PERCUTANEOUS MANAGEMENT OF GRADE II UPPER URINARY TRACT TRANSITIONAL CELL CARCINOMA: THE LONG-TERM OUTCOME

Current Evidence on Utility, Outcomes, and Limitations of Endoscopic Laser Ablation for Localized Upper Urinary Tract Urothelial Carcinoma: Results from a Scoping Review

Context

The occurrence of upper urinary tract urothelial carcinoma (UTUC) is uncommon and is usually identified at an advanced and multifocal stage. Currently, there is growing interest in utilizing endoscopic laser ablation (ELA).

Objective

To evaluate the survival rates and perioperative complications of ELA.

Evidence acquisition

We performed a literature search through PubMed, Web of Science, and Scopus. The analysis included observational studies that examined the oncological outcomes of patients with UTUC treated with ELA.

Evidence synthesis

Neodymium and diode lasers are no longer used due to their high complication rates. Holmium:yttrium-aluminum-garnet (YAG) and thulium:YAG lasers provided excellent tumor ablation and hemostasis in both the collecting system and the ureter. These lasers offer good disease-free and cancer-specific survival, especially for low-grade tumors.

Conclusions

Advancements in laser technology and ablation techniques, and understanding of UTUC tumor biology hold significant promise in improving the use of conservative UTUC treatment, with excellent safety and good oncological outcomes for low-grade diseases.

Patient summary

With the advancement of technology, the conservative approach utilizing endoscopic laser ablation for upper tract urothelial tumors has been proved to be both safe and effective, showcasing promising survival rates.

Oncologic and Safety Outcomes for Retrograde and Antegrade Endoscopic Surgeries for Upper Tract Urothelial Carcinoma: A Systematic Review and Meta-analysis

The aim of this study was to identify and summarize available data on oncologic and safety outcomes for retrograde versus antegrade endoscopic surgery in patients with upper tract urothelial carcinoma (UTUC). We systematically searched studies reporting on endoscopic surgery in patients with UTUC. The primary outcome of interest was oncologic control, including bladder and upper urinary tract recurrences. The secondary outcomes were any-grade and major complications. Twenty studies comprising 1091 patients were included in our analysis. The pooled bladder recurrence rate was 35% (95% confidence interval [CI] 28.0-42.3%; I² = 48%) after retrograde endoscopic surgery and 17.7% (95% CI 6.5-32.1%; I² = 29%) after antegrade endoscopic surgery. The pooled upper urinary tract recurrence rate was 56.4% (95% CI 41.2-70.9; I² = 93%) after retrograde endoscopic surgery and 36.2% (95% CI 25.5-47.6%; I² = 57%) after antegrade endoscopic surgery. The pooled complication rate was 12.5% (95% CI 0.8-32.8%; I² = 94%) for any-grade complications and 6.6% (95% CI 0.1-19.1%; I² = 89%) for major complications in the retrograde endoscopic cohort. In summary, our analyses suggest promising oncologic benefits of antegrade kidney-sparing surgery in terms of bladder and upper urinary tract recurrence rates in UTUC. Retrograde endoscopic surgery is a safe procedure with a minimal risk of complications and acceptable oncologic outcomes. Research should address the hypothesis that endoscopic antegrade surgery can be a safe and effective alternative for well-selected patients. PATIENT SUMMARY: One of the surgical options for treatment of cancer of the upper urinary tract is removal of the tumor through a small telescope called an endoscope. The endoscope can be inserted via the urethra (called a retrograde approach) or through a small incision in the skin (antegrade approach). Our review shows that the antegrade approach seems to provide acceptable cancer control rates. Further research could help to identify the role for endoscope surgery in cancer of the upper urinary tract.

Olaparib is effective for recurrent urothelial carcinoma with BRCA2 pathogenic germline mutation: first report on olaparib response in recurrent UC

Urothelial carcinoma (UC) is a common malignancy of the lower and upper urinary tract. Recurrent UC has poor prognosis due to delayed diagnosis and a lack of clinical management guidance, especially for upper urinary tract UC. Patients with germline or somatic BRCA1/2 mutations are a special population in UC. No evidence is available so far on the effectiveness of poly ADP-ribose polymerase inhibitor (PARPi) in this population. Here, we report a 60-year-old female patient diagnosed with left ureter high-grade UC. Recurrent lesions were found 20 months after radical surgery. Computed tomography (CT) examination showed a slightly high-density soft tissue mass (3.2 × 3.1 cm) on the left posterior wall of the abdomen (waist), soft tissue mass adjacent to the left inner wall of the pelvis (3.2 × 4.2 cm), and multiple enlarged lymph nodes to the left of abdominal aorta. A next-generation sequencing (NGS)-based 605-gene panel detected a novel BRCA2 pathogenic germline mutation c.1670T>A (p.L557*), and a series of somatic insertion and deletion (INDEL) mutations of BRCA1, RB1, and JAK2, and single nucleotide variation (SNV) mutations of TP53, KMT2D, MET, ROS1, and IL7R. The above lesions were reduced significantly or disappeared (partial response, PR) after a 3-month Olaparib treatment, and the patient’s general condition remained well. In conclusion, this study proved for the first time that PARPi was effective for UC treatment in patients carrying germline BRCA2 pathogenic mutations, providing new treatment options for such patients. In addition, the circulating tumor DNA (ctDNA) test can be used for drug selection and response monitoring in UC treatment.

Endoscopic Treatment of Upper Tract Urothelial Carcinoma

PURPOSE OF REVIEW

This study aims to make the reader be aware of recent trends regarding the endoscopic management of upper tract urothelial carcinoma (UTUC) via review of the urologic literature over the past 5 years. Given the rare incidence of this disease, and the lack of level 1 evidence, systematic reviews and meta-analyses were also evaluated. Studies of importance are also considered and outlined in the annotated reference section.

RECENT FINDINGS

The PubMed database was queried using the following medical subject headings (MeSH terms): "carcinoma, transitional cell," "ureter," "ureteral neoplasms," "kidney pelvis," "endoscopy," "laser therapy," "ureteroscopy," "urologic surgical procedures," and "ureteroscopes." MeSH terms were linked together in varying combinations and limited to human studies in English. Given the relatively rare nature of upper tract urothelial carcinoma (UTUC), level 1 evidence regarding the efficacy of endoscopic treatment does not exist, even after 30+ years of experience. Rather, the literature available mostly is in the form of single institutional retrospective series consisting of relatively small numbers of patients with short to intermediate follow-up. Only within the last 3 years have published series with larger numbers of patients and mean follow-up over 5 years been made available. Even with these more robust experiences, comparisons among series are difficult given variable treatment and follow-up approaches. Most endoscopically managed UTUC will locally recur, especially with longer follow-up. Renal preservation rate is high, however, approaching 80% with follow-up well over 3 years. Patients with high-grade disease often fare poorly regardless of treatment modality. As such, endoscopic management for high-grade urothelial carcinoma should only be used in exceptional circumstances (i.e., in those patients medically unfit for NU or those with solitary kidneys wishing to avoid the morbidity of dialysis). No level 1 evidence exists for the routine use of intraluminal adjuvant therapy for UTUC (i.e., BCG and Mitomycin C) and multiple retrospective observational series claim there is no overt benefit. The recent formation of multiple international groups with interest in UTUC may eventually lead to the production of level 1 studies regarding optimal treatment; however, uniformity in treatment approach will likely still offer challenges.

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.

Contralateral ureteral metastasis 4 years after radical nephrectomy

INTRODUCTION

Metastasis of renal cell carcinoma to the contralateral ureter is extremely rare. To date, only 50 cases of metastatic RCC to the ureter have been reported, among whom 6 cases occur at the contralateral site. We herein report a rare case of metastatic RCC in the contralateral ureter 4 years after radical nephrectomy.

PRESENTATION OF CASE

A 74-year-old man presented with gross, painless hematuria for one month. Computed tomography scan confirmed that a 1.5 cm × 0.5 cm tumor occurred in the contralateral distal ureter. A 3.5 cm segment of ureter was resected and a uretero-vesical anastomosis with psoas hitch was accomplished.

DISCUSSION

The reappearance of hematuria after radical nephrectomy is the most common manifestation of the metastasis to the bladder or ureter. The mechanism of metastasis is not clear. In pathology, vimentin and cytokeratins might help to differentiate between metastatic clear cell renal cell carcinoma and clear cell transitional cell carcinoma.

CONCLUSION

Metastasis of renal cell carcinoma to the contralateral ureter is rare. Early recognition is extremely important in protecting the remaining renal function and prolonging life-expectancy for post-nephrectomy patients. Complete metastectomy suitable anastomosis have been shown to improve survival.

Surgical management for upper urinary tract transitional cell carcinoma

BACKGROUND

Upper tract transitional cell carcinomas (TCC) are uncommon and aggressive tumours. There are a number of surgical approaches to manage this condition including open radical nephroureterectomy and laparoscopic procedures.

OBJECTIVES

To determine the best surgical management option for upper tract transitional cell carcinoma.

SEARCH STRATEGY

A sensitive search strategy was developed to identify relevant studies for inclusion in this review. The following databases were searched for randomised trials evaluating surgical approaches to the management of upper tract TCC: Medline EMBASE, the Cochrane Central Register of Controlled Trials (CENTRAL), CINAHL, British Nursing Index, AMED, LILACS, Web of Science®, Scopus, Biosis, TRIP, Biomed Central, Dissertation Abstracts, and ISI Proceedings.

SELECTION CRITERIA

The following criteria that were considered for this review.Types of studies - All randomised or quasi-randomised controlled trials comparing the various surgical methods and approaches for the management of localised upper tract transitional cell carcinoma. Types of participants - All adult patients with localised transitional cell carcinoma. Localised disease was defined as limited to the kidney or ureter with no gross regional lymph nodal enlargement on imaging. Types of interventions - Any surgical method or approach for managing localised upper tract transitional cell carcinoma. Types of outcome measures - Overall and cancer-specific survival were primary outcomes. Surgery-related morbidity. Quality of life and health economics outcomes were secondary outcomes.

DATA COLLECTION AND ANALYSIS

Two review authors examined the search results independently to identify trials for inclusion.

MAIN RESULTS

We identified one randomised controlled trial that met our inclusion criteria. The trial showed that the laparoscopic approach had superior peri-operative outcomes compared to open approach. Laparoscopic was superior and statistically significant for blood loss (104 mL (millilitres) versus 430 mL, P < 0.001) and mean time to discharge (2.3 days versus 3.7, P < 0.001). Oncological outcomes (bladder tumour-free survival, metastasis-free survival, cancer-specific survival curves), at a median follow up of 44 months and in organ-confined disease, were comparable for both groups.

AUTHORS' CONCLUSIONS

There is no high quality evidence available from adequately controlled trials to determine the best surgical management of upper tract transitional cell carcinoma. However, one small randomised trial and observational data suggests that laparoscopic approach is associated with less blood loss and early recovery from surgery with similar cancer outcomes when compared to open approach.

Complex percutaneous resections for upper-tract urothelial carcinoma

BACKGROUND AND PURPOSE

Percutaneous endoscopic resection is a viable treatment option for upper-tract urothelial carcinoma (UC) in selected patients. We present our experience with patients who underwent percutaneous resections for complex urothelial tumors.

PATIENTS AND METHODS

Patients who were undergoing percutaneous treatment for UC were identified within a prospectively maintained database at a single institution. Charts were reviewed to identify complex patients (n = 16) who met the following criteria: (a) tumor size >2.5 cm (n = 8), (b) preoperative creatinine level >3.0 mg/dL (n = 3), or (c) anatomic variant (cystectomy/urinary diversion [n = 2]; autotransplanted kidney [n = 1]; ipsilateral partial nephrectomy [n = 1]; distal ureterectomy [n = 1]). Demographic, operative, and oncologic data were captured. Recurrence-free, cancer-specific, and overall survivals were calculated and compared with a control group of noncomplex cases (n = 23).

RESULTS

No difference was found in mean age (69.7 +/- 10.8 years vs 69.8 +/- 11.2 years), complication rate (6.3% vs 7.1%), or change in creatinine level (1.53 mg/dL to 1.51 mg/dL vs 1.88 mg/dL to 1.57 mg/dL) between noncomplex and complex cases. The incidences of high-grade tumors (55% vs 71%), invasive tumors (15% vs 20%), solitary kidney (82% vs 92%), contralateral nephroureterectomy (52% vs 60%), and history of bladder cancers (47% vs 38%) were similar between the two groups. Median follow-up was 36 months. No difference was seen in cancer-specific survival (P = 0.98) or recurrence-free survival (P = 0.39). An improved trend in overall survival (P = 0.20) was seen in the noncomplex patients when compared with the complex group.

CONCLUSIONS

These findings suggest that patients with large tumors, poor renal function, and significant anatomic variations may be well served by endoscopic treatment for upper-tract UC when indicated.

Endourologic management of upper tract transitional cell carcinoma following cystectomy and urinary diversion

Traditionally, nephroureterectomy is the gold standard therapy for upper tract recurrence of transitional cell carcinoma (TCC) following cystectomy and urinary diversion. With advances in endoscopic equipment and improvements in technique, conservative endourologic management via a retrograde or antegrade approach is technically feasible with acceptable outcomes in patients with bilateral disease, solitary renal units, chronic renal insufficiency, or significant medical comorbidities. Contemporary studies have expanded the utility of these techniques to include low-grade, low-volume disease in patients with a normal contralateral kidney. The aim of this report is to review the current outcomes of conservative management for upper tract disease and discuss its application and relevance in patients following cystectomy with lower urinary tract reconstruction.

A 20-year experience with percutaneous resection of upper tract transitional carcinoma: is there an oncologic benefit with adjuvant bacillus Calmette Guérin therapy?

OBJECTIVES

To determine whether there is an oncologic benefit of adjuvant bacillus Calmette Guérin (BCG) after resection of upper tract transitional cell carcinoma (UTTCC).

METHODS

A total of 133 renal units (RU) treated by percutaneous resection for UTTCC between 1985 and 2005 were retrospectively analyzed. Forty-four RU were excluded because of carcinoma in situ, high grade/stage, metastatic disease present at initial presentation, and/or the patient could tolerate loss of RU. Eighty-nine RU treated primarily by percutaneous resection were then analyzed. Fifty RU received adjuvant BCG therapy 2 weeks after endoscopic management for a total of 6 courses. Recurrence was defined as a positive biopsy result after the third-look nephroscopy. Progression of disease was assessed at time of recurrence and defined as an increase in grade/stage of disease.

RESULTS

Mean age (+/- SD) of 89 RU was 70.9 +/- 11.1 years. Overall follow-up was 61.1 + 54.8 months. Grade distribution was 56.2% (50 of 89) and 43.8% (39 of 89) for low- and high-grade disease, respectively. There was no statistical difference with regard to tumor grade or stage between treated and nontreated groups (P > .05). Recurrence, time to recurrence, and progression of disease among RU treated with BCG were subselected by grade and compared with the corresponding nontreated group. Statistical significance between any of the treated and nontreated groups was not demonstrated (P > .05).

CONCLUSIONS

Our data demonstrate that there is no overall oncologic benefit in the administration of adjuvant BCG with regard to disease recurrence, interval to recurrence, and progression of disease in the treatment of UTTCC.

[Conservative treatment of upper urinary tract tumors]

The histological appearance and the clinical behaviour of upper urinary tract urothelial tumours are almost identical to those of the bladder. Superficial papillary tumours rarely progress and turn to invasive disease despite a high frequency of recurrence. Technical developments in the endourology field have allowed full endoscopic access to upper tract tumours. Endoscopic resection or ablation of the tumour can be undertaken safely and effectively through ureteroscopy or percutaneous nephroscopy with low risk of extra-renal tumour seeding. For superficial (Ta, T1), low grade (I, II) tumours, a conservative approach can be selected without compromising survival and prognosis. For muscle invasive > T2 or high grade (III) tumours, nephroureterectomy remains the treatment of choice. Intracavitary BCG used after percutaneous resection reduces the risk of recurrence of upper tract urothelial tumours regardless of the grade. Finally, the world literature and our personal experience have shown that the tumour grade and stage are the two independent factors that affect survival of patients with upper urinary tract tumours.

Upper urinary tract transitional cell carcinoma: recurrence rate after percutaneous endoscopic resection

OBJECTIVES

To assess oncologic outcomes in patients undergoing percutaneous management for upper urinary tract transitional cell carcinoma (UUT-TCC) of the renal cavities.

METHODS

We performed a retrospective review of data for patients who underwent percutaneous conservative surgery for a UUT-TCC between 1989 and 2005: sex; age at diagnosis; mode of diagnosis; smoking; history of bladder cancer; type of surgery; complications; tumour site, size, stage and grade, and recurrence and progression. We evaluated recurrence and survival rates.

RESULTS

Data were analyzed for 24 patients. Median age was 70 yr. The tumour was located in the renal pelvis in 11 patients and in the caliceal system in 13 patients. Mean tumour size was 1.8 cm (range: 0.8-2.9). Four patients had a history of bladder carcinoma. Three patients experienced perioperative blood loss requiring transfusion, and one experienced colon wound. Median follow-up was 62 mo. Eight (33.3%) patients experienced local recurrence (three in the treated urinary tract, one in the contralateral tract, four in the bladder). Five patients underwent nephroureterectomy (NUT) during follow-up. Five (20.8%) patients have died, four from disease progression and one from cardiovascular causes. The 5-year disease-specific and tumour-free survival rates were 79.5% and 68%, respectively.

CONCLUSIONS

Percutaneous management can be recommended as an alternative to NUT or ureteroscopy for low-grade or superficial UUT-TCCs localised in the renal cavities. These patients require long-term postsurgical surveillance. For patients with high-grade or invasive tumours, open NUT remains the gold standard.

Partial nephrectomy for renal urothelial tumors: clinical update

OBJECTIVES

To evaluate the contemporary indications and outcome after partial nephrectomy for renal urothelial cancer. Partial nephrectomy is an established treatment for renal cell cancer but its use for renal urothelial tumors has been studied less extensively.

METHODS

Records were reviewed for patients undergoing partial nephrectomy for renal urothelial tumors between January 1990 and December 2001. Partial nephrectomy was selected for those with a solitary kidney, chronic renal insufficiency, or bilateral synchronous tumors. Partial nephrectomy was performed according to the principles of partial nephrectomy. Follow-up included ultrasonography, intravenous urography, computed tomography, metastatic workup, and renal function evaluation.

RESULTS

This study included 12 patients (12 kidneys, 10 solitary) with a mean age of 68.5 +/- 21 years and a mean follow-up of 40.8 +/- 32 months. The pathologic T stage was Tis in 1 patient, T1 in 3, T2 in 2, and T3 in 6 patients. Of the 12 patients, 6 had negative surgical margins, and 4 of the 12 patients (30%) were tumor free after a mean follow-up of 57.7 months. Of the 6 patients with positive surgical margins (Stage T1 in 2 and T3 in 4), 1 developed recurrence and 3 developed metastasis; 4 died after a mean of 31.3 months. Overall recurrence was seen in 5 (42%) and progression (metastasis) in 6 (50%) patients. Of the 12 patients, 6 were alive, 4 of them were well (mean serum creatinine 1.83 mg/dL) at 62 months of follow-up. Two patients required dialysis. The overall long-term survival rate was 50%.

CONCLUSIONS

Partial nephrectomy for renal urothelial tumors is feasible and should be considered in a select population. Dialysis or renal replacement can be delayed or avoided in most of these patients, but strict surveillance remains mandatory.

Endourologic treatment of upper urinary tract transitional cell carcinoma

The traditional treatment for upper tract transitional cell carcinoma (UTTCC) consists of radical nephroureterectomy. A more conservative approach, however, was required in cases of bilateral UTTCC and in patients with disease in a solitary kidney but who had underlying comorbidities that made them unsuitable candidates for open surgery. Minimally invasive treatment methods were developed for these select groups of patients. Because of technological advancements and refinement in endoscopic techniques, most patients with UTTCC, even those with normal contralateral kidneys, can now be offered minimally invasive treatment with single or multimodal approaches involving ureteroscopy or percutaneous resection. For patients with low-stage, low-grade UTTCC, five-year survival rates are comparable for those treated endourologically and those treated by nephroureterectomy. High-grade lesions have much higher recurrence and progression rates than lower-grade lesions, and nephroureterectomy is therefore recommended in patients with high-grade disease. The use of adjuvant instillation in the treatment of UTTCC, administered via antegrade and retrograde methods, has been shown to improve outcomes. For recurrences to be diagnosed and treated in a timely manner, and acceptable cancer-free survival rates maintained, long-term rigorous follow-up after endourologic treatment, with regular surveillance ureteroscopy, is crucial.

Percutaneous Management of Upper-Tract Transitional Cell Carcinoma

The gold standard treatment for supravesical urothelial carcinoma has been open radical nephroureterectomy based on the premise that this cancer is a field defect. However, nephroureterectomy is an extensive procedure that may not be tolerated by all patients. Percutaneous and ureteroscopic approaches have been utilized in an attempt to avoid the potential morbidity associated with traditional open surgery. This review provides an update on percutaneous management of upper-tract urothelial transitional-cell cancer based on a review of the pertinent literature.

Current Practice Patterns in Urologic Management of Upper-Tract Transitional-Cell Carcinoma

PURPOSE

To determine the current practice patterns in the management of upper-tract transitional-cell carcinoma (TCC) among a large group of urologists.

MATERIALS AND METHODS

A survey was sent to 220 practicing members of the Society of Urologic Oncology (SUO) and the Endourological Society (ES) and members of the American Urological Association who did not belong to either society. The survey consisted of 16 focused questions pertaining to the surveillance and management of upper-tract TCC. The responses were used to create a database, which was then analyzed to determine practice trends.

RESULTS

Eighty-four of the urologists responded, for a response rate of 38%. Fourteen responses were excluded because of multiple answers to a given question, so 70 were included in the final analysis. Eighty percent of the respondents were in academic practice. A CT urogram was the favored initial procedure for diagnosis of upper-tract TCC and an intravenous urogram was the next commonest choice (53% and 40%, respectively). Ureterorenoscopy was the surveillance tool of choice (70%) after conservative treatment of upper- tract TCC. Laparoscopic nephroureterectomy was the preferred procedure (73%) for a high-grade, large renal-pelvic TCC. Twenty-one percent of the endourologists recommended ureteroscopic ablation for a high-grade, large distal ureteral tumor. This was in sharp contrast to 77% of the respondents who favored a distal ureterectomy for the same clinical scenario.

CONCLUSIONS

This study confirms that most urologists treating upper-tract TCC follow the principles reported in the published literature regarding the management of these patients. Further, most urologists, regardless of society affiliations or years in practice, favor minimally invasive techniques for the management of upper-tract TCC. This information may be useful in formulating clear guidelines for the management of this disease.

What are the Oncological Risks of Minimal Access Surgery for the Treatment of Urinary Tract Cancer?

OBJECTIVES

A review of the oncological safety of minimal access surgery for the treatment of urinary tract cancers. The particular areas reviewed were port-site metastases, local tumour recurrence and long-term survival.

METHODS

Review of the literature using Medline.

RESULTS

There is a low rate of port-site metastases following laparoscopic surgery for urological malignancies, these are usually related to the stage and grade of the tumour. So far follow-up data shows that laparoscopic surgery for urological malignancy does not result in higher levels of local recurrence or shorter survival than open surgery. Percutaneous (PCN) and ureteroscopic (URS) resection of TCC of the upper urinary tract are acceptable forms of treatment for grade 1 and 2 TCCs even in patients with normal contralateral kidneys. However, for grade 3 TCC nephroureterectomy should be utilised because of increased risk of local recurrence (URS) and track seeding (PCN).

CONCLUSIONS

Provided the principles of cancer surgery, combined with proper case selection are followed, minimal access surgery for urological cancer is safe and is rapidly emerging as the standard of care for many upper tract tumours.

Percutaneous nephroscopic management of upper urinary tract transitional cell carcinoma: recurrence and long-term followup

PURPOSE

We present long-term results of the percutaneous approach and resection of upper urinary tract transitional cell carcinoma, and we evaluate the prognostic factors related to recurrence.

MATERIALS AND METHODS

A total of 34 patients underwent primary percutaneous resection of an upper urothelial tumor. We treated the patients with a superficial tumor that was completely resected macroscopically. Adjuvant topical chemotherapy or immunotherapy was administered. Patients were followed with excretory urography. Ureteroscopy and computerized tomography were obtained when clinically indicated.

RESULTS

With a mean followup of 51 months ipsilateral recurrence developed in 41.2%. Median time to recurrence was 24 months. The rate of kidney preservation was 73.5%. Two patients died of the disease. There was a trend of recurrence in patients with multifocal tumors (OR 2.66, 95% CI 0.07-1.92), history of bladder carcinoma in situ (OR 2.4, 95% CI 1.61-3.74), tumor in renal pelvis (OR 6.45, 95% CI 0.01-1.46) and multiple tumor locations (OR 6.53, 95% CI 0.01-1.54).

CONCLUSIONS

The percutaneous approach to renal urothelial tumor should be considered a valid option with a good long-term outcome. Recurrence is not uncommon and, as transitional cell carcinoma superficial bladder cancer it may be treated with endourological maneuvers or radical surgery, but with the obligation to a long lasting, strict surveillance.

Predictive factors for applicability and success with endoscopic treatment of upper tract urothelial carcinoma

PURPOSE

We report on endoscopic treatment outcomes for upper tract urothelial carcinoma and identify predictive factors for success.

MATERIALS AND METHODS

A total of 61 renal units were referred for endoscopic treatment of an upper tract tumor, 69% of which did not have a traditional indication for nephron sparing approaches. Tumor pathology and operative findings were assessed retrospectively for treatment outcomes and influential factors.

RESULTS

Initial ureteroscopic inspection was undertaken in 53 renal units with resection attempted in 18 (34%) resulting in an 89% success rate with 16 treated. A percutaneous approach in 19 renal units (11 after ureteroscopy) was 100% successful in achieving tumor-free status, for a total of 35 renal units successfully treated endoscopically. Surveillance then began on 27 renal units with a recurrence rate of 88% and mean time to recurrence of 5.8 months (range 2 to 20). Of patients undergoing surveillance (31% of whom had high grade disease), 54% remain or have died of unrelated disease, during a mean followup of 21.0 months (range 3 to 48). Higher tumor grade, larger size, renal pelvis location (all p <0.01) and multifocality (p = 0.05) significantly correlated with decreased recurrence-free survival, but did not predict failure of local control by endoscopic surveillance.

CONCLUSIONS

Although endoscopic techniques can render most patients tumor-free, there is a high associated recurrence rate and many need repeat procedures. Recurrence-free survival is greater in patients with low grade, solitary or less bulky disease. However, rigorous surveillance after endoscopic resection can lead to success even in patients with high grade, multifocal or large volume disease, resulting in preservation of renal units.

Transitional cell carcinoma of the ureter and renal pelvis

Transitional cell carcinoma (TCC) of ureter and renal pelvis is relatively uncommon. Smoking, occupational carcinogens, analgesic abuse, Balkan nephropathy are the risk factors. Cytogenetic studies revealed that the most frequent aberration is the partial or complete loss of chromosome 9. Approximately 20-50% of patients with upper urinary tract (UUT) TCC have bladder cancer at some point on their course, whereas the incidence of UUT TCC after primary bladder cancer is 0.7-4%. Excretory urography and retrograde pyelography are the conventional diagnostic tools; however, ureteropyeloscopy combined with cytology and biopsy is more accurate. Grade and stage of the disease have the most significant impact on survival. Nephroureterectomy with bladder cuff excision has been the mainstay of treatment. Local resection may be appropriate for distal ureteral lesions especially when the disease is low grade and stage. Advances in endourology have made it possible to treat many tumors conservatively. Ureteroscopic and to a certain extent percutaneous surgical approaches are widely used today especially in patients with low grade, low stage disease. Endoscopic close surveillance is mandatory for these patients. Adjuvant topical therapies appear to be safe but confirmation of any benefits awaits the results of further large studies. More recently, laparoscopic techniques have become a viable alternative to open surgery, but long term cancer control data are lacking. Aggressive surgical resection does not affect the outcome of patients with advanced disease. Adjuvant radiotherapy is ineffective, and systemic chemotherapy results in a low complete response rate for patients with metastases.

Percutaneous management of renal pelvic urothelial tumors: long-term followup

PURPOSE

We present the long-term outcome of percutaneous resection of renal urothelial tumor.

MATERIALS AND METHODS

A total of 24 patients underwent primary percutaneous resection of renal urothelial tumor. Patients with low stage pT0-1 disease were treated primarily with percutaneous surgery. All pelvicaliceal tumors were taken for biopsy and treated with percutaneous resection. Patients with multi-segmental pelvicaliceal system involvement, stage greater than pT1, high grade histology or additional ureteral tumors were considered for nephroureterectomy. Topical chemotherapy (mitomycin C or epirubicin) was administered via nephrostomy tube or intravesical instillation after Double-J stent (Medical Engineering Corp., New York, New York) insertion. Surveillance included upper tract cytology, nephroscopy or fiberoptic ureterorenoscopy. Long-term followup was correlated with histopathology.

RESULTS

Of the 24 cases 2 had squamous cell carcinoma, 5 had grade III transitional cell carcinoma, 15 had grade I to II transitional cell carcinoma and 2 had no tumor. Control was established with initial percutaneous resection in 18 (75%) cases and second look nephroscopy in 4. Early recurrences were detected by excretory urography (IVP) in 3 cases, small pelvic recurrences by IVP in 2, fiberoptic ureterorenoscopy in 2 and bladder tumors by flexible cystoscopy in 3 after 1 year. A total of 10 nephroscopies were performed in 5 cases, 24 flexible uretereorenoscopies in 9 and IVP in 6. Three synchronous, grade I bladder tumors were managed conventionally. All patients with high grade disease died of malignancy except one (with no further treatment) and 6 of the 15 patients with low grade noninvasive transitional cell carcinoma underwent nephroureterectomy during followup either due to progression of disease, concomitant tumor or complications. Two patients with solitary kidneys died of renal failure unrelated to malignancy. High grade tumors or tumors greater than T1 were treated with nephroureterectomy early during management. There was no perioperative mortality and 9 (60%) of the low grade cases the kidneys were preserved at a mean followup +/- SD of 64 +/- 15 months. All excised tracks from patients who underwent nephroureterectomy and the renal fossae were free of tumor on histopathological examination.

CONCLUSIONS

Percutaneous resection of transitional cell tumor should be considered primarily in patients with early stage disease excluding tumors crossing caliceal infundibula, ureteropelvic junction tumor, tumor extending over multiple calices and synchronous ureteral tumors. The long-term outcome of low grade tumors is good and they should be managed by either form of minimally invasive surgery. Nephron sparing is possible in a large percentage of low grade disease but high grade tumors should be treated with nephroureterectomy.

Conservative elective treatment of upper urinary tract tumors: a multivariate analysis of prognostic factors for recurrence and progression

PURPOSE

We evaluate the safety and efficacy of conservative elective treatment of upper urinary tract tumors, and determine predictive factors for recurrence and progression to optimize indications of this type of treatment.

MATERIALS AND METHODS

Since 1984 we have performed a prospective study of conservative treatment of single, low grade and stage, less than 3 cm. upper tract tumors. The study includes 54 patients with a normal contralateral kidney who had been followed for more than 36 months. Open conservative surgery was performed in 31 cases and endourological surgery in 23. Minimum followup was 36 months, maximum 210 and mean 84.8. Univariate and multivariate analyses of recurrence and progression were performed in relation to age, sex, association with a bladder tumor, bladder tumor stage and grade, sequence of bladder tumor in relation to upper urinary tract tumor, number of previous bladder tumor recurrences, association with bladder carcinoma in situ, upper urinary tract tumor grade, stage, location, size and therapy, and upper urinary tract cytology.

RESULTS

Of the 54 patients 19 (35%) had recurrence, which was bilateral recurrence in 4, and progression occurred in 9 (16%). At the end of analysis 44 (62.9%) patients were disease-free and alive at a mean time of 92.88 months, 13 (24%) died disease-free at a mean of 72.7 months and 7 (12.9%) died of disease at a mean of 97.85 months. Cause specific mortality occurred in 7 (12.9% cases). Among the 54 initially conservatively treated units 42 (77.7%) kidneys were ultimately preserved. On univariate and multivariate analysis tumor location in the renal pelvis and association with a previous multi-recurrent bladder tumor were variables significantly related to recurrence and progression, as well as bilateral recurrence.

CONCLUSIONS

Conservative treatment is an optional approach for select upper urinary tract tumors. The strongest risk factors for recurrence and progression were association with a previous multi-recurrent bladder tumor and tumor location in the renal pelvis but these conditions were also the strongest risk factors for bilateral recurrence. Conservative treatment can also be recommended in these cases but only with compliant patients and close followup.

Solitary contralateral renal pelvis metastasis 9 years after removal of renal adenocarcinoma

Extremely rarely, renal cell carcinoma metastasizes to the contralateral renal pelvis or ureter. The present report concerns a case where a metastatic tumour was successfully removed from the left renal pelvis 9 years after right nephrectomy for the primary tumour.