Single-Position Intraperitoneal Laparoscopic Surgery (SP-ILS) for Radical Nephroureterectomy in a Modified Supine Position

Introduction: Radical nephroureterectomy (RNU) with bladder cuff excision (BCE) is the standard, often curative, therapy for upper tract urothelial carcinoma. In recent years, various authors have shared their experiences and results in single-position laparoscopic RUN (LRNU). However, laparoscopic BCE presented technically challenging, as the pelvic operative field is limited in the flank position, especially in obese patients. 1 Methods: This video shows a technique of modified single-position intraperitoneal laparoscopic surgery (SP-ILS) for adequate surgical exposure during both LRNU and BCE. Results: A 59-year-old male presented to the hospital with painless hematuria. Preoperative contrast-enhanced CT showed a tumor with a size of 5.0 cm × 4.5 cm in the left renal pelvis. There was no evidence of local or distant metastases. His body mass index was 30.4 kg/m 2 . Patients were placed in a supine position with an inflatable pillow on the flank, which provides a 30-degree rotation of the abdomen. This positioning strategy has been successfully applied in our previous laparoscopic procedures. 2 The procedure began with an open Hasson technique to place a 10 mm paraumbilical camera port. Two working 12-mm trocars were placed bilaterally at the umbilical level, at the lateral edges of the rectus abdominis muscle. A 5-mm working port was placed 5 cm below the xiphoid, with placements adjusted to optimize access. 3 The total operative time was 120 minutes, with an estimated blood loss of 20 mL. The patient was discharged 3 days postoperatively without complications. Conclusion: SP-ILS improves exposure and surgical efficiency during both LUNU and BCE without patient repositioning. During LRNU, it maintains an adequate visual field by using a cotton tape to retract the colon. To displace the small intestine laparoscopically in the supine position, a retractor is often required. 4 During BCE, it provides ergonomic comfort for surgeons experienced in standard pelvic surgeries and enables better pelvic access even in obese patients. The video accompanying this submission showcases the critical steps of the procedure. The authors have received and archived patient consent for video recording/publication in advance of video recording the procedure. This is an original work carried out in a tertiary care public hospital, and there are no conflicts of interest or obligations resulting from it to any of the authors. Runtime of video: 5 mins 47 secs