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Taratkin M, Singla N, Babaevskaya D, Androsov A, Shariat SF, Fajkovic H, Baniel J, Enikeev D. A Review of How Lasers Are Used in UTUC Surgery: Can the Choice of Laser Affect Outcomes? Cancers (Basel) 2023; 15:cancers15061874. [PMID: 36980763 PMCID: PMC10047311 DOI: 10.3390/cancers15061874] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2023] [Revised: 03/17/2023] [Accepted: 03/20/2023] [Indexed: 03/30/2023] Open
Abstract
Upper tract urothelial carcinoma (UTUC) is a relatively rare disease with an aggressive phenotype compared to urothelial carcinoma in the bladder. In recent years, kidney-sparing surgery (KSS) and, in particular, endoscopic surgery have become the procedure of choice among urologists where the treatment of localized UTUC is concerned. Endoscopy tends to result in satisfactory oncological disease control while lowering morbidity and minimizing complications amongst the appropriately selected cohort of patients. While endoscopic surgery for UTUC might appear to be standardized, it, in fact, differs considerably depending on the source of energy used for resection/ablation. There has been little reliable data up to now on which laser energy source is the most superior. The goal of this review is, therefore, to outline the results of endoscopic UTUC treatment using different lasers and to analyze how these laser-tissue interactions may affect the surgery. We start by pointing out that the data remains insufficient when trying to determine which laser is the most effective in the endoscopic management of UTUC. The ever-growing number of indications for minimally invasive treatment and the increasing number of centers using laser surgery will, hopefully, lead to novel randomized controlled trials that compare the performance characteristics of the lasers as well as the effects of UTUC on patients.
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Affiliation(s)
- Mark Taratkin
- Institute for Urology and Reproductive Health, Sechenov University, 119435 Moscow, Russia
| | - Nirmish Singla
- Department of Urology, James Buchanan Brady Urological Institute, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
- Department of Oncology, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
| | - Diana Babaevskaya
- Institute for Urology and Reproductive Health, Sechenov University, 119435 Moscow, Russia
| | - Alexander Androsov
- Institute for Clinical Medicine, Sechenov University, 119021 Moscow, Russia
| | - Shahrokh F Shariat
- Institute for Urology and Reproductive Health, Sechenov University, 119435 Moscow, Russia
- Department of Urology, Medical University of Vienna, 1030 Vienna, Austria
- Department of Urology, Weill Cornell Medical College, New York, NY 10065, USA
- Department of Urology, University of Texas Southwestern, Dallas, TX 75390, USA
- Division of Urology, Department of Special Surgery, Hourani Center for Applied Scientific Research, Al-Ahliyya Amman University, Amman 19328, Jordan
- Department of Urology, Second Faculty of Medicine, Charles University, 150 06 Prague, Czech Republic
| | - Harun Fajkovic
- Department of Urology, Medical University of Vienna, 1030 Vienna, Austria
- Karl Landsteiner Institute of Urology and Andrology, 3100 Vienna, Austria
| | - Jack Baniel
- Division of Urology, Rabin Medical Center, Petach Tikva 4920232, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv 6997801, Israel
| | - Dmitry Enikeev
- Institute for Urology and Reproductive Health, Sechenov University, 119435 Moscow, Russia
- Department of Urology, Medical University of Vienna, 1030 Vienna, Austria
- Karl Landsteiner Institute of Urology and Andrology, 3100 Vienna, Austria
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Chien AL, Chua KJ, Doppalapudi SK, Ghodoussipour S. The role of endoscopic management and adjuvant topical therapy for upper tract urothelial cancer. FRONTIERS IN UROLOGY 2022; 2:916259. [PMID: 38855025 PMCID: PMC11160966 DOI: 10.3389/fruro.2022.916259] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Indexed: 06/11/2024]
Abstract
Upper tract urothelial carcinoma (UTUC) has traditionally been managed with radical nephroureterectomy, and while this approach remains the gold standard for high-risk disease, endoscopic, kidney-sparing management has increasingly been adopted for low-risk disease as it preserves kidney function without compromising oncologic outcomes. Ureteroscopy and percutaneous renal access not only provide diagnoses by tumor visualization and biopsy, but also enable treatment with electrocautery or laser ablation. Several modalities exist for laser ablative treatments including thulium:YAG, neodymium:YAG, holmium:YAG, and combinations of the preceding. Furthermore, due to high recurrence rates after endoscopic management, adjuvant intracavitary instillation of various agents such as mitomycin C and bacillus Calmette-Guerin have been used given benefits seen in non-muscle invasive urothelial bladder cancer. Other formulations also being studied include gemcitabine, anthracyclines, and immunotherapies. More recently, Jelmyto, a mitomycin reverse thermal gel, has been developed to allow for adequate drug delivery time and potency since urine flow could otherwise dilute and washout topical therapy. In this article, the authors review techniques, indications, best practices, and areas of current investigation in endoscopic management and adjuvant topical therapy for UTUC.
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Affiliation(s)
- Austin L. Chien
- Section of Urologic Oncology, Rutgers Cancer Institute of New Jersey, New Brunswick, NJ, United States
- Division of Urology, Department of Surgery, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ, United States
| | - Kevin J. Chua
- Section of Urologic Oncology, Rutgers Cancer Institute of New Jersey, New Brunswick, NJ, United States
- Division of Urology, Department of Surgery, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ, United States
| | - Sai Krishnaraya Doppalapudi
- Section of Urologic Oncology, Rutgers Cancer Institute of New Jersey, New Brunswick, NJ, United States
- Division of Urology, Department of Surgery, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ, United States
| | - Saum Ghodoussipour
- Section of Urologic Oncology, Rutgers Cancer Institute of New Jersey, New Brunswick, NJ, United States
- Division of Urology, Department of Surgery, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ, United States
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Gurbuz C, Youssef RF, Shariat SF, Lotan Y, Wood CG, Sagalowsky AI, Zigeuner R, Kikuchi E, Weizer A, Raman JD, Remzi M, Roscigno M, Montorsi F, Bolenz C, Kassouf W, Margulis V. The impact of previous ureteroscopic tumor ablation on oncologic outcomes after radical nephrouretectomy for upper urinary tract urothelial carcinoma. J Endourol 2011; 25:775-9. [PMID: 21388245 DOI: 10.1089/end.2010.0396] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Abstract We investigated whether a history of endoscopic tumor ablation impacts oncologic outcomes after radical nephroureterectomy (RNU) for upper urinary tract urothelial carcinoma (UTUC). Using a multi-institutional database that contained patients who were treated with RNU, oncologic outcomes were assessed according to history of ureteroscopic tumor ablation. Disease-free survival (DFS) and cancer-specific survival (CSS) were estimated using the Kaplan-Meier survival analysis. Multivariate Cox regression analyses were performed to determine independent predictors of disease recurrence and cancer-specific mortality after RNU. The study included 1268 patients, 853 men and 415 women, with a mean age of 67.5 years (range 32-94 y) and 52.8 months median follow-up after RNU. A total of 175 (13%) patients underwent RNU after endoscopic tumor ablation and 1093 (87%) patients underwent RNU without a history of endoscopic ablation. The 5-year DFS and CSS rates were 72% and 77% in those with a history of tumor ablation vs 69% and 73% in those without a history of ablation (P = 0.171 and P = 0.365, respectively). In multivariate Cox regression analysis, history of ablation therapy was not associated with disease recurrence or cancer-specific mortality (hazard ratio [HR]: 0.79, P = 0.185 and HR: 0.7, P = 0.078, respectively). Our collaborative international efforts suggest that in selected patients, endoscopic tumor ablation does not adversely affect the recurrence and survival after subsequent RNU for UTUC. Our data support the continued role of ureteroscopic ablation of UTUC in appropriately selected patients.
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Affiliation(s)
- Cenk Gurbuz
- University of Texas Southwestern Medical Center, Dallas, Texas 75390-9110, USA
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Weber B, McCallum TJ, Tulip J, Moore RB. Laser photoablation of renal pelvic tumours. Can Urol Assoc J 2008; 2:413-6. [PMID: 18781220 DOI: 10.5489/cuaj.842] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
We evaluated the clinical effects of the Zeiss OPMILAS (Oberkochen, Germany) multi-yttrium-aluminum-garnet (YAG) laser in the treatment of renal pelvic tumours as an alternative to nephroureterectomy. Four patients with evidence of transitional cell carcinoma (TCC) in the renal pelvis and a previous history of TCC of the bladder or opposite renal pelvis were treated with the Zeiss OPMILAS multi-YAG laser. Three patients underwent a retrograde ureteroscopic approach and 1 patient required percutaneous resection. Two wavelengths were used: 1060 nm continuous coagulative mode and 1440 nm pulsed ablative mode. The patients were followed for 12, 24, 76 and 84 months, respectively. Two patients showed no evidence of recurrence as determined by cystoscopy, retrograde pyelography and selective pelvic urine cytology. One patient experienced a recurrence of TCC requiring subsequent treatment. The ureteroscopic approach was associated with fewer complications and a more rapid recovery, compared with the percutaneous approach. All patients with solitary kidneys avoided dialysis.
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Affiliation(s)
- Bryce Weber
- Division of Urology, Department of Surgery, University of Toronto, Toronto, Ont., the
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Phillips CK, Landman J. Lasers in the upper urinary tract for non-stone disease. World J Urol 2007; 25:249-56. [PMID: 17562052 DOI: 10.1007/s00345-007-0179-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2007] [Accepted: 05/03/2007] [Indexed: 10/23/2022] Open
Abstract
Though the most common use for lasers in the genitourinary tract is for urolithiasis, a number of other urologic conditions can be treated with lasers because of their unique ablative, destructive and hemostatic properties. This paper reviews the advantages and disadvantages of laser technology for a number of non-stone indications.
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Affiliation(s)
- Courtney K Phillips
- Department of Urology, Columbia University School of Medicine, 161 Fort Washington Avenue, Room 1111, New York, NY 10032, USA
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Abstract
Technological advances have increased the applicability of endoscopic treatment for upper-tract transitional-cell carcinoma (TCC). Percutaneous and ureteroscopic tumor resection have become reasonable treatment options for patients with anatomically or functionally solitary kidneys, bilateral upper-tract tumors, significant renal insufficiency, or comorbid disease that would preclude standard open surgery. This approach also is being used increasingly on those with a normal contralateral kidney in whom nephroureterectomy and en bloc removal of the ipsilateral ureteral orifice and surrounding bladder cuff is considered the standard therapy. This paper reviews the current role of ureteroscopic management of upper-tract TCC.
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Affiliation(s)
- Khai-Linh V Ho
- Department of Urology, Mayo Clinic, Rochester, MN 55905, USA
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Razdan S, Johannes J, Cox M, Bagley DH. Current Practice Patterns in Urologic Management of Upper-Tract Transitional-Cell Carcinoma. J Endourol 2005; 19:366-71. [PMID: 15865529 DOI: 10.1089/end.2005.19.366] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
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.
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Affiliation(s)
- Sanjay Razdan
- Department of Urology, Thomas Jefferson University, 1025 Walnut Street, Philadelphia, PA 19107, USA
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Abstract
INTRODUCTION There has been a steady increase in the number of ureteroscopic laser lithotripsy. In addition to its soft tissue applications Holmium:YAG laser has also been found an excellent intracorporeal lithotripter for all kinds of stones. We here present the results of patients treated with Holmium:YAG laser lithotripsy in our clinic. METHODS Between June 1997 and December 2002, 205 patients with a diagnosis of ureteric calculi were treated with ureteroscopy using Holmium:YAG laser as an intracorporeal lithotriptor. The stones were localized in the distal ureter in 158 patients (77), middle and proximal ureter in 47 patients (23). Stones ranged in size from 5 x 5 mm to 20 x 10 mm and the operation time was about 35 minutes (ranged 25-65 minutes). Follow-up evaluations have done at first and third months. RESULTS The ureteral stone could not be reached in 10 patients (4.8). Stone fragmentation or removal was accomplished in all other patients. Four patients (1.9) had proximal migration of the fragments and later treated with extra corporeal shock wave lithotripsy, and three patients (1.5) had ureteral perforation. They were managed by double J stent placement. Two of the patients had ureteral obstruction on the third month of procedure. One of the patients was treated with open surgery. For the other one, ureteroscopic balloon dilatation was performed and catheterized by double J stent and there wasn't any complication after the removal of stent. CONCLUSIONS Ureteroscopic Holmium:YAG laser lithotripsy is a safe, technically feasible and efficacious treatment for ureteral stones.
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Affiliation(s)
- Y Ilker
- Department of Urology, Medical Faculty, Marmara University School of Medicine, Turkey
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Droller MJ. Primary care update on kidney and bladder cancer: a urologic perspective. Med Clin North Am 2004; 88:309-28, x. [PMID: 15049580 DOI: 10.1016/s0025-7125(03)00170-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
The past decade has witnessed many substantive changes in the approach to the diagnosis and treatment of both kidney and bladder cancer. In part, this is based on changes in the understanding of their carcinogenesis and pathogenesis, an appreciation of new concepts in their classification, and the incorporation of new technologies that have emerged. This article reviews advances and updates changes that have been made in the understanding of and approaches to these malignancies from the perspective of their urologic assessment and management while in the context of primary care issues.
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Affiliation(s)
- Michael J Droller
- Department of Urology, Mount Sinai School of Medicine, 1 Gustave L. Levy Place, Box 1272, New York, NY 10029-6574, USA.
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10
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Abstract
The expanding experience with endoscopic techniques for treating upper tract urothelial malignancy demonstrates its safety and efficacy in carefully selected patients. Diagnostic accuracy can be enhanced, and pathologic confirmation of tumor grade and stage is possible. In carefully selected patients who have low-grade and low-stage disease, the results of endourologic management have been encouraging. Patients with an anatomic or functionally solitary kidney, bilateral disease, or significant renal insufficiency can often be considered candidates for endoscopic treatment as the first line of therapy. In the setting of low-grade, low-stage disease in a patient with a normal contralateral kidney, the role of endourologic management remains controversial. Adjuvant topical therapy with mitomycin C or BCG seems to be safe and well tolerated after endoscopic management of upper tract TCC.
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Affiliation(s)
- John S Lam
- Department of Urology, Columbia University College of Physicians and Surgeons, 161 Fort Washington Avenue, Irving Pavilion, 11th Floor, New York, NY 10032, USA
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Matsuoka K, Lida S, Tomiyasu K, Inoue M, Noda S. Transurethral endoscopic treatment of upper urinary tract tumors using a holmium:YAG laser. Lasers Surg Med 2003; 32:336-40. [PMID: 12766954 DOI: 10.1002/lsm.10184] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND AND OBJECTIVES The feasibility of treating upper urinary tract tumors with a holmium:YAG (Ho:YAG) laser in transurethral endoscopy was examined. STUDY DESIGN/MATERIALS AND METHODS Thirty-three treatments were performed on 30 patients with renal pelvic and ureteral carcinomas. After vaporization and coagulation eliminated the tumors, the surrounding mucosa was fully coagulated. Postoperative follow-up consisted of urinary cytology once a month, cystoscopy every 3 months, excretory pyelography every 6 months, and uretero-pyeloscopy every 6-12 months. RESULTS The recurrence rate after the first treatment was 86% in the imperative indication group. The tumor-free rate (median follow-up, 37 months) in the imperative indication group was 57%. In the elective indication group, those values were 20 and 95% (median follow-up, 33 months), respectively. CONCLUSIONS Transurethral endoscopic treatment of upper urinary tract tumors using Ho:YAG laser can be a useful method on limited cases identified into specific treatments groups combined with a strict follow-up.
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Affiliation(s)
- Kei Matsuoka
- Department of Urology, Kurume University School of Medicine, Kurume City 8300011, Japan.
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Abstract
Laser coagulation of benign prostatic hyperplasia (BPH) encompasses a variety of techniques using different laser wavelengths, application systems, and surgical techniques to achieve contrasting tissue effects. During transurethral laser coagulation, known as visual laser ablation of the prostate (VLAP), the prostate is irradiated by free-beam Nd:YAG or diode laser energy. The coagulated and necrotic tissue sloughs off within weeks to months. In randomized studies comparing laser coagulation and transurethral resection of the prostate (TURP), symptoms and some voiding parameters improved significantly after laser coagulation, although not to the level obtained with TURP. However, the operative duration and the length of hospitalization have been shorter than for TURP, and major complications have not occurred. Follow-up clinical data and retreatment rates are available for up to 5 years with a remarkable variability. Although retreatment rates may be high, patients who are "responders" to the treatment after 2 to 3 years seem to have durable results after 4 to 5 years and even longer.
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Affiliation(s)
- Rolf Muschter
- Department of Urology, Diakoniekrankenhaus Academic Teaching Hospital, Rotenburg, Germany.
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Abstract
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.
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Affiliation(s)
- Ziya Kirkali
- Department of Urology, Dokuz Eylul University School of Medicine, Inciralti, Izmir 35340, Turkey.
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Daneshmand S, Quek ML, Huffman JL. Endoscopic management of upper urinary tract transitional cell carcinoma: long-term experience. Cancer 2003; 98:55-60. [PMID: 12833455 DOI: 10.1002/cncr.11446] [Citation(s) in RCA: 120] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND The efficacy and long-term results of endoscopic management of upper tract transitional cell carcinoma (TCC) were examined. The authors evaluated the accuracy of endoscopic biopsy in determining tumor grade in the subset of patients who underwent open surgical excision. METHODS Between 1987 and 2001, 50 patients (17 with a solitary kidney) underwent ureteroscopy and biopsy of upper tract TCC. Eleven patients underwent ureterectomy or nephroureterectomy shortly after endoscopic biopsy. There was no follow-up for nine patients. Thirty patients underwent endoscopic ablation of their primary tumor with laser or electrofulguration at the time of the initial biopsy and were followed with close endoscopic surveillance at 3-4-month intervals. RESULTS For the 30 patients who underwent endoscopic ablation, mean follow-up was 38 months (range, 4-106 months). There was an average of 3.4 recurrences, with an average time to first recurrence of 7 months. Ten of the 30 patients underwent open resection during follow-up. Six patients exhibited tumor progression at follow-up. During the follow-up period, one patient died of recurrent disease, and six died of other causes. Endoscopic biopsy accurately predicted the tumor grade for 8 of the 9 patients who had open tumor resection within 2 months of their last biopsy and for 10 of the 11 patients who had open resection shortly after their initial endoscopic biopsy (overall accuracy, 18 of 20 [90%]). CONCLUSIONS Endoscopic treatment of focal low-grade TCC of the upper urinary tract is feasible and safe, provided that vigilant follow-up and endoscopic surveillance are performed. Endoscopic biopsy provides accurate information regarding tumor grade.
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Affiliation(s)
- Siamak Daneshmand
- Department of Urology, University of Southern California, Keck School of Medicine, Los Angeles, California, USA.
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Kawauchi A, Fujito A, Ukimura O, Yoneda K, Mizutani Y, Miki T. Hand assisted retroperitoneoscopic nephroureterectomy: comparison with the open procedure. J Urol 2003; 169:890-4; discussion 894. [PMID: 12576807 DOI: 10.1097/01.ju.0000046453.38141.dd] [Citation(s) in RCA: 73] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
PURPOSE We report our initial experience with hand assisted retroperitoneoscopic nephroureterectomy for upper urinary tract transitional cell carcinoma and compared our results to those of a contemporary series of open nephroureterectomy. MATERIALS AND METHODS Clinical data on 34 consecutive patients who underwent hand assisted retroperitoneoscopic nephroureterectomy were reviewed and compared with those on 34 who underwent open nephroureterectomy. All specimens were extracted intact. RESULTS Total operative time was similar in the 2 groups (233 versus 236 minutes). Estimated blood loss was significantly less in the hand assisted laparoscopy group (236 versus 427 ml.). During convalescence the frequency of parenteral analgesia postoperatively was significantly lower in the laparoscopy group than in the open surgery group. The former patients had a significantly shorter interval to oral intake and ambulation as well as a shorter hospital stay and convalescence compared with those who underwent open surgery. In each group the complication rate was 12% (4 of 34 cases). In the hand assisted laparoscopy group 1 conversion to an open procedure was due to bleeding. There was recurrence in 4 of the 34 patients (12%) in the laparoscopy group, including 2 with bladder recurrence and 2 with metastases, at an average followup of 13.1 months. CONCLUSIONS Hand assisted retroperitoneoscopic nephroureterectomy is an effective and safe alternative to open nephroureterectomy for upper urinary tract transitional cell carcinoma.
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Affiliation(s)
- Akihiro Kawauchi
- Deparment of Urology, Kyoto Prefectural University of Medicine, Kawaramachi-Hirokoji, Japan
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Elliott DS, Segura JW, Lightner D, Patterson DE, Blute ML. Is nephroureterectomy necessary in all cases of upper tract transitional cell carcinoma? Long-term results of conservative endourologic management of upper tract transitional cell carcinoma in individuals with a normal contralateral kidney. Urology 2001; 58:174-8. [PMID: 11489692 DOI: 10.1016/s0090-4295(01)01109-8] [Citation(s) in RCA: 124] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
OBJECTIVES To evaluate the endoscopic management of upper urinary tract transitional cell carcinoma (TCC) as a first-line treatment in patients with a normal contralateral kidney. METHODS During an 11-year period, 21 patients diagnosed with upper tract TCC were treated with conservative endourologic techniques using either neodymium:yttrium-aluminum-garnet laser or electrocautery at our institution. The 21 patients were followed up for a mean of 6.1 years (range 1 to 11.6). RESULTS A total of 8 renal pelvic tumors and 13 ureteral tumors were found. All tumors were Stage T1 or less and grade 3 or less. All tumors were less than 2 cm in the greatest dimension (range 0.4 to 2). Of the 21 patients, 7 (33%) had one local recurrence and 1 (4.7%) developed two local recurrences. Of the 13 ureteral tumors, 6 (46%) recurred; 1 (12%) of the 8 renal pelvic tumors recurred. No recurrent tumor was shown to have an increase in grade. Of the 21 target renal units, 17 (81%) were preserved; 4 (19%) of 21 patients required nephroureterectomy because of tumor recurrence. Overall, 11 patients in the series died, 10 of non-TCC etiology and 1 secondary to invasive bladder TCC that developed after treatment for upper tract TCC. No patients died as a result of conservative management of their upper tract TCC. CONCLUSIONS Endourologic techniques and conservative treatment of upper tract TCC is an evolving field; however, in properly selected patients, endoscopic treatment can be safely and effectively used as a first-line treatment for upper tract TCC.
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Affiliation(s)
- D S Elliott
- Department of Urology, Mayo Clinic, Rochester, Minnesota 55905, USA
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Liatsikos EN, Dinlenc CZ, Kapoor R, Smith AD. Transitional-cell carcinoma of the renal pelvis: ureteroscopic and percutaneous approach. J Endourol 2001; 15:377-83; discussion 397. [PMID: 11394449 DOI: 10.1089/089277901300189385] [Citation(s) in RCA: 55] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
There are a variety of publications advocating the ureteroscopic or the percutaneous approach for the treatment of transitional cell carcinoma of the renal pelvis. The diagnostic tool of choice for the upper urinary tract and collecting system is the flexible ureteroscope. One of the major concerns about ureteroscopic management of renal disease initially was the lack of flexibility of the instruments and therefore the inability to deal with demanding sites. The advent of new ureteroscopic techniques, as well as the continuous evolution of the technology, have paved the way for safe and effective access to the upper urinary tract. In the hands of an experienced urologist, such procedures can provide reliable treatment options for small upper urinary tract lesions. Coupling minimal morbidity with ever-improving optics and flexibility, the ureteroscope of today leaves no area of the urinary tract unseen. In patients with bulky tumors or in whom easy access and resection is not possible ureteroscopically, the percutaneous approach to the renal pelvis, although more invasive, provides a better working environment. Clearly, the most difficult aspect of ureteroscopic access to the lower pole is not just visibility but the loss of deflection caused by passage of various instruments through the working channel. Direct access via percutaneous approach with a large resectoscope avoids these problems.
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Affiliation(s)
- E N Liatsikos
- Department of Urology, Albert Einstein College of Medicine, Long Island Jewish Medical Center, New Hyde Park, New York 11042, USA
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Stifelman MD, Hyman MJ, Shichman S, Sosa RE. Hand-assisted laparoscopic nephroureterectomy versus open nephroureterectomy for the treatment of transitional-cell carcinoma of the upper urinary tract. J Endourol 2001; 15:391-5; discussion 397. [PMID: 11394451 DOI: 10.1089/089277901300189402] [Citation(s) in RCA: 47] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND AND PURPOSE For patients with upper tract transitional-cell carcinoma (TCC), nephroureterectomy with removal of a bladder cuff is the standard of care. Historically, it has been performed using two incisions or one large incision extending from the lateral flank to the symphysis pubis. We describe an alternative using endoscopic management of the bladder cuff combined with hand-assisted laparoscopic (HAL) nephroureterectomy. We compared our results using these minimally invasive advances with those of a contemporary open nephroureterectomy series. PATIENTS AND METHODS Between May 1998 and June 1999, we performed 11 HAL nephroureterectomies with endoscopic management of the bladder cuff for the treatment of upper tract TCC. The results were compared with those in a contemporary series of 11 patients undergoing the traditional open operation at our institution. The patient age, male:female ratio, and ASA classification were similar in the two groups. Intraoperative measures considered were operative time, estimated blood loss, need for transfusion, complications, specimen weight and volume, pathologic stage and grade of the tumor, and the status of the surgical margins. Postoperative endpoints were time to sustained fluid intake; epidural, parenteral, and oral narcotic requirements; length of stay; and complications. Follow-up, specifically disease recurrence and overall survival, was recorded. RESULTS The mean operative time was 291 minutes for HAL v 232 minutes for the open operation (P = NS). The average blood loss was 144 v 311 mL (P = 0.04), the mean specimen weight 368 v 392 g (P = NS), and the mean specimen volume was 630 v 693 cc (P = NS). No patient in the HAL group had a positive surgical margin, but one patient in the open surgery group did. The time to sustained fluid intake postoperatively averaged 1.4 v 2.3 days for the HAL and open groups, respectively (P = NS). The epidural narcotic requirement was 0 v 2.7 days (P < 0.001), the mean parenteral narcotic requirement was 45 v 44 mg of morphine sulfate equivalent (P = NS), and the oral narcotic requirement was 5.8 v 16 tablets (P < 0.04). The average length of stay was 4.6 days for the HAL group v 6.1 days for the open group (P = 0.04). In both groups, 7 of the 11 patients (63%) were without evidence of disease with a mean follow-up of 13 (HAL) and 17 (open) months. CONCLUSIONS Hand-assisted laparoscopic nephroureterectomy with endoscopic management of the bladder cuff is an efficacious alternative to open surgery. The operative time, specimen weight and size, and risk of recurrence for the two procedures are similar. However, convalescence, as measured by pain medication requirements and length of stay, is significantly better with laparoscopy. Longer follow-up with larger numbers of patients is in progress.
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Affiliation(s)
- M D Stifelman
- James Buchanan Brady Foundation, Department of Urology, New York Presbyterian Hospital, Weill Medical College-Cornell University, New York 10032, USA
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Minowada S, Homma Y, Takeuchi T, Kamijo T, Kitamura T. Long-term outcome of endoscopic biopsy and subsequent nephroureterectomy for upper urinary tract tumor. Int J Urol 2001; 8:6-9. [PMID: 11168690 DOI: 10.1046/j.1442-2042.2001.00236.x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
BACKGROUND Upper urinary tract tumors can be biopsied using a flexible ureterorenoscope. This study examined retrospectively possible adverse effects of this procedure on patient outcome. METHODS The study subjects consisted of 16 consecutive patients with renal pelvic tumor (n = 13) and upper ureteral tumor (n = 3). All subjects underwent endoscopic biopsy of their tumor and subsequent total nephroureterectomy between 1989 and 1995. The follow-up period ranged from 4.1 to 9.5 (mean 5.2) years. RESULTS The overall 5-year survival rate was 87.0%, being 100% in 12 patients with tumors of grade 1 or 2. In contrast, of four patients with grade 3 tumor, three (75%) developed systemic lymphogenous and/or multiple lung metastases within 1 year postoperatively. CONCLUSIONS The excellent patient outcomes deny any adverse effect of endoscopic biopsy on patients with grade 1 or 2 tumor. However, the endoscopic procedure should be performed prudently when a high grade tumor is suspected.
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Affiliation(s)
- S Minowada
- Department of Urology, Faculty of Medicine, The University of Tokyo, Japan.
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Assimos DG, Hall MC, Martin JH. Ureteroscopic management of patients with upper tract transitional cell carcinoma. Urol Clin North Am 2000; 27:751-60. [PMID: 11098772 DOI: 10.1016/s0094-0143(05)70123-3] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Endoscopic therapy for the management of upper urinary tract TCC is mainly indicated for patients with an anatomically or functionally solitary kidney, renal insufficiency, bilateral tumors, or severe medical comorbidity. It may be a reasonable alternative to distal ureterectomy with bladder-cuff resection in individuals with low-grade superficial distal ureteral tumors. Although use of this approach has been suggested for treating standard patients with low-grade, low-stage collecting system tumors, this recommendation should not be embraced until more supporting evidence is generated. The efficacy of adjuvant therapy for the prevention of recurrent or progressive disease needs to be defined. If current adjuvant strategies prove ineffective, alternative ones will need to be developed. It is anticipated that advancements in endoscopic technology will facilitate the performance of this type of surgery in the future.
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Affiliation(s)
- D G Assimos
- Department of Urology, Wake Forest University School of Medicine, Winston-Salem, North Carolina, USA.
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Stifelman MD, Sosa RE, Andrade A, Tarantino A, Shichman SJ. Hand-assisted laparoscopic nephroureterectomy for the treatment of transitional cell carcinoma of the upper urinary tract. Urology 2000; 56:741-7. [PMID: 11068291 DOI: 10.1016/s0090-4295(00)00751-2] [Citation(s) in RCA: 49] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES Nephroureterectomy with removal of the bladder cuff is the standard of care for patients with upper tract transitional cell carcinoma. Historically, it has been performed using two separate incisions or one large incision extending from the lateral flank to the symphysis pubis. We describe an alternative technique using endoscopic and hand-assisted laparoscopic techniques and present our experience. METHODS During the past 18 months, 22 patients at two institutions underwent hand-assisted laparoscopic nephroureterectomy. In 19 patients, the distal ureter and bladder cuff were managed endoscopically. In 3 patients, the distal ureter and the bladder cuff were removed by an extravesical, laparoscopic technique. The intraoperative parameters assessed included operative time, estimated blood loss, specimen weight, surgical margin status, pathologic grade and stage, and acute complications. Postoperative endpoints included the time to sustained fluid intake, parenteral narcotic requirement (milliequivalents of morphine sulfate), oral narcotic requirement (number of tablets), length of stay, time until return to normal activity, and rate of tumor recurrence. RESULTS The average age of our patient population was 65 years (range 42 to 86), 10 patients were men and 12 were women, and the average American Society of Anesthesiologists classification was 2.2. All but 2 patients had their specimens removed en bloc. No intraoperative complications occurred. The average operative time was 272 minutes (range 190 to 440), and the average blood loss was 180 mL (range 50 to 400); no patient required a transfusion. The mean specimen weight was 457 g (range 190 to 1420). All 22 patients had negative surgical margins. Postoperatively, the time to sustained fluid intake averaged 2.1 days (range 1 to 7), the mean parenteral narcotic requirement was 55 mEq (range 12 to 107.8) of morphine sulfate, the mean oral narcotic requirement was 5.8 tablets (range 1 to 14), and the average length of stay was 4.1 days (range 3 to 14). One patient developed thrombophlebitis of the right external jugular vein from a central line and required 2 weeks of intravenous antibiotics. The mean time to return to normal activity was 19 days; the mean follow-up was 13 months. Six patients had disease recurrence: four low-grade, low-stage bladder tumors and two metastatic tumors. All patients were alive at 18 months. CONCLUSIONS Hand-assisted laparoscopic nephroureterectomy with endoscopic management of the bladder cuff is a viable and efficacious alternative to open nephroureterectomy. The technique allows the surgeon to perform an en bloc resection of the kidney, ureter, and bladder cuff without compromising oncologic principles. Patients benefit from a decrease in pain and hospital stay and quicker convalescence. Longer follow-up and comparative studies to standard open techniques are underway.
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Affiliation(s)
- M D Stifelman
- Department of Urology, James Buchanan Brady Foundation, New York Presbyterian Hospital, Weill Medical College, Cornell University, New York, New York, USA
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Affiliation(s)
- A Borkowski
- University Clinic of Urology, Warsaw, Poland
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Grafstein LA, Selman SH. Thermal lasers in urologic oncology. JOURNAL OF CLINICAL LASER MEDICINE & SURGERY 1998; 16:49-54. [PMID: 9728131 DOI: 10.1089/clm.1998.16.49] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
Urology is a surgical specialty that relies heavily on the endoscopic approach for diagnosis and treatment of disease. Electrosurgical instruments have been the standard vehicle for endoscopic tumor ablation. Over the last 30 years a number of investigators have explored the use of the medical laser as either an alternative or an adjunct to standard electrosurgical techniques. The development of small caliber flexible and rigid endoscopic application. In addition, the potential for very limited and precise distribution of laser energy in targeted tissue is clinically appealing for endoscopic applications. In this article, we review the use of thermal laser in urologic oncology.
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Affiliation(s)
- L A Grafstein
- Department of Urology, Medical College of Ohio, Toledo, USA
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Bagley DH. Ureteroscopic laser treatment of upper urinary tract tumors. JOURNAL OF CLINICAL LASER MEDICINE & SURGERY 1998; 16:55-9. [PMID: 9728132 DOI: 10.1089/clm.1998.16.55] [Citation(s) in RCA: 46] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
OBJECTIVE To summarize the present status of ureteroscopic laser treatment of upper urinary tract tumors. SUMMARY AND BACKGROUND DATA Small diameter rigid and flexible ureteroscopes can provide convenient access to the upper urinary tract. The small diameter of the instruments and the working channels are ideally suited for the placement of laser fibers as an intraluminal ablative technique. METHODS The authors reviewed the literature and their own experience with laser treatment of upper tract tumors for the description of instruments, techniques, and the results achieved. RESULTS At least 12 reports have presented the results after using lasers for treating upper tract tumors. The Nd:YAG laser has been used in most series but more recently, the holmium:YAG laser has become available. Each laser has particular advantages and each can be delivered along the same low water content quartz fibers. Less scarring with stricture formation has been reported after use of the laser versus electrofulguration. Among the series reported, local recurrences occurred in 33% of patients with renal pelvic tumors or ureteral tumors. In the authors' experience, the holmium:YAG laser was most frequently used and the combination of holmium and Nd:YAG was nearly as common. The Nd:YAG was used alone in less than 10% of patients. CONCLUSIONS The ureteroscopic treatment of upper tract transitional cell carcinoma is a reasonable alternative to surgical removal in many patients. It provides a major advantage in patients with specific indications for conservative therapy and may be a reasonable elective therapy in others with small, low grade, tumors. The holmium laser alone or in combination with the Nd:YAG laser has become our primary mode of therapy.
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Affiliation(s)
- D H Bagley
- Department of Urology, Jefferson Medical College, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
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Minimo C, Tawfiek ER, Bagley DH, McCue PA, Bibbo M. Grading of upper urinary tract transitional cell carcinoma by computed DNA content and p53 expression. Urology 1997; 50:869-74. [PMID: 9426716 DOI: 10.1016/s0090-4295(97)00404-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
OBJECTIVES Transitional cell carcinomas of upper urinary tract (uttTCC) constitute 5% to 6% of all urothelial tumors. Ureteropyeloscopy has become the standard for clinical evaluation of uutTCC. Moreover, endoscopic treatments have been advocated as a conservative approach for low grade tumors or patients with intermediate grade tumors whose renal function is compromised. Therefore, grading has become the most predictive variable in defining therapeutic approach. In addition to morphologic evaluation, a series of biologic markers may be used to increase the accuracy of grading such as DNA analysis and p53 protein expression. In this study, we have evaluated these markers by means of cell image analysis with the SAMBA 400 system. METHODS Thirteen cases of uttTCC were studied with cytologic smear, cell block, and histologic confirmation. DNA analysis was performed on cytologic smear. Immunostaining was performed on cell blocks. A grade was assigned on the basis of DNA evaluation and p53 expression quantitation. These grades were combined for each case and compared with the initial cytologic grading and the final histologic grading. RESULTS Cytology alone diagnosed TCC in all but 1 case that was diagnosed atypical. Discrepancies were found in primary grading: cytologic grading concurred with histologic grading in 6 of the 13 cases. CONCLUSIONS These results, although in a limited but selected number of cases, show the potential of computerized evaluation of biologic markers as parameters for a more objective grading of tumors.
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Affiliation(s)
- C Minimo
- Department of Pathology/Cell Biology, Thomas Jefferson University, Philadelphia 19107-5244, USA
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26
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Abstract
Advances in ureteroscopic techniques have made it possible to treat many upper-tract tumors conservatively. Such treatment has demonstrated acceptable survival and renal preservation in high-risk patients, particularly those with a solitary kidney, bilateral tumors, poor renal function, or prohibitive operative risk. It is also preferred in patients with grade I TCC, particularly when located in the distal ureter. For patients with regionally extensive upper-tract urothelial neoplasms, use of endourologic techniques should be considered to control hemorrhage, relieve obstruction, and preserve as much functioning renal tissue as possible. Success with small, solitary, low-grade tumors allows the application of this technique to patients with a normal contralateral kidney on an elective basis. Adjuvant BCG or mitomycin C therapy appears to be safe, but confirmation of any benefits awaits the results of larger trials. Benign neoplasms can occur in the upper urinary tract and should be distinguished from TCC, thus avoiding more radical treatment for a benign lesion. Endoscopic surveillance should be maintained because recurrences can develop without radiographic evidence.
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Affiliation(s)
- E R Tawfiek
- Department of Urology, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
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Rey A, Lara PC, Redondo E, Valdés E, Apolinario R. Overexpression of p53 in transitional cell carcinoma of the renal pelvis and ureter. Relation to tumor proliferation and survival. Cancer 1997; 79:2178-85. [PMID: 9179065 DOI: 10.1002/(sici)1097-0142(19970601)79:11<2178::aid-cncr16>3.0.co;2-t] [Citation(s) in RCA: 44] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND Clinical management of patients with tumors of the upper urinary tract is based mainly on histologic grade and stage of the tumors. In recent years, tumor proliferation has also proved to be an important factor in determining the prognosis of these and other transitional cell tumors. The aim of this study was to assess the role of p53 in regulating cell proliferation and tumor progression and to define its value in predicting the long term survival of patients with these tumors. Such information could be of use in selecting treatment in individual cases. METHODS Eighty-three patients with urothelial tumors of the renal pelvis and ureter diagnosed and treated between 1975 and 1993 were included in this study. p53 immunostaining was performed on paraffin embedded tissue. Tumor location, histologic grade, histologic pattern, tumor proliferation by Ki-67, local (T classification), lymph node (N classification), vascular and perineural invasion, and clinical stage (TNM) were assessed in relation to p53 overexpression (Mann-Whitney U test and analysis of variance comparisons) and as prognostic factors for survival in both univariate analysis (log rank test) and multivariate analysis (Cox proportional hazards model). RESULTS Overexpression of p53 was related to tumor proliferation as assessed by Ki-67 (P < 0.01), T classification (Ta vs. T1-4; P < 0.01), N classification (P < 0.054), and TNM staging (Stage 0 vs. I-IV; P < 0.01). There was also a statistically significant relation to vascular (P < 0.002) and perineural invasion (P < 0.04). Fifteen-year actuarial survival for the whole group was 75%. Patients having tumors with low p53 overexpression (< 30% of stained nuclei) had a better survival rate (88%) than those having tumors with high (> 30%) p53 overexpression (65%) (P < 0.02), and this effect reached statistical significance with high grade (P < 0.02) and infiltrating tumors (P < 0.04). Patients with low p53 and Ki-67 expression had a 15-year survival rate of 100%; in contrast, patients with overexpression of both markers had a 15-year survival rate of 61% (P < 0.003). In a multivariate analysis, only T classification (P < 0.001) and p53-Ki-67 expression (P < 0.026) were statistically significant. CONCLUSIONS Overexpression of p53 is related to increased tumor proliferation and disease progression and is of value in determining the long term survival of patients with tumors of the renal pelvis and ureter. p53 immunostaining can be used to distinguish low risk patients in the theoretically unfavorable high grade, high stage group, and when used together with Ki-67 index, it is a predictive factor for survival.
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Affiliation(s)
- A Rey
- Department of Pathology, Hospital Nuestra Señlora del Pino, Las Palmas de Gran Canaria, Spain
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Keeley FX, Bibbo M, Bagley DH. Ureteroscopic Treatment and Surveillance of Upper Urinary Tract Transitional Cell Carcinoma. J Urol 1997. [DOI: 10.1016/s0022-5347(01)64793-1] [Citation(s) in RCA: 195] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Francis X. Keeley
- From the Departments of Urology, Radiology and Cytology, Jefferson Medical College, Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Marluce Bibbo
- From the Departments of Urology, Radiology and Cytology, Jefferson Medical College, Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Demetrius H. Bagley
- From the Departments of Urology, Radiology and Cytology, Jefferson Medical College, Thomas Jefferson University, Philadelphia, Pennsylvania
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Wong AK, Lupu AN, Shanberg AM. Laser ablation of renal pelvic transitional cell carcinoma in a solitary kidney: a 9-year follow-up. Urology 1996; 48:298-300. [PMID: 8753746 DOI: 10.1016/s0090-4295(96)00173-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Neodymium:yttrium-aluminum-garnet (Nd:YAG) laser ablation of upper-tract urothelial tumors has been well documented in the urologic literature. However, the standard treatment of choice remains radical nephroureterectomy with excision of a cuff of the bladder for most patients. We report on a patient with recurrent superficial transitional cell carcinoma of the renal pelvis in a solitary kidney treated with Nd:YAG laser with a 9-year follow-up.
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Affiliation(s)
- A K Wong
- Division of Urology, UCI Medical Center, Orange 92668, USA
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31
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Elliott DS, Blute ML, Patterson DE, Bergstralh EJ, Segura JW. Long-term follow-up of endoscopically treated upper urinary tract transitional cell carcinoma. Urology 1996; 47:819-25. [PMID: 8677570 DOI: 10.1016/s0090-4295(96)00043-x] [Citation(s) in RCA: 120] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
OBJECTIVES This report focuses on the long-term follow-up of patients with endoscopically treated upper tract transitional cell carcinoma (TCC) to determine the effectiveness of endoscopic therapy. METHODS From May 1983 to April 1994, 44 patients with TCC of the upper urinary tract underwent conservative endourologic treatment with either electrocautery fulguration or neodymium:yttrium-aluminum-garnet laser at our institution. The mean follow-up period was 5 years (range, 3 months to 11 years). RESULTS Renal pelvic tumor sizes ranged from 0.4 to 4.0 cm (mean, 1.5) and ureteral tumors from 0.2 to 1.0 cm (mean, 0.5). The majority of tumors were of pathologic grade 3 or less, and all were Stage T2 or less. Seventeen of 44 patients (38.6%) had local tumor recurrence (mean time to recurrence, 12.8 months; range 1.5 to 64). Mean recurrence time was 7.3 months for renal pelvic tumors and 17.8 months for ureteral tumors. Nineteen of 44 patients (43.2%) developed bladder tumors. The overall 5-year disease-free rate was 57%. No recurrent tumor was shown to have increased in grade, and one recurrent tumor was proved to have progressed in stage. Six patients (14%) ultimately required a nephroureterectomy for recurrence. There were no major complications as a result of endoscopic therapy. Six patients (14%) died of the effects of metastatic TCC, 5 of whom had known muscle invasive bladder TCC. CONCLUSIONS Endourologic techniques and the conservative treatment of upper urinary tract TCC is an evolving field and can be safely and effectively used as a first-line treatment for upper tract TCC in selected patients.
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Affiliation(s)
- D S Elliott
- Department of Urology, Mayo Clinic and Mayo Foundation, Rochester, Minnesota 55905, USA
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Patel A, Soonawalla P, Shepherd SF, Dearnaley DP, Kellett MJ, Woodhouse CR. Long-term outcome after percutaneous treatment of transitional cell carcinoma of the renal pelvis. J Urol 1996. [PMID: 8583595 DOI: 10.1016/s0022-5347(01)66330-4] [Citation(s) in RCA: 70] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
PURPOSE The application of conservative surgery has been established in the treatment of transitional cell tumors of the renal pelvis. We reviewed retrospectively the long-term outcome after percutaneous treatment of select patients referred to a tertiary center with transitional cell tumors of the renal pelvis. MATERIALS AND METHODS We studied 28 patients referred with a presumptive diagnosis of transitional cell carcinoma of the renal pelvis based on filling defects noted on excretory urograms. At percutaneous endoscopy tumor was resected in 26 patients, while no tumor was found in 2. All 19 men and 7 women smoked, and mean age at presentation was 65 years. Of the patients 18 presented with hematuria and 6 had bilateral upper tract tumors. After percutaneous resection, the access tract was irradiated either with iridium wire in 12 patients or a commercial high dose rate radiation delivery system in 12. Thiotepa was instilled into the nephrostomy tube without brachytherapy in 1 patient and 1 received no adjuvant treatment in all. All patients were followed by excretory urography and urine cytology. Cystoscopy and retrograde pyelography were performed when technically possible. RESULTS After percutaneous tumor resection 6 patients (23%) had local recurrence in the treated renal pelvis, including 3 at 44, 55 and 60 months, respectively. Further conservative treatment was initially possible in 4 of these patients but ultimately only 2 (both of whom had late recurrences) retained the treated kidney. Of the 11 patients with recurrence elsewhere in the urinary tract the bladder was invariably involved (11), while synchronous or metachronous ureteral recurrence was less common (3). Nine patients remained free of any urothelial recurrence in the upper or lower tract. No patient had recurrent tumor in the nephrostomy tract. Of the patients 7 suffered from procedure-related complications, including 1 who had a persistent urinary fistula that failed to heal after brachytherapy and required nephroureterectomy. There have been 6 deaths during followup, of which 2 were disease related. The 3-year estimated local recurrence-free survival rate was 86% (95% confidence interval 63 to 95%), cause-specific survival rate 91% (95% confidence interval 67 to 98%) and overall survival rate 78% (95% confidence interval 55 to 90%). Differences in recurrence-free survival, comparing those with recurrence in the treated renal pelvis or elsewhere in the urothelium and those remaining disease-free, did not translate to a significant overall survival difference (p < 0.5) between these groups. CONCLUSIONS Our results suggest that the combination of percutaneous local resection and tract irradiation offers an effective long-term alternative to radical extirpation in the management of select patients with superficial transitional cell carcinoma confined to the renal pelvis. When the postoperative nephrostogram demonstrates a leaking renal pelvis, tract irradiation should not be given.
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Affiliation(s)
- A Patel
- Department of Urology, Royal Marsden Hospital, London, United Kingdom
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Affiliation(s)
- M Alagiri
- Fox Chase Cancer Center, Philadelphia, Pennsylvania, USA
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Abstract
The holmium: YAG laser produces light of 2100 nm, which has tissue penetration of less than 0.5 mm. The energy can be delivered endoscopically with a low water-content quartz fiber and can fragment all types of calculi and ablate tissue, both neoplasms and strictures. Application of this laser in 43 procedures in 37 patients demonstrated its safety and effectiveness for these different applications throughout the urinary tract.
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Affiliation(s)
- M J Erhard
- Department of Urology, Thomas Jefferson University, Philadelphia, PA, USA
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Ilker Y, Dillioğlugil O, Tarcan T, Türkeri L, Akdaş A. The role of ureteroscopy as a diagnostic and therapeutic tool in various indications. Int Urol Nephrol 1994; 26:647-54. [PMID: 7759200 DOI: 10.1007/bf02767719] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
Ureteroscopy is now in routine use for the diagnosis and treatment of various pathologies in the upper urinary tract. We report here on our experience in diagnostic and therapeutic applications of the 11.5 F rigid ureteroscope in 85 patients and 88 ureters. An overall success rate of 68.18% (60/88) was achieved when therapeutic and diagnostic interventions were evaluated together. Success rate was 66.65% in the treatment of ureteral stones (all locations), 100% in the removal of retained catheters, and 81.82% in diagnostic interventions. Frequencies of complications like postoperative fever, stone migration, and various degrees of ureteral perforation were 5.68%, 5.68%, and 7.95%, respectively, consistent with current literature. We conclude that rigid ureteroscopy can be safely applied for appropriate indications in the hands of competent urologists.
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Affiliation(s)
- Y Ilker
- Department of Urology, Marmara University School of Medicine, Istanbul, Turkey
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Andersen JR, Kristensen JK. Ureteroscopic management of transitional cell tumors. SCANDINAVIAN JOURNAL OF UROLOGY AND NEPHROLOGY 1994; 28:153-7. [PMID: 7939466 DOI: 10.3109/00365599409180492] [Citation(s) in RCA: 27] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
Eighty-nine ureteroscopies, comprising 102 renal units, were performed on 31 patients for diagnosis, treatment or follow-up of transitional cell tumors of the upper urinary tract. The indications were hematuria or filling defect (29 endoscopies), treatment of tumor (19) and follow-up (41), i.e. 33, 21 and 48 renal units. Ureteroscopy (including 2 peroperative) was satisfactorily completed in 93 units. Tumor was suspected or diagnosed in 57 units, but later disproved in 11. Two tumors were overlooked at endoscopy. Surgery was performed in 21 cases (bilateral in 3), with indications based on ureteroscopic findings in 58%. Electroresection, laser photocoagulation or fulguration was done on ten units (average treatment sessions 2.6). Inadequate ureteroscopic treatment led to surgery in two of these units, but in seven open surgery was avoided (follow-up 6-47, mean 25 months). One old patient had no further treatment. Follow-up ureteroscopy was planned for 48 units and completed in 42. Complications occurred after 11 of 89 endoscopies. Ureteroscopic management of upper-tract urothelial tumors can be satisfactory, with long freedom from recurrence.
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Affiliation(s)
- J R Andersen
- Department of Urology D, Rigshospitalet, University of Copenhagen, Denmark
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Anson K, Seenivasagam K, Miller R, Watson G. The role of lasers in urology. BRITISH JOURNAL OF UROLOGY 1994; 73:225-30. [PMID: 7512883 DOI: 10.1111/j.1464-410x.1994.tb07509.x] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Affiliation(s)
- K Anson
- Department of Urology and Minimally Invasive Therapy, Whittington Hospital, London, UK
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O'Sullivan DC, Mynderse L, Barrett DM. Subcutaneous port for longterm access and administration of topical chemotherapy to the upper urinary tract. J Urol 1993; 150:1034-7. [PMID: 8345581 DOI: 10.1016/s0022-5347(17)35681-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
Fourteen silicone pigtail catheters were inserted into the renal pelves of ten 25 kg. pigs. These catheters were connected to injection ports implanted in the flank. Each animal received 15 mg. of thiotepa, into one port, weekly for 8 weeks. These were well tolerated. Percutaneous radiography and histological examination showed effective distribution of thiotepa throughout the upper urinary tract. Microscopic changes included cytoplasmic vacuolation, cystic changes and denudation of the mucosa. There was edema and chronic inflammatory infiltrate in the submucosa. This method of access to the upper tracts should be considered for long-term recurrent treatment of upper tract superficial transitional cell carcinoma.
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Affiliation(s)
- D C O'Sullivan
- Department of Urology, Mayo Clinic, Rochester, Minnesota
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