A prognostic study of urothelial renal pelvic tumors: comparison between the prognosis of patients treated with intrafascial nephrectomy and perifascial nephroureterectomy

Retroperitoneal lymph nodes in transitional cell carcinoma of the kidney and ureter

The incidence of transitional cell carcinoma of the kidney and ureter is low and for that reason limited data exists regarding the appropriate management of regional retroperitoneal lymph nodes. Lymph node metastases have consistently been associated with an adverse prognosis. However, five-year cancer-specific survival following nephroureterectomy and lymphadenectomy for patients with lymph node involvement ranges from 0–39%, suggesting a therapeutic benefit. This review covers the primary tumor characteristics associated with lymph node involvement, imaging of the lymph nodes, as well as the rationale, role, patient selection, suggested anatomic templates, and technical considerations for lymphadenectomy.

Urothelial carcinoma of the upper urinary tract: surgical approach and prognostic factors

OBJECTIVES

Open radical nephroureterectomy (O-RNU) has been the gold standard for the treatment of upper urinary tract urothelial carcinoma (UUT-UC) for decades. With the advances in laparoscopic techniques and endourologic procedures, this concept has been increasingly challenged. Oncologic outcome prediction is mainly based on stage and grade. With progress in medical treatment, adjuvant therapies may gain importance in the future. This review assesses the values of the variety of available treatments as well as prognostic factors that may become relevant regarding patient selection for future adjuvant treatment trials.

METHODS

We performed a systematic literature research using MEDLINE with emphasis on open surgical, laparoscopic, and endourologic (ureteroscopic or percutaneous) techniques and prognostic contents.

RESULTS

Overall, no evidence level 1 information from prospective randomised trials is available for treatment of UUT-UC. Laparoscopic radical nephroureterectomy (L-RNU) is increasingly challenging open surgery. Currently, L-RNU should be reserved for low-stage, low-grade tumours. Ureteroscopy and percutaneous nephron-sparing techniques show favourable survival data but high local recurrence rates. Regarding prognosis, estimation of outcome still relies mainly on stage and grade because no additional parameters have been introduced in a routine clinical setting.

CONCLUSIONS

O-RNU still represents the gold standard for the treatment of UUT-UC. The laparoscopic approach is not yet standard of care and should be reserved for low-stage, low-grade tumours. Endourologic nephron-sparing treatments are still experimental in elective indications due to high local recurrence rates. For prognosis, no parameters in addition to stage and grade have been standardised.

Retroperitoneal lymph node dissection (RPLD) in conjunction with nephroureterectomy in the treatment of infiltrative transitional cell carcinoma (TCC) of the upper urinary tract: impact on survival

OBJECTIVES

To evaluate the prognostic impact of retroperitoneal lymph node dissection (RPLD) performed during nephroureterectomy on time to recurrence and survival in patients with infiltrative transitional cell carcinoma (TCC) of the upper urinary tract.

METHODS

The charts of 82 patients with T2-T4 TCC of the upper tract were retrospectively reviewed. The median patient age was 67.7 yr. Seventy-nine patients underwent nephroureterectomy and three had partial nephrectomy. Forty patients (48.8%) had RPLD with removal of more than five nodes after nephroureterectomy (group 1), whereas 42 (51.2%) had nephroureterectomy only (group 2). Median follow-up was 64.7 mo. The prognostic role of RPLD, T (2 vs. 3-4), G (2 vs. 3), N (0 vs. 1-2 vs. x), age (<65 vs. >65 yr) and sex on time to recurrence and survival were evaluated.

RESULTS

Median time to recurrence and overall survival were 51.2 and 52.5 mo, respectively, in group 1 and 18.5 and 21.2 mo in group 2. Univariate analysis demonstrated that RPLD and T and N status were significantly related both to time to recurrence (p=0.009, 0.008, and 0.009, respectively) and survival (p=0.000006, 0.003, and 0.003). When analyzed using the Cox proportional hazard model, RPLD and T category were the only two factors demonstrating independent significance on overall survival (p=0.004 and 0.008).

CONCLUSIONS

The results indicate a possible curative role of RPLD in the treatment of patients with infiltrative TCC of the upper urinary tract. Further randomized trials are needed to confirm these results.

Prognostic value of lymphovascular invasion in transitional cell carcinoma of upper urinary tract

OBJECTIVES

To elucidate the prognostic significance of lymphovascular invasion (LVI) in patients with upper tract transitional cell carcinoma.

METHODS

Of 86 patients with upper tract transitional cell carcinoma who underwent nephroureterectomy with bladder cuff (95%) or parenchymal-sparing (5%) surgery from 1991 to 2002, and who met our inclusion criteria, the data of 73 were available for pathologic review of LVI. The mean patient age was 59.1 years, and the median follow-up was 42.3 months. Using univariate and multivariate analyses, we determined the influence of multiple prognostic factors, including age, sex, tumor stage (T or N), tumor grade, and LVI, on the 5-year disease-specific and recurrence (local recurrence or distant metastasis)-free survival rates. We generated 5-year disease-specific and recurrence-free survival curves in terms of LVI in patients without lymph node involvement.

RESULTS

The overall 5-year disease-specific and recurrence-free survival rate was 88% and 75%, respectively (n = 73). In univariate analysis, T stage, grade, and LVI significantly affected both survival rates. N stage was significant for 5-year recurrence-free survival. In multivariate analysis, LVI was the only significant predictor of recurrence-free survival, and no factor was significant for disease-specific survival. Of 10 patients with positive lymph nodes, 7 had LVI. In patients without lymph node involvement or Stage T4 disease (Ta-T3N0M0, n = 62), the 5-year disease-specific and recurrence-free survival rate was 98% and 94%, respectively, in the absence of LVI and 70% and 60%, respectively, in the presence of LVI (P = 0.0005 and P = 0.0007, respectively).

CONCLUSIONS

LVI is an independent prognostic factor for recurrence-free survival in transitional cell carcinoma of the upper urinary tract. Because LVI is strongly associated with a poorer prognosis, systemic adjuvant therapy should be considered in the presence of LVI, even if the lymph nodes are not involved.

Retroperitoneoscopy-assisted total nephroureterectomy for upper urinary tract transitional cell carcinoma

OBJECTIVES

To apply retroperitoneoscopy-assisted nephroureterectomy (RTN) and examine its benefit compared with traditional open nephroureterectomy. The reference standard of treatment for upper urinary tract transitional cell carcinoma is standard total nephroureterectomy (STN) with excision of a bladder cuff.

METHODS

Retroperitoneoscopic radical nephrectomy was performed, followed by open distal ureterectomy with excision of a bladder cuff. The specimen was removed en bloc from the lower pararectal incision that was used during distal ureterectomy. From January 1999, 17 patients with upper urinary tract transitional cell carcinoma underwent this procedure at our institution. For comparison, the most recent 17 STNs were also reviewed.

RESULTS

The operative time was longer in the RTN group than in the STN group but not to a significant extent (239.5 versus 286.8 minutes; P = 0.2663). On the other hand, the estimated blood loss, duration to potential discharge, and recovery to normal activities were significantly reduced in the RTN group (151.1 versus 299.6 minutes, 2.7 versus 4.2 days, and 15.9 versus 19.3 days; P = 0.0262, 0.0479, and 0.0363, respectively). From an oncologic standpoint, local recurrence occurred in 1 patient of the RTN group and 4 patients of the STN group (median follow-up of 8.8 and 23.0 months, respectively). No significant difference was detected in the disease-free survival rate between the two groups (P = 0.6775).

CONCLUSIONS

RTN can make total nephroureterectomy less invasive. From an oncologic standpoint, although it revealed a disease-free survival rate comparable with the standard open procedure with limited follow-up, further follow-up of additional cases with simultaneous extended lymphadenectomy is necessary to evaluate the effectiveness of this procedure.

Laparoscopic nephroureterectomy. A new standard for the surgical management of upper tract transitional cell cancer

Laparoscopic nephroureterectomy for upper tract TCC still remains somewhat controversial. Unlike laparoscopic radical nephrectomy, which has become widely accepted, LNU is still in its earliest stages. Although there are obvious benefits for the patient who has LNU--less pulmonary complications, less postoperative discomfort, a shorter hospital stay, a better cosmetic result, and a brief convalescence--there are significant concerns. The longer operative time creates a negative financial and professional inducement to learn this technique. Operative times need to fall into the 4-hour range or less to make the procedure cost-effective. Analysis of the efficacy of laparoscopic nephroureterectomy as a curative treatment modality is important. In the short-run, LNU seems to provide similar results to open nephroureterectomy for upper TCC. Although concerns over port site seeding, bladder recurrence, and intraperitoneal seeding have been voiced, these problems have not occurred. The higher incidence of local recurrence noted in the authors' series, however, is of concern and remains an unsettled issue. Despite these local recurrences, the overall cancer survival for a given grade and stage of upper tract TCC seem to be similar to survivals recorded after open nephroureterectomy. Still, the number of LNU cases remains small, and follow-up is brief. These patients need to be monitored closely, with follow-up CT scans over the next decade. The authors believe that there are still several significant hurdles standing in the path of LNU before it can become a widely accepted procedure. Issues of cost, training, and long-term efficacy must be answered definitively. To obtain these types of data, it will be necessary to create a multi-institutional, cooperative study to obtain sufficient numbers of patients with a more than 5-year follow-up on which to base future recommendations.

[Follow up of patients with bladder cancer treated with radical cystectomy]

Radical cystectomy provides excellent local control of the disease in cancer patients, although specific 5-year mortality is about 50%. Additionally, nearly half the patients show complications after surgery usually due to urinary by-pass. Patients should undergo periodical monitoring for life. For rescue treatment to be as effective as possible, follow-up schemes should allow for early detection of relapsing-recurrent tumours, metastasis and complications. Knowledge of the "natural evolution" in these patients allows to optimise the frequency of visits and complementary examinations based on each patient's risk at specific time-points. Cost-efficacy relationship will also be optimised. We analyze here the current literature and our own experience of what we know as "natural evolution" of these patients and propose a follow-up scheme for patients with cancer of the bladder treated with radical cystectomy and urinary by-pass.

The significance of lymphadenectomy in transitional cell carcinoma of the upper urinary tract

OBJECTIVE

To determine the efficacy of lymphadenectomy after nephroureterectomy in patients with transitional cell carcinoma (TCC) of the upper urinary tract.

PATIENTS AND METHODS

Between January 1986 and December 1995, 72 patients (mean age 67 years, range 45-82) underwent nephroureterectomy for primary TCC of the upper urinary tract. In 35 patients, a lymphadenectomy was also performed. The clinicopathological data were analysed retrospectively, focusing on the significance of lymphadenectomy.

RESULTS

Lymph vessel invasion was found in 28 patients and its incidence was closely correlated with both tumour grade and pathological stage. Of the 35 patients who underwent lymphadenectomy, lymph node metastases were found in 13 patients, all of whom had lymph vessel invasion. There was no significant difference in the survival rate between patients with and without lymphadenectomy; however, among the 44 patients with no lymph vessel invasion, the survival rate of those with lymphadenectomy was significantly higher than in those without (P<0.05).

CONCLUSION

Lymphadenectomy may provide a therapeutic advantage in patients with upper urinary tract TCC and no lymph vessel invasion. However, patients with lymph vessel invasion seem to have systemic disease; therefore, aggressive systemic adjuvant therapies rather than regional lymphadenectomy should be applied in these patients.

Single incision, endoscopically assisted nephroureterectomy for tumours of the upper urinary tract

In five patients undergoing nephroureterectomy for urothelial tumour of the upper urinary tract, the lower end of the ureter was resected by resectoscope (rip and pluck procedure). We recommend this technique for common use, since it is safe and time-saving.

Is CIS of the ureter responsible for skipped lymph node metastasis? A case report

A case of skipped lesion of lymph node metastasis of left ureteral tumour with concurrent carcinoma in situ in the affected ureter is presented. Postoperatively, lymph node metastasis was de novo detected in the left retrocrural and renal hilar regions on CT scan, although only the obturator lymph node was histologically metastatic among the regional lymph nodes completely dissected. The possible explanations of this rare metastatic mode are discussed.

Adenocarcinoma of the renal pelvis in an elderly woman

Adenocarcinoma of the renal pelvis is so rare that many reviews of renal tumours fail to include any instance of this lesion. We present a 75-year-old female patient with no previous history of urological disease in whom a renal pelvic tumour was diagnosed. Histological examination after radical nephroureterectomy proved the tumour to be a rare adenocarcinoma. The course of the disease, the possible predisposing factors, the treatment of the tumour and the prognosis are discussed.

Carcinoma of the renal pelvis. Experience of 80 cases

The clinical course and association with other urothelial carcinomas was studied in 80 patients with carcinoma of the renal pelvis. At the time of diagnosis macroscopic haematuria was the most common symptom. Urography and retrograde pyelography gave the most accurate diagnoses. Sixty-eight patients (85%) had transitional cell carcinomas, 39 had a history of another urothelial carcinoma either before or after the diagnosis of the renal tumour, usually in the urinary bladder. A previous urothelial carcinoma together with a small renal tumour were predictive of the subsequent development of another urothelial tumour. Regular cystoscopy is recommended during follow-up because of the short observed interval between the development of carcinoma of the renal pelvis and a subsequent urothelial malignancy. The overall five-year survival was 20%. Survival did not depend on the operation, but was significantly related to the extent of locoregional or distant metastases at the time of diagnosis. Patients with such renal tumours that were preceded by or associated with other urothelial carcinomas had a more favourable median survival (42 months) than patients whose renal tumour was their first urothelial carcinoma (19 months).

Treatment of primary squamous cell carcinoma of the upper urinary tract

Forty-six patients with primary squamous cell carcinoma of the upper urinary tract treated over a 44-year period were studied. The lack of characteristic presentation caused delay in diagnosis. Associated urinary calculi were found in only five (11%) of the patients. Almost all of the tumors were histologically high grade; at surgery, 84% of the tumors were locally advanced or metastatic. Prognosis is poor independent of treatment; the overall 24-month survival rate was 22%. Comparison with a previous study of renal pelvic transitional cell carcinoma indicates that these two forms of urothelial neoplasm are biologically different.

Papillary adenocarcinoma of the renal pelvis in a child: case report and brief review of the literature

Tumors of the renal pelvis are not common in adults and are extremely rare in children. Forty-eight cases of adenocarcinoma of the renal pelvis have been reported, with only one patient under 32 years of age. We report the youngest patient (an 11 year old boy) diagnosed with this tumor and discuss our approach to therapy. We also review the literature with respect to the characteristics and histogenesis of this rare neoplasm.

Intussusception ureterectomy

A modification of intussusception ureterectomy is described. Dilatation of the ureter is unnecessary before the procedure and closure of the bladder wall defect is recommended to avoid urine extravasation.

Tumours of the renal pelvis and ureter. Observations in 170 patients

A study was made of 170 patients with renal pelvis or ureteric tumours, 160 of whom underwent surgery between 1948 and 1981. The most important aetiological factor was chronic phenacetin abuse: 21.7% of 83 patients with renal pelvis tumours and 11.4% of those with ureteric tumours gave a history of phenacetin abuse. The latency periods ranged from 24 to 26 years. This is the first report of a relationship between abuse of analgesics and urothelial tumours from the Federal Republic of Germany.

Clinical analysis of ureteral tumours with or without renal pelvic neoplasms

Twelve patients with ureteral tumours with or without ipsilateral renal pelvic neoplasms were retrospectively analysed. Haematuria was the most common symptom. Location of all tumours was preoperatively detected by conventional diagnostic methods, such as intravenous or retrograde pyelography, washing cytology of the upper urinary tract, computed tomography, echogram and abdominal aortography. Cumulative proportion survivals of 1, 3 and 5 years were 81.9%, 68.2% and 45.5%, respectively. Patients with high Karnovsky rating survived longer (p less than 0.05) than those with low rating. Patients with low-stage tumours (T1, T2) showed longer survival rate (p less than 0.001) than those with high-stage tumours (T3, T4). Vascular invasion of tumour cells was present in removed specimens in 4 out of 7 patients who died or are alive with cancer, but none in those who survived without disease. Good therapeutic response could not be achieved unless surgery was performed.

Surgical staging of genitourinary tumors

Regional retroperitoneal lymphadenectomy usually is performed with radical nephrectomy for renal cell carcinoma and sometimes is performed with nephroureterectomy for upper tract urothelial tumors; however, no therapeutic benefit has been proven. Pelvic lymphadenectomy usually is performed with radical cystectomy for bladder cancer and may confer therapeutic benefit on patients having only minimal nodal involvement. A limited extraperitoneal pelvic lymphadenectomy, including only the nodes surrounding the obturator nerves, is performed in prostate cancer patients who are considered to be potential candidates for radical prostatectomy, but is of doubtful therapeutic benefit. The effectiveness of chemotherapy for germ-cell testicular tumors has diminished the utilization of routine surgical staging and also has decreased the scope of lymphadenectomy when performed. The substantial complications associated with traditional ilioinguinal lymphadenectomy for carcinoma of the penis and the unreliability of aspiration or excisional node biopsy have militated against routine surgical staging of patients having clinically negative nodes. This policy should be reconsidered in light of suboptimal treatment results and newer surgical techniques.

Renal pelvic carcinoma: morphological correlates of metastatic behavior

We report a clinicopathological analysis of morphological parameters in relation to subsequent biological behavior in 48 patients with renal pelvic carcinoma. The relationships of subsequent metastasis to tumor stage and grade, as well as the presence of vascular, renal parenchymal or renal hilar invasion were evaluated by parametric and nonparametric statistical tests. Corrected 5-year survival rates for grades 1 to 3 tumors were 100, 67 and 5 per cent, respectively. Grade 3 tumors demonstrated more invasion of the blood vessels, hilus and renal parenchyma compared to grades 1 and 2 tumors (p less than 0.005, 46 patients). Moreover, invasion of renal hilar tissues had greater predictive value for subsequent distant metastatic spread (95 per cent, nonparametric) than either vascular (83 per cent) or renal parenchymal (77 per cent) invasion. Metastases developed in 27 of 48 patients during followup periods of 2 to 39 years. The pattern of metastatic lesions revealed that local spread to hilar soft tissues occurred in 92 per cent of the patients who subsequently had distant metastases. Spread to retroperitoneal lymph nodes and ipsilateral ureteral mucosa occurred in 84 and 44 per cent of the patients, respectively. Our study illustrates the potential value of analysis of individual histological parameters to evaluate the likelihood of subsequent metastasis.

Percutaneous management of renal pelvic tumors: a treatment option in selected cases

Nine patients with renal pelvic transitional cell carcinomas were selected for treatment with percutaneous resection because of a solitary kidney (3), bilateral synchronous disease (1), renal insufficiency (1), poor surgical risk (2) or preoperative evidence of a single, low grade, superficial tumor (2). Eight patients underwent second-look procedures 2 to 28 days postoperatively, at which time 6 received neodymium: YAG laser irradiation. Supplemental intracavitary therapy through the nephrostomy tube was given in 6 patients (mitomycin C in 1 and bacillus Calmette-Guerin in 5). Of those patients 2 had third-look procedures. Five patients remain free of recurrence with a followup of 3 to 28 months (mean 9.5 months). In the other 4 patients there was recurrent disease in the renal pelvis (3) or reappearance of positive cytology studies (1) 4 to 5 months postoperatively. Extrarenal tumor recurrence was not observed. Percutaneous surgery provided adequate information to assess tumor architecture, grade, invasiveness and multifocality, and the presence of contiguous mucosal abnormalities, which, along with positive cytology and a history of or concurrent tumors in other segments of the urinary tract, increased the likelihood of tumor recurrence. Second-look procedures appeared to be useful to assess the effectiveness of the initial procedure and to remove any residual disease. Our results suggest that percutaneous surgery can provide results similar to those of an open conservative operation, although further investigation is needed to determine the ultimate place of this technique.

Primary carcinoma of the upper urinary tract

Thirty-seven patients with upper urinary tract tumours were evaluated for grade, stage, histological type, location, presence or absence of vascular invasion, abnormalities in the urothelium adjacent to the tumours, tumour multiplicity and patient survival. A good correlation between tumour grade and stage was found in the transitional cell tumours. Squamous cell carcinomas and adenocarcinomas were high-stage tumours. Vascular invasion was present in most high-grade tumours, squamous cell carcinoma and adenocarcinomas. Four patients had multifocal tumours of both pelvis and ureter. Three developed ureteric stump carcinomas and 13 had further development of bladder carcinomas. The cumulative 5 and 10 year survival rates were 43 and 23% respectively.

Squamous cell carcinoma of renal pelvis

Squamous carcinoma of the renal pelvis was diagnosed in only 11 of 2,166 renal tumors (0.5%) seen over a twenty-seven-year period. The combination of an insidious onset and a prolonged duration of symptoms (median: 5 months) resulted in all patients having invasive disease at diagnosis. Ten patients died two to twenty-eight months after diagnosis (median survival: 5 months), and only 1 patient is currently alive at nine months. We conclude that the treatment of choice is radical nephrectomy followed by adjuvant chemotherapy.

Treatment of urothelial tumors of the upper urinary tract by nephroureterectomy, renal autotransplantation, and pyelocystostomy

Nephroureterectomy, renal autotransplantation, and pyelocystostomy have been performed in eight patients with urothelial tumors of the upper urinary tract. One patient had tumors in a solitary kidney, two patients had bilateral tumors, and five patients had unilateral tumors. Three patients have had recurrent calyceal tumors which were successively managed by the transurethral route. In one patient the kidney had to be removed after 4.5 years because of infiltrating tumor recurrence. Two patients died; the renal pelvis of the graft was tumor free at autopsy in both cases. The other five patients are alive and free from tumor recurrence. The procedure implies increased radicality compared with conventional conservative treatment and simplified follow-up. It may be considered in patients with bilateral tumors or tumors of a solitary kidney, and in selected patients with unilateral low-grade, low-stage tumors.

Primary carcinoma of ureters

Thirty-two patients with primary carcinoma of the ureter were treated at our institution from 1961 to 1968 using various modes of therapy. Sixteen of these patients underwent segmental resections, with a five-year survival of 71.4 per cent and a ureteral recurrence rate of 6 per cent. Twelve other patients received a complete nephroureterectomy, with a subsequent five-year survival of 50 per cent. We believe that segmental resection is indicated for all low-grade and low-stage primary ureteral tumors regardless of their location and with a small change for recurrence.