A 20-year experience with percutaneous resection of upper tract transitional carcinoma: is there an oncologic benefit with adjuvant bacillus Calmette Guérin therapy? Urology. 2009;73:27-31. [PMID: 18929398 DOI: 10.1016/j.urology.2008.06.026]

Percutaneous nephroscopic resection of pyelocaliceal transitional cell carcinoma in solitary kidney

Percutaneous approaches to upper tract urothelial cancers have been performed in patients unsuitable for radical nephroureterectomy. We present two cases of transitional cell carcinoma involving the renal pelvis in either functional or anatomical solitary kidney, which were successfully treated by percutaneous nephroscopic resection using monopolar electrocautery.

Comparison of 3 upper tract anticarcinogenic agent delivery techniques in an ex vivo porcine model

OBJECTIVE

To evaluate the degree of urothelial exposure using 3 upper tract delivery techniques in an ex vivo porcine model, to determine the optimal modality to locally deliver topical anticarcinogenic agents in patients with upper tract urothelial carcinoma.

MATERIALS AND METHODS

An indigo carmine solution was infused into en bloc porcine urinary tracts to test the 3 techniques: antegrade infusion via nephrostomy tube, reflux via indwelling double-pigtail stent, and retrograde administration via a 5F open-ended ureteral catheter. Nine renal units (3 per delivery method) were used. After a 1-hour dwell time, the urinary tracts were bivalved and photographed. Each renal unit was evaluated by 3 blinded reviewers who estimated the total percentage of stained urothelial surface area using a computer-based area approximation system. In addition, as a surrogate for exposure adequacy, a validated equation was used to calculate the staining intensity at 6 predetermined locations in the upper tract, with lower values representing more efficient staining.

RESULTS

Mean percent of surface area stained for the nephrostomy tube, double-pigtail stent, and open-ended ureteral catheter groups was 65.2%, 66.2%, and 83.6%, respectively (P = .002). Mean staining intensities were 40.9, 33.4, and 20.4, respectively (P = .023).

CONCLUSION

Our results suggest that retrograde infusion via open-ended ureteral catheter is the most efficient method of upper tract therapy delivery. Larger studies using in vivo models should be performed to further validate these findings and potentially confirm this method as optimal for delivery of topical anticarcinogenic agents in upper tract urothelial carcinoma.

Ureteroscopic laser treatment of upper urinary tract urothelial cell carcinomas: can a tumour free status be achieved?

Introduction. In cases of anatomic or functional single kidney with urothelial tumours of the upper urinary tract, the endoscopic laser ablation has proven efficacious. Based on the knowledge that low-grade, low-stage upper tract transitional cell carcinomas rarely progress to invasive lesions, indications for endoscopic laser ablation have expanded to include patients with bilateral functioning kidneys and low-grade tumours. The question that remains to be answered is whether endoscopic laser ablation has the ability to completely eradicate upper urinary tract tumours. Methods. We performed in 25 patients in a period of 11 years 288 ureteroscopies and, if needed, laser ablation of upper urinary tract tumours in imperative indication. Results. In 32% of the patients the cancer remained even after several laser sessions. 64% of patients were tumour free after one or more laser sessions but remained clear only for the next 3 months. Only 1 patient was tumour free for a period of 68 months after 1 session of laser treatment. The procedure had low complication rates. Conclusion. The laser technology and the introduction of small diameter semirigid and flexible ureteroscopes made ablation of upper urinary tract tumours possible and safe. Nevertheless a complete resection of the carcinomas is rarely possible.

Endoscopic management of upper urinary tract urothelial carcinoma

Upper urinary tract urothelial carcinoma (UTUC) is relatively uncommon. Radical nephroureterectomy with an ipsilateral bladder cuff excision has been the gold standard treatment for UTUC. However, recent advances in technology have made possible the increased use of endoscopic management for the treatment of UTUC. The definitive goal of endoscopic management of UTUC is cancer control while maintaining renal function and the integrity of the urinary tract. Endoscopic management includes both the retrograde ureteroscopic and antegrade percutaneous approaches. The endoscopic management of UTUC is a reasonable alternative for patients with renal insufficiency or a solitary functional kidney, bilateral disease, or a significant comorbidity that precludes radical surgery. Select patients with a functional contralateral kidney who have low-grade, low-stage tumors may also be candidates for endoscopic management. The careful selection of patients is the most important point for the successful endoscopic management of UTUC. It is crucial that patients are compliant and motivated, because a lifetime protocol of strict surveillance is necessary. Adjuvant topical therapy with Bacillus Calmette-Guerin or mitomycin C can be used after endoscopic management of UTUC in an attempt to reduce recurrence. In this article, we review current endoscopic techniques, indications for endoscopic treatment, clinical outcomes of endoscopic management, adjuvant topical therapy, and surveillance in patients with UTUC.

Outcomes of intrarenal Bacillus Calmette-Guérin/interferon-α2B for biopsy-proven upper-tract carcinoma in situ

BACKGROUND AND PURPOSE

While nephroureterectomy (NU) remains the gold-standard treatment for upper-tract carcinoma in situ (UT-CIS), it may be unnecessarily aggressive in comparison with the treatment of bladder CIS. Upper-tract administration of bacillus Calmette-Guérin (BCG) has shown promise for UT-CIS, but with limited reports and varied results. Furthermore, all previous reports included patients with positive cytology results without biopsy-proven CIS, or combined BCG with other topical therapies that are used for bladder CIS. We report our experience using a novel technique to directly instill BCG with interferon-α2B (BCG/IFN) into the upper-tract in patients with biopsy-proven UT-CIS.

PATIENTS AND METHODS

Patients who received a diagnosis of isolated, biopsy-proven UT-CIS from September 2003 to January 2012 were included. After biopsy, all patients received a 6-week induction course of BCG/IFN, administered via an open-ended ureteral catheter. Initial follow-up was scheduled 1 month after the completion of the intrarenal therapy and consisted of flexible ureteroscopy, selective urinary cytology, retrograde pyelography, and rebiopsy of the upper tract. Complete response (CR) was defined as the absence of visualized lesions on ureteroscopy, negative selective cytology results, and absence of clinical progression. Absence of visualized lesions with persistently positive cytology results or persistence of lesions after induction was considered no response (NR). New upper-tract lesions after an initial CR were considered recurrences. Patients with a CR were placed on maintenance therapy for 2 years. Surveillance was performed every 3 months with ureteroscopy, selective cytology, and imaging.

RESULTS

Eleven patients (mean age=73 years) were followed for a median of 13.5 months (3.7-103.3 mos). Eight patients had an initial CR, while three initially had NR. Two of the NR patients had negative biopsy results but persistently positive cytology results; both of these patients underwent a second induction course and achieved a CR. The third NR patient had persistence of lesions after induction and was offered a nephroureterctomy. Total kidney preservation rate was 91% (10/11). There were no treatment-related adverse events.

CONCLUSION

This study demonstrates the safety and efficacy of intrarenal BCG/IFN maintenance therapy for patients with UT-CIS. Unlike other mechanisms of delivery, including percutaneous administration or reflux via double pigtail stents, this office-based technique spares the morbidity of a chronically indwelling nephrostomy tube or ureteral stent.

Results and outcomes after endoscopic treatment of upper urinary tract carcinoma: the Austrian experience

INTRODUCTION

Through evolution in technology, endoscopic treatment has gained popularity for the treatment of upper tract urothelial carcinoma (ENDO-UTUC).

METHODS

A total of 20 patients with ENDO-UTUC were compared to 178 treated by radical nephroureterectomy (RNU) for a pTa-1 UTUC, and a systematic review was performed.

RESULTS

Mean age for ENDO-UTUC was 71.9 ± 16.0 years, and tumor features were favorable (90 % papillary, 14 low grade, 11 pTa). All ENDO-UTUC were performed ureteroscopically. Mean follow-up was 20.4 ± 30 months. The 5-year overall survival (OS) rate was 45 %. Local (LR) and bladder recurrence (BR) was 25 and 15 %. Time to definitive treatment was longer, ASA higher, LR rates higher, OS lower for ENDO-UTUC (all p < 0.001), but no difference was recorded for BR (p = 0.056) and cancer-specific survival (CSS) (p = 0.364). Postoperative kidney function (KF) was better in the ENDO-UTUC (p = 0.048), though preoperative KF showed no difference. The maximal level of evidence was 3b, patients were highly selected, numbers of patients were low, and ASA scores high. OS was rather low and CSS high. LR rate was high (61 %) and BR rate moderate (39 %) for ureteroscopic and 36 and 28 %, respectively, for percutaneous approach.

CONCLUSIONS

LR for ENDO-UTUC is high. In high-grade UTUC, oncological outcome is worse. RNU is associated with a significant loss of KF, but LR is rare. ENDO-UTUC is reserved for selected cases if elective. In imperative cases, it has to be balanced between KF, morbidity of the procedure, risk of operation and tumor control. ENDO-UTUC is not necessarily underused in Austria, because of lack in evidence, but 41 % of all RNU were performed in pTa/pTis/pT1 lesions.

Upper tract urothelial carcinoma: current treatment and outcomes

The reference standard treatment of upper tract urothelial carcinoma is open radical nephroureterectomy. Many centers have advocated less-invasive treatment modalities. We reviewed contemporary treatments of upper tract urothelial carcinoma and their outcomes. A MEDLINE search was conducted for all relevant published data during the past 15 years. Endoscopic management is feasible for low-grade disease with strict surveillance protocols. Radical nephroureterectomy remains the reference standard for upper tract urothelial carcinoma. The intermediate-term oncologic outcomes are similar between the laparoscopic and open approaches. Controversies still exist regarding the optimal management of the distal ureter, the utility of topical therapy, and the role of lymphadenectomy.

Endoscopic management of upper tract transitional cell carcinoma

Upper urinary tract transitional cell carcinoma (TCC) accounts for up to 10% of cases of neoplasm of the upper urinary tract. The “gold standard” management of upper tract TCC is nephroureterectomy. Technological innovations, miniaturisations and increased availability of energy sources such as Holmium laser fibers have improved the armamentarium of endoscopic management of upper tract TCC. Endoscopic management of upper tract TCC includes the percutaneous (antegrade) and retrograde approaches. Modern flexible ureterorenoscopy allows retrograde approach to small (<1.5cm), low grade and noninvasive tumors, which is inaccessible to standard rigid ureteroscopes without breaching the urothelial barrier. In patients with large tumors or in whom retrograde access is difficult, the percutaneous approach to the renal pelvis, although more invasive, provides an alternative access and control. Both retrograde and percutaneous approaches allow instillation of various chemotherapeutic agents. Careful selection of patients is the key point in the successful endoscopic management of upper tract TCC. Patient selection is based on tumor size, grade and multifocality and other patient factors such as comorbidities, single kidney, post kidney transplant and patient choice. Both motivation and compliance of patients are needed for long-term successes. However, until large randomized trials with long term follow-up are available, endoscopic management of upper tract TCC should be reserved for only selected group of patients. This review summarizes the current techniques, indications, contraindications and outcomes of endoscopic management of UTTCC and the key published data.

Bacillus Calmette-Guérin for upper tract urothelial cancer: is there a role?

Since the first reported case of using adjuvant topical immunotherapy utilizing bacillus Calmette-Guérin (BCG) was published by Herr and associates, several institutions have utilized numerous agents for topical infusion therapies (BCG, Mitomycin, Epirubicin, Thiotepa or combination therapy of BCG/INF) as adjuncts in the treatment of upper tract papillary transitional cell carcinoma. A comprehensive review of the current data in the treatment of upper tract transitional cell carcinoma (Ta/T1 disease) with adjuvant BCG therapy was completed. Currently, the efficacy of adjuvant BCG therapy was not demonstrated.

Lasers in percutaneous renal procedures

INTRODUCTION

Since the invention of lasers in 1960, they have been increasingly used in medicine. In this review paper, the types of lasers used in urology, in addition to their applications to percutaneous renal surgery will be reviewed. Specifically, use of lasers in the percutaneous management of renal stones, upper tract transitional cell carcinoma and stricture will be reviewed.

MATERIALS AND METHODS

Pubmed was searched for citations since 1966. The following terms were used: "lasers", "calculi", "endopyelotomy", and "transitional cell carcinoma".

RESULTS

Due to its minimal depth of penetration, holmium laser has proven to be safe and efficacious. It is currently the primary energy source for flexible instrumentation, and also has demonstrated efficacy in percutaneous lithotripsy (faster than ultrasonic lithotripsy and safer than electrohydraulic lithotripsy). Holmium laser been used for antegrade endopyelotomy and percutaneous resection of upper tract transitional cell carcinoma.

CONCLUSIONS

Holmium laser is safer than other lasers and has become the gold standard for laser lithotripsy for flexible instrumentation. It has been used successfully in the percutaneous management of renal stones, ureteropelvic junction obstruction, and upper tract transitional cell carcinoma. Holmium laser is an alternative energy source to conventional lithotripters and electrocautery for endopyelotomy and resection of upper tract transitional cell carcinoma.