Modified “pluck” technique with Tissucol for the management of distal ureter during nephroureterectomy

Introduction & Objectives: Nephroureterectomy is a well established technique for managing the upper urinary tract urothelial carcinoma (UTCC). However, management of the distal ureter remains a controversial issue. We describe a modified method of “pluck” technique using fibrin glue (Tissucol™) in order to improve the oncologic efficacy of this technique. Material & Methods: Since 2007 to September 2008, 10 consecutive patients underwent nephrouretherectomy (6 open and 4 laparoscopic) with our modified distal ureter technique for pelvis and/or caliceal UTCC. Patients were placed in lithotomy position. Cystoscopy was performed with a 23 Fr cystoscope and a 8 Fr ureteral catheter was inserted in the ureter up to 10 cm. At this point, an injection of Tissucol™ 2 ml was performed in order to create a fibrin obstructive cup. After 30 sec, by a 24 Fr resectoscope the ureteric stump was further dissected until the perivescical fat was reached. Results: In both procedures, laparoscopic and open nephrouretherectomy, the ureter was easily identified at the level of iliac artery. The ureter clearly resulted to be overfilled by the obstructive cup. At the end of the procedures all the ureteric specimens were spatulated and transversally dissected in order to evaluate the efficacy of the Tissucol™ cup. In all cases Tissucol™ provided an airtight lumen obstruction. Conclusions: Our modified technique appeared to be a simple, less invasive and oncologically safe method to manage the distal ureter.