iliac vein (EIV), and the genitofemoral nerve was preserved if possible. The boundary of the true pelvis was then exposed, and the convergence area of the obturator nerve and the EIV was located. Subsequently, the obturator nerve was skeletonized, and the obturator artery and the obturator vein were preserved if possible. At the angle between the EIV and the true pelvis, the Cloquet lymph node was dissected. Dissection was then carried out along the ventral side of the EIA and EIV. The lymphatic adipose tissue covering the CIA and the EIA was incised, and the CIA and the EIA were skeletonized. The same procedure was performed on the EIV. As the gap between lymphatic adipose tissue, peritoneum, and the bladder wall was partly separated during the ureterectomy, the PLND specimen could then be easily and completely removed from the peritoneum and the bladder wall for the pathological test (Figures 2,3 and Video 1).

Figure 2 The template-based pelvic lymph node dissection procedure during lateral decubitus-positioned total retroperitoneal laparoscopic radical nephroureterectomy. (A,B) Separation along the surface of the PMM. (C) Exploration of the ON. (D) Skeletonization of the ON. (E-G) Skeletonization of the CIA, EIA and EIV. (H) Dissection of the Cloquet LN. (I) Removal of the lymphatic adipose tissue from the UA. CIA, common iliac artery; EIA, external iliac artery; EIV, external iliac vein; GFN, genitofemoral nerve; LN, lymph node; ON, obturator nerve; PMM, psoas major muscle; UA, umbilical artery.

Figure 3 The effect of skeletonization after template-based pelvic lymph node dissection.

Results

General characteristics of patients

Among the 11 patients enrolled in the study, the mean age was 71.82±9.93 years, the ratio of males to females was 1.75:1, and the mean BMI was 21.95±2.90 kg/m². In 8 cases, the tumor was located on the left side, the remaining 3 were on the right side (ratio 2.67:1). Among the 11 cases, the primary tumors were found in the section from the median to the end of the ureter; moreover, 1 (9.09%) patient had severe scoliosis, 1 (9.09%) had a history of laparoscopic radical prostatectomy, 2 (18.18%) had EIA tortuosity, 1 (9.09%) had CIA tortuosity, and 1 (9.09%) had lower calyceal/pelvic cancer and tumoral thrombus in the inferior vena cava (Mayo Clinic grade I), which was also removed retroperitoneally (Table 1).

Efficacy

Based on preoperative imaging assessment or intraoperative judgements, PLND was performed in all cases, with 1 patient with caliceal/pelvic UTUC also undergoing LLND. The largest resected lymph node in PLND was 5 cm in diameter and located in the para-EIV region. The mean operation time was 142.55±40.94 min, with 46.00±14.66 min for laparoscopic nephrectomy, 62.91±26.80 min for laparoscopic ureterectomy, and 31.18±8.62 min for PLND.

Although a few patients had severe scoliosis, a history of laparoscopic radical prostatectomy, EIA or CIA tortuosity, or inferior vena cava tumoral thrombus (for which thrombectomy was performed in 18 min), there were no conversions to an open approach, and the success rate of surgery was 100% (Table 2).

Number of trocars

For the whole procedure, 4–5 trocars (4.36±0.67) were used, with 3.20±0.42 being used for nephrectomy. An additional 0.91±0.30 trocars were needed for laparoscopic ureterectomy and 0.40±0.50 for PLND. In one patient, only three trocars were needed to complete the entire RNU procedure, including the PLND (Video 1), because of the patients’ low BMI and suitable anatomical structure (Table 2).

Complications

The total estimated blood loss was 118.18±94.64 mL (Table 2), and no transfusions were needed. Only one patient had anemia (Clavien-Dindo grade I) after surgery, which was managed conservatively without the need for blood transfusion. The follow-up duration was 17.36±7.39 months (Table 2).

Pathological results

Regarding pathological outcomes, UTUC was confirmed in all patients (100.00%), and 1 (9.09%) patient had accompanying neuroendocrine differentiation. Carcinoma in situ (CIS) was accompanied with other grades and stages. Among the patients, 10 (90.91%) had high-grade disease [3 (27.27%) with CIS], and 1 (9.09%) had low-grade disease. As for T stage, 0 (0.00%), 3 (27.27%), 1 (9.09%), 2 (18.18%), 8 (72.73%), and 0 (0.00%) patients were classified as Ta, Tis, T1, T2, T3, and T4, respectively. The pathologically positive rate of PLND was 1/11 (9.09%), 1 of the 2 patients (50%) who underwent LLND had lymph node metastasis, and 2/11 (18.18%) patients had a positive surgical margin (Table 2).

Discussion

UTUC cells can detach into the urine to spread and implant (13). During RNU, there are two anatomical barriers that can prevent urine leakage: (I) the renal pelvis, ureter, and bladder; and (II) the peritoneum (12,14). During the complete removal of DUBC, the bladder wall is excised (15). For severe hydronephrosis, the renal pelvis, ureter, and renal parenchyma can rupture during the operation. Therefore, the first anatomical barrier will definitely rupture, and the peritoneum will be the final one (16). It is important to restore the integrity of the bladder (the first anatomical barrier) immediately and preserve the integrity of the peritoneum (the second anatomical barrier) (10). The optimal approach for RNU is total retroperitoneal laparoscopy, as it provides suitable management of the DUBC in terms of oncological considerations.

It was previously considered impossible for RNU to be performed via total retroperitoneal laparoscopy due to the narrow extraperitoneal space (4,17). Several minimally invasive methods have been applied for the management of the DUBC: (I) the intravesical approach (pluck and stripping techniques), (II) transvesical approach, and (III) extravesical approach (4,18-20). In the intravesical approach, the bladder barrier cannot be restored immediately, and the tumor implantation rate is about 19.3–24% (21), and the operative position must be changed. There is no pronounced distinction between the transvesical and intravesical approaches. The earlier developed minimally invasive extravesical approach involves lateral decubitus-positioned total transperitoneal laparoscopic RNU (LTTL-RNU) and modified single-position intraperitoneal laparoscopic RNU, which sutures the bladder incision immediately without a change in position (22,23), yet it completely destroys the integrity of the peritoneum. Although it has been reported that the retroperitoneal and transperitoneal approaches produce similar outcomes (24), it has also been found that, in comparison to retroperitoneal procedures, transperitoneal procedures are associated with a worse prognosis (8). In our previous study, LTRL-RNU provided a better prognosis at 6 months post-surgery and progression-free survival at 12 months than did LTTL-RNU (9). Moreover, the transperitoneal approach requires a greater number of trocars (8,9,24).

Inspired by the ureteroscopic approach, we determined that management of the DUBC could be feasibly achieved using retroperitoneal laparoscopy from the caudal angle. It has been demonstrated that the DUBC can be entirely resected and sutured under direct vision, with this approach improving patient prognosis (25). Furthermore, the retroperitoneal approach, as compared to transperitoneal one, provides more natural and facile sparing of the round ligaments of the uterus (26). However, the full realization and optimization of this technique depends on the development of LRL-PLND (9).

UTUC has a relatively high rate of lymph node metastasis, possibly due to an abundant blood supply (27). Lymphovascular invasion leads to decreased cancer specific survival (28). Lymph node dissection has been demonstrated to provide prognostic benefits for patients with UTUC and is particularly recommended in high risk cases (29). It was reported that in cases with ≥pT2 renal pelvis UTUC, lymph node dissection yielded a significantly higher 3-year cancer-specific survival than did treatment without LND (30). In cases of enlarged lateral pelvic lymph nodes (such as in the case listed in Table 1), PLND is necessary, which involves conversion from nephroureterectomy to RNU. Indeed, the pathological results from our study support the necessity of including the LRL-PLND technique into the LTRL-RNU technical system, and lymph node dissection has been considered one of the four key components of RNU’s “tetrafecta” (10,11). Although the pathologically positive rate in our study for PLND was only 9.09%, there was at least one negative patient who had pelvic recurrence (around the affected iliac vessels) at nearly one year after the surgery (after the end of the adjuvant therapy).

In our study, we assessed the practicability of LRL-PLND and demonstrated that PLND can be conducted retroperitoneally in the lateral decubitus position with peritoneum-sparing. This technique was also successfully applied in cases with severe scoliosis, EIA tortuosity, CIA tortuosity, a history of laparoscopic radical prostatectomy, or tumoral thrombus in the inferior vena cava. However, if there is severe bleeding of iliac vessels and the suture angle cannot be obtained through the retroperitoneal approach, conversion to the transperitoneal approach or an open approach should be considered. It should be noted that the process of LRL-PLND in LTRL-RNU differs significantly from that of the PLND in laparoscopic radical cystectomy (LRC) performed by most urologists. In the majority of PLND procedures completed during LRC, the view is tilted toward the lateral pelvic wall, and the dissection is first performed from the surface of the iliac vessels. A small portion of surgeons initially dissects from the dorsal side of the iliac vessels to find the obturator nerve. The LTRL-RNU method reported by our team requires only 3–5 trocars. The view is directed toward the dorsal side of the iliac vessels. Therefore, in the exposure of the obturator nerve, separation only occurs from the dorsal side of the iliac vessels. This process is the same as that for the second PLND method in LRC, but the view is completely different and needs to be adapted.

For surgeons who preferred the ventral approach to expose the obturator nerve during LRC, the learning curve for our technique will be longer and more challenging (at least 20–30 cases needed). Conversely, the learning curve will be much shorter for surgeons who are accustomed to the dorsal approach. In our study, the surgeon has practiced the exposure of obturator nerve during LRC by dorsal approach for nearly 10 years, and thus the rapid learning curve.

The PLND procedure is executed in the space constructed during the procedure of RNU. Before PLND, the specimen is removed from the pelvic, and the ruptured peritoneum is repaired by Hem-o-Lok or V-Loc, so that the space is generally enough for PLND. The most difficult step of the PLND technique is to find out the obturator nerve, which is performed from the dorsal side of the iliac vessels, far from the peritoneum. Thus, in cases of peritoneal rupture occurring during the RNU, LRL-PLND technique can still generally be performed. The peritoneal rupture rate during PLND in our study was 0%.

Certain limitations of this study on our initial experience of LRL-PLND in LTRL-RNU should be noted. Notably, the sample size was small, and further research with a larger sample is needed. Nonetheless, given the satisfactory outcomes achieved in a variety of conditions, we have reason to believe that this technique could be well integrated into the LTRL-RNU technical system and meaningfully contribute to improving treatment.

Conclusions

LRL-PLND is feasible, safe, and minimally invasive and may represent an improvement to conventional LTRL-RNU. Due to the small sample size of this study, further research is needed to verify the advantages and disadvantages of LRL-PLND.

Acknowledgments

None.

Footnote

Reporting Checklist: The authors have completed the SUPER reporting checklist. Available at https://tau.amegroups.com/article/view/10.21037/tau-2026-0332/rc

Data Sharing Statement: Available at https://tau.amegroups.com/article/view/10.21037/tau-2026-0332/dss

Peer Review File: Available at https://tau.amegroups.com/article/view/10.21037/tau-2026-0332/prf

Funding: This work was funded by grants from the Science and Technology Commission of Shanghai Municipality Project (No. 21S31903700), and the Guangci Clinical Technology and Innovation Program (GCTIP) of Ruijin Hospital (No. GCQH-2024-15).

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://tau.amegroups.com/article/view/10.21037/tau-2026-0332/coif). All authors report grants from the Science and Technology Commission of Shanghai Municipality Project (No. 21S31903700), and the Guangci Clinical Technology and Innovation Program (GCTIP) of Ruijin Hospital (No. GCQH-2024-15). The authors have no other conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. The study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments. The study protocol was approved by the Ruijin Hospital Ethics Committee (approval No. 144; year: 2021), and all patients provided written informed consent.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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(English Language Editor: J. Gray)