Systematic mapping of nephroureterectomy specimens removed for urothelial cancer: pathological findings and clinical correlations

Role of lymph node dissection at the time of open or minimally invasive nephroureterectomy

Unlike urothelial carcinoma of the bladder, there is no guideline-based consensus on whether a lymph node dissection (LND) should be performed at the time of radical nephroureterectomy (RNU) for upper tract urothelial carcinoma (UTUC). Variable lymphatic drainage based on primary tumor location, lack of prospective trials, and difficulties in developing a risk-adapted approach to LND for UTUC are all challenges to the development of an established approach. The UTUC literature consists of an evidence pool that has historically been limited to single-institution series with heterogenous inclusion criteria for LND and variable LND templates. Areas of controversy exist regarding migration to the great vessel LN beds for mid and distal tumors. A lack of template standardization limits the interpretation of studies relative to one another and a lack of uniformity in reporting templates may lead to inaccuracies in the estimation of lymph node metastasis landing sites. Most clinicians agree that there is a staging benefit to LND for UTUC. Although the data is somewhat heterogenous, it demonstrates a prognostic and staging benefit to LND in higher stages of UTUC. Unlike the staging benefits provided by LND for UTUC, the therapeutic benefits are not as clearly established. Several studies have evaluated differences in cancer-specific survival (CSS) and demonstrated LND to be an independent predictor of CSS when compared to patients not undergoing LND. However, this finding is not consistent across all studies and the literature is again limited by inclusion heterogeneity and inconsistent or lack or template-based resections. LND for UTUC at the time of RNU is a safe and feasible procedure that seems to especially benefit patients with muscle-invasive or locally advanced disease. Prospective, randomized studies with strict inclusion criteria and defined anatomic templates are needed to definitely characterize the role of LND for UTUC.

Survival Benefits Based on the Number of Lymph Nodes Removed during Radical Nephroureterectomy for Upper Tract Urothelial Carcinoma: Systematic Review and Meta-Analysis

The role of lymph node dissection (LND) is still controversial for upper tract urothelial carcinoma (UTUC), and there are no guidelines regarding its use. This study was conducted to find a higher level of evidence for the survival benefits based on the number of LNs removed during radical nephroureterectomy (RNUx) through a systematic review and meta-analysis. We included studies comparing patients who underwent LND during RNUx for UTUC. We searched the major electronic databases (Pubmed, Embase^®, and Scopus^®) and conducted manual searches of the electronically available abstracts of the major international urology cancer meetings [American Society of Clinical Oncology (ASCO), American Urological Association (AUA), and Eropean Association of Urology (EAU)] prior to April 2019 using grouped terms of nephroureterectomy (nephroureterectom*) and lymph node excision (lymphadenectomy; lymph + node*; lymph* + metasta*) with variations in the terms. Study selection, data collection, and risk of bias assessment were performed by two independent authors (A and B). Six retrospective case-control studies included a total of 33,944 patients who underwent RNUx for UTUC, 5071 of whom underwent LND and were finally included in the meta-analysis. The pooled hazard ratio (HR) in these studies revealed that an increased number of LNs removed during RNUx was associated with improved cancer-specific survival (CSS) in patients with UTUC (HR = 0.95, 95% CI: 0.91–0.99; p = 0.07). In addition, increased numbers of LNs removed were associated with improved overall survival (OS) in pN0 patients. However, in pN+ patients, the number of LNs removed showed no survival benefit on CSS, overall survival (OS), or progression-free survival (PFS). Higher numbers of LNs removed during RNUx were associated with improved survival outcomes in patients with UTUC. This study confirmed that LND also has oncological benefits in UTUC patients. Although still a controversial topic, meticulous LND must be considered, and efforts should be made to eliminate as many LNs as possible when administering RNUx for UTUC, especially in patients without clear evidence of LN metastasis.

Current role of lymphadenectomy in the upper tract urothelial carcinoma

Introduction

Lymphadenectomy (LND) has recently attracted considerable interest from urological surgeons, as extended lymphadenectomy might have a role in accurate staging or improving patient survival in those patients with urological malignancies.

Upper tract urothelial carcinoma (UTUC) is a relatively rare neoplasm, accounting for about 5% of all urothelial cancers. Up to 30% of patients with muscle-invasive UTUC have metastasis in the regional lymph nodes (LNs), which represents a well-established poor prognostic factor.

Material and methods

A medline search was conducted to identify original articles and review articles addressing the role of lymphadenectomy LND in UTUC. Keywords included lymphadenectomy, lymph node excision, nephroureterectomy, and upper tract urothelial carcinoma.

Results

LND instead of lymphadenectomy has recently attracted considerable interest from urological surgeons and might have a potential role in improving the oncological outcome in patients with urothelial carcinoma. LND ideally improves disease staging; thereby, we need to find the way to identify the patients who could really benefit from adjuvant systemic theraphy. Template-based LND with Radical Nephroureterectomy (RNU) for high risk disease is gaining support based on accumulating retrospective data and supports its utility as a potentially therapeutic maneuver. RNU is still the gold standard treatment for UTUC, but minimal invasive procedures such as laparoscopic RNU and Robot Assisted Nephroureterectomy (RANU) are becoming more employed in recent years and should be used by expert hands.

Conclusions

Therapeutic benefits of LND and nodal status on disease free survival (DFS) and Cancer Free Survival (CSS) remains controversial. Although most of the data comes from retrospective studies, we encourage performing well designed, prospective, and multicentre studies to clarify this in the coming years.

Contemporary role of lymph node dissection at the time of radical nephroureterectomy for upper tract urothelial carcinoma

PURPOSE

To review the contemporary data on the role of lymph node dissection (LND) at the time of radical nephroureterectomy (RNU) for upper tract urothelial carcinoma (UTUC).

METHODS

A computerized bibliographic search using the following protocol ("Nephroureterectomy") AND ("Lymphadenectomy" OR "Lymph node" OR "Lymphatic") was performed in MEDLINE to identify all original and review articles that addressed the role of LND for UTUC.

RESULTS

Regional lymph node (LN) boundaries of UTUC have been recently investigated in mapping studies to propose anatomic templates of LND according to the laterality and location of primary tumor. Although these anatomic templates remained poorly described, most reports supported the staging benefit of LND that allowed for risk stratification of patients with (pN+) or without (pN0) LN metastases from those who did not undergo such a procedure (pNx). In addition, the therapeutic benefit of LND at the time of RNU was supported by better oncological outcomes obtained after complete LND when compared to incomplete or no LND, especially in the group of patients with advanced disease. The number of LNs removed was also correlated with both, more accurate staging and greater cancer-specific survival after LND, whose feasibility and safety have been validated in prospective studies.

CONCLUSIONS

Despite mostly based on data with level of evidence 3, our comprehensive review of the literature supports the staging and therapeutic benefits of LND at the time of RNU for UTUC, which are particularly significant for patients with muscle-invasive or locally advanced disease.

Carcinoma in situ is significantly underdetected by prenephroureterectomy ureteroscopy in the management of upper tract urothelial cancers

Objective. Diagnostic reliability of prenephroureterectomy ureteroscopy (PNU) for the detection of upper tract carcinoma in situ (CIS) remains unproven in particular and underreported in general. Methods. Patients who underwent radical nephroureterectomy (RNU) in a large multicentre retrospective study for upper tract transitional cell carcinoma (UT-TCC) between January 2002 and December 2013 were identified from our hospitals databases. PNU appearances, stage, and grade of ureteroscopic biopsy were compared with final histology results of RNU to assess the diagnostic reliability of PNU for carcinoma in situ (CIS). Results. Three hundred patients underwent RNU for UT-TCC. 106 (106/300; 35.3%) of the cohort had PNU using white light with biopsies taken in most (92/106; 86.7%). Postnephroureterectomy histology of the cohort showed CIS in 65 (65/300; 21.6%) patients. Thirty nine of patients with CIS (39/65; 60%) had prenephroureterectomy ureteroscopy biopsies. Out of ten patients with CIS on ureteroscopic biopsies, six did not show CIS on final histopathology (6/10; 60%). Moreover, grading and staging on PNU biopsies of obvious tumours showed a significant nonconcordance with final histopathology of RNU specimen (P = 0.02). Overall survival was also shorter in patients with CIS compared with those without; this showed strong statistical significance (P = 0.004). Conclusions. There is a high incidence of CIS in upper tract with significant underdetection and discordance rate between the histopathology of biopsy samples obtained by white light PNU and resected specimen of radical nephroureterectomy. The presence of concomitant CIS and high stage disease in the upper tract TCC carried a poor prognosis following radical nephroureterectomy.

Role of lymphadenectomy in the management of urothelial carcinoma of the bladder and the upper urinary tract

The role of lymphadenectomy has been controversial in urological malignancies. Urothelial carcinoma of the bladder and upper urinary tract has a high potential to spread through the lymphatic network compared with other malignancies, including renal cell carcinoma or prostate cancer. In urothelial carcinoma of the bladder, lymphadenectomy of pelvic nodes had been considered as the standard procedure when radical cystectomy was carried out. Recently, many investigators have examined the influence of its extent, and the majority of the studies have supported the beneficial role of extended lymphadenectomy in accurate staging or in improving patient survival. Although randomized controlled trials are required to establish a greater level of evidence, more urological surgeons have already noticed the necessity for extended lymphadenectomy in bladder cancer. In contrast to bladder cancer, there have been far fewer studies on urothelial carcinoma of the upper urinary tract. This might be because of the smaller number of the patients with urothelial carcinoma of the upper urinary tract and the lack of understanding of regional nodes. However, studies of lymph node mapping and the retrospective analyses with respect to the benefit of lymphadenectomy have been carried out in urothelial carcinoma of the upper urinary tract by some investigators, although the results are still controversial. However, the results from multi-institutional studies by high volume centers have supported the beneficial role of lymphadenectomy in urothelial carcinoma of the upper urinary tract, as it has been proposed in bladder cancer. Thus, lymphadenectomy for urothelial carcinoma of the bladder and the upper urinary tract might have a potential role in staging and improving the oncological outcomes.

The role of lymph node dissection in the management of urothelial carcinoma of the upper urinary tract

Urothelial carcinoma of the upper urinary tract (UCUUT) is a disease with poor prognosis and a high incidence of lymphatic metastasis at 30-40%. Lymphadenectomy may be a possible surgical strategy to control the spread of lymphatic cancer, but its therapeutic benefit in UCUUT has remained controversial in contrast to bladder cancer in which consensus has been almost reached with respect to the necessity of extended lymphadenectomy. We hypothesized that radical lymphadenectomy may also be important for UCUUT since UCUUT is histologically similar to bladder cancer. One of the major reasons for uncertainty about whether lymphadenectomy has any therapeutic value may have resulted from an incomplete understanding of the regional nodes. Thus, we started our analyses by clarifying this issue, and found that the primary sites of lymphatic metastases encompassed a relatively wide area, especially on the right side, when compared with the conventional recognition. We further reported complete lymphadenectomy in which all regional sites which were dissected appeared to provide a survival benefit for patients with UCUUT at an advanced stage. To date, several studies from the other institutes have added supportive evidence for the therapeutic role of lymphadenectomy. Although there are several points to be determined such as the extent of the template, the minimum number of lymph nodes removed, or the candidate for lymphadenectomy, performing lymphadenectomy is unlikely to have a negative effect on the patient. In the future, we expect that controlled prospective studies will further clarify the potential role of lymphadenectomy in UCUUT.

Concomitant carcinoma in situ and tumour size are prognostic factors for bladder recurrence after nephroureterectomy for upper tract transitional cell carcinoma

OBJECTIVE

To identify prognostic risk factors for the development of subsequent bladder recurrence in patients undergoing nephroureterectomy (NU) for upper tract transitional cell carcinoma (TCC).

PATIENTS AND METHODS

The data of 79 patients who underwent NU for localized upper tract TCC were collected retrospectively, and analysed for clinical and pathological variables. Patients with previous invasive bladder tumours were excluded. Age, sex, tumour location, previous/synchronic bladder tumours, stage, grade, concomitant upper tract carcinoma in situ (CIS), and size were all analysed. Univariate and multivariate analyses were done using the Kaplan-Meier Method, with the log-rank test, and the Cox proportional hazards regression model, respectively.

RESULTS

The median follow-up was 71 months, during which bladder tumours were detected in 42 patients (54%). On univariate analyses, tumour stage ≥ pT2 (P = 0.015), concomitant upper tract CIS (P = 0.001), high-grade tumour G3 (P = 0.027) and tumour size > 4 cm (P = 0.011) were statistically significant predictors of intravesical recurrence. After multivariate analyses, concomitant CIS (P = 0.005, hazard ratio 2.9, 95% confidence interval 1.4-5.8) and tumour size > 4 cm (P = 0.042; 1.9, 1-3.7) were significantly related to bladder tumour recurrence.

CONCLUSION

There is a high bladder recurrence rate after NU for upper tract TCC. Patients with tumours of > 4 cm and concomitant upper tract CIS have a major risk of developing subsequent bladder recurrence. Therefore, closer surveillance of the bladder is needed in these patients and they may potentially benefit from prophylactic intravesical instillation therapy.

Bladder recurrence after surgery for upper urinary tract urothelial cell carcinoma: frequency, risk factors, and surveillance

OBJECTIVE

To highlight the main risk factors for metachronous bladder recurrence after treatment of an upper urinary tract urothelial cell carcinomas (UUT-UCCs) based on the recent literature.

MATERIALS AND METHODS

Data on urothelial malignancies after UUT-UCCs management in the literature were searched using MEDLINE and by matching the following key words: urinary tract cancer; bladder carcinomas, urothelial carcinomas, upper urinary tract, renal pelvis, ureter prognosis, carcinoma, transitional cell, renal pelvis, ureter, bladder cancer, cystectomy, nephroureterectomy, minimally invasive surgery, recurrence, and survival.

RESULTS

No evidence level 1 information from prospective randomized trials was available. A range of 15% to 50% of patients with a UUT-UCC will subsequently develop a metachronous bladder UCC. Intraluminal tumor seeding and pan-urothelial field change effect have both been proposed to explain intravesical recurrences. In most cases, bladder cancer arises in the first 2 years after UUT-UCC management. However the risk is lifelong and repeat episodes are common. The identification of variables that allow accurate risk stratification of UUT-UCC patients with regards to future bladder relapse is disappointing. No factors have been identified to date that can reliably predict bladder recurrences. A history of bladder cancer prior to UUT-UCC management and upper tract tumor multifocality are the only frequently reported clinical risk factors among current literature.

CONCLUSION

Prior histories of bladder cancer and upper tract tumor multifocality are the most frequently reported risk factors for bladder tumors following UUT-UCCs. Surveillance regimen is based on cystoscopy and on urinary cytology for at least 5 years.

Bladder cancer following upper tract urothelial carcinoma

Upper tract urothelial carcinoma (UTUC) is uncommon relative to primary bladder transitional cell carcinoma, with notable differences at the genetic, molecular and clinical levels. A variety of management options with similar oncologic outcomes are available for UTUC. Regardless of upper tract treatment modality, recurrence in the bladder consistently occurs in 20-50% of patients, thus presenting a significant clinical challenge. The initial intravesical relapse typically occurs within the first 2 years following upper tract therapy, but the risk is lifelong and repeat episodes are common. The identification of variables that allow accurate risk stratification of UTUC patients with regards to future bladder relapse is crucial. Unfortunately, to date, no variables have been identified that can reliably predict such bladder recurrences. A history of bladder cancer prior to UTUC resection and upper tract tumor multifocality are frequently reported clinical risk factors. Candidate molecular markers, such as E-cadherin, also hold promise for improving patient risk stratification. The impact of bladder recurrences on patient survival is still poorly defined. The risk of progression to invasive bladder disease is not well documented but appears to be an infrequent event. This article highlights important recent observations and key current issues regarding UTUC and subsequent bladder cancer. In addition, we suggest a bladder surveillance regimen following UTUC and provide recommendations for managing patients with intravesical recurrences.

Endoscopic treatment of upper tract transitional cell carcinoma

PURPOSE

To review the current literature and data describing primary endoscopic treatment of upper tract transitional cell carcinoma (TCC).

MATERIALS AND METHODS

Published, peer-reviewed articles on ureteroscopic, percutaneous, and laparoscopic treatment of upper tract TCC were identified using the MEDLINE database.

RESULTS

Nephroureterectomy has been considered the "gold standard" for upper tract TCC. Minimally invasive approaches, initially advocated for patients requiring a nephron sparing approach (i.e., solitary kidney or renal insufficiency) or those with significant comorbidities precluding definitive surgery, have been increasingly used with the further refinement of ureteroscopy, percutaneous renal surgery, and laparoscopy. Ureteroscopy has been used successfully, resulting in recurrence rates ranging from 31% to 65% and disease-free rates of 35% to 86%. Progression and metastatic rates are low and correlate with tumor grade. Likewise, percutaneous approaches show disease specific survival and recurrence rates correlating with tumor grade. Patients with low-grade tumors (Grades 1-2) do well with this approach with recurrence rates and disease specific survival rates of 26% to 28% and 96% to 100%, respectively. For those patients requiring complete extirpation of the kidney and ureter, laparoscopic nephroureterectomy results in decreased postoperative pain, shorter hospital stay, and more rapid convalescence without compromising cancer control.

CONCLUSIONS

Nephron sparing approaches in well-selected patients with low stage and low-grade disease can be treated endoscopically with ureteroscopy and percutaneous renal surgery. Laparoscopic nephroureterectomy offers a safe, minimally invasive alternative to traditional open surgical techniques for patients with TCC of the upper urinary tract.

Abnormal selective cytology results predict recurrence of upper-tract transitional-cell carcinoma treated with ureteroscopic laser ablation

BACKGROUND AND PURPOSE

Endoscopic management of transitional-cell carcinoma (TCC) of the upper urinary tract remains associated with a significant rate of recurrence. We evaluated the impact of selective upper-tract cytology findings on tumor recurrence and renal salvage rate after ureteroscopic laser tumor ablation.

PATIENTS AND METHODS

From 1993 though 2003, 38 patients with upper-tract TCC underwent ureteroscopic laser tumor ablation. Cytology specimens were collected from the upper urinary tract prior to ablation. "Abnormal cytology" was defined as the presence of malignant or atypical cells. Patients with abnormal cytology results were compared with patients with those having negative findings for tumor recurrence and renal salvage rates using the X (2) test.

RESULTS

Of the 38 patients, 26 (68.4%) experienced at least one recurrence at a mean follow-up of 37.2 months. Pretreatment upper-tract cytology results were available in 34 of these patients: 17 (50%) were negative, and 17 were abnormal. Sixteen of the patients (94.1%) with abnormal cytology results had tumor recurrence after ablation, compared with 8 of the 17 (47.1%) with negative cytology findings (P = 0.0026). Twelve patients (31.5%) underwent nephroureterectomy during follow-up: 8 of the 17 (47.1%) with abnormal cytology, and 4 of the 17 (23.5%) with negative cytology (P = 0.15).

CONCLUSION

Abnormal selective cytology results were associated with a significantly higher rate of tumor recurrence and a trend toward increased renal loss in patients with upper-tract TCC treated with ureteroscopic ablation. These findings suggest a prognostic value for upper-tract cytology analysis in patients undergoing endoscopic therapy.

Primary care update on kidney and bladder cancer: a urologic perspective

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.

Hand-assisted laparoscopic nephroureterectomy with cystoscopic en bloc excision of the distal ureter and bladder cuff

Various hand-assisted and purely laparoscopic nephroureterectomy techniques have been described in the urologic literature. We describe a technique of hand-assisted laparoscopic nephroureterectomy with cystoscopic en bloc excision of the distal ureter and bladder cuff that duplicates open surgical excision of these structures and obviates bladder trocar placement and midprocedural patient repositioning. The patient is placed in a modified dorsal lithotomy position with the tumor side elevated 30 degrees. Allen stirrups are utilized to allow simultaneous access to the urethra. A transperitoneal hand-assisted laparoscopic nephrectomy is performed. The technique is modified in that the ureter is clipped prior to the kidney dissection to avoid distal migration of tumor cells during kidney manipulation. After the kidney is isolated, the intact ureter is liberated distal to the intramural hiatus. The remaining dissection is completed intravesically under cystoscopic guidance. While the surgeon's intra-abdominal hand places the ureter on tension, the cystoscopist transurethrally excises the bladder cuff and intramural ureter with a Collings knife. The complete surgical specimen is removed en bloc through the hand port. The bladder is not closed. A urethral catheter connected to straight drainage remains until the seventh postoperative day, when a cystogram is performed; if it is normal, the catheter is removed.

Bladder neoplasms after nephroureterectomy: does the surgery of the lower ureter, transurethral resection or open surgery, influence the evolution?

OBJECTIVE

Nephroureterectomy is the treatment of choice for tumors of the upper urinary tract (UUTT). In 1952, a modified version of this technique was described, involving endoscopic detachment of the ureter followed by nephroureterectomy with a single lumbar incision. We reviewed a retrospective survey to assess whether UUTT patients treated with nephroureterectomy with no prior history of bladder tumor had different rates of incidence or different sites of bladder recurrence according to the specific technique employed.

METHODS

Patients were divided into group A, 87 patients who underwent a double incision nephroureterectomy and group B with 58 patients with prior detachment of the ureter. In both groups, incidence was calculated for two variables (bladder tumor recurrences and homolaterality of such recurrences) and chi-square tested.

RESULTS

Bladder tumor was diagnosed at follow-up in 39% of patients in group A and 34.5% in group B, with no statistically significant difference (N.S.). Bladder tumor recurrences were homolateral to UUTT in 50% of group A cases and 55% of group B cases (N.S.).

CONCLUSIONS

Although this is a retrospective survey of two asynchronous groups, given the similar nature of the UUTT cases in both groups and the fact that no statistically significant differences have been found, it is reasonable to conclude that nephroureterectomy with prior endoscopic detachment of the ureter is a safe and radical procedure.

When is partial ureterectomy acceptable for transitional-cell carcinoma of the ureter?

Because the disease is so often multifocal and has a high likelihood of recurrence, transitional-cell carcinoma of the ureter traditionally has been treated by nephroureterectomy. As reviewed in this article, partial ureterectomy may be a feasible option for some patients, particularly those with a solitary kidney, bilateral tumors, or renal insufficiency. This conservative procedure also may be appropriate for patients with grade 1 and possibly grade 2 tumors in stage Ta/T1.

Ureteroscopic biopsy of upper tract urothelial carcinoma: improved diagnostic accuracy and histopathological considerations using a multi-biopsy approach

PURPOSE

We assessed the diagnostic accuracy of a ureteroscopic multi-biopsy approach to upper tract urothelial carcinoma compared with subsequently resected surgical specimens.

MATERIALS AND METHODS

From 1990 to 1998, 45 upper tract lesions were ureteroscopically evaluated and biopsied with 3Fr cup forceps and/or an 11.5Fr resectoscope before nephroureterectomy or ureterectomy. A definitive diagnosis of urothelial carcinoma was made by biopsy in 40 lesions (89%). Each tumor was histopathologically graded but only staged if the lamina propria were uninvolved (Ta), and if the lamina propria were invaded by tumor (T1+).

RESULTS

Of the 40 urothelial tumors 16 (40%) were in the renal pelvis, and 8 (20%) in the proximal and 16 (40%) in the distal ureter. Of the lesions 95% were papillary and 65% were grade 2. Ureteroscopic biopsy grade matched surgical pathological grade in 31 of the 40 cases (78%), and was less than surgical pathological grade in the remainder. Lamina propria was detected in 27 of the 40 biopsies, including 21 of the 34 cup (62%) and all 6 resection loop (100%) biopsies. Ureteroscopic biopsy staging in 27 cases revealed Ta and T1+ disease in 22 and 5, respectively. In the 5 cases in which ureteroscopic biopsy stage was T1+ surgical pathological stage was also pT1+ (range pT1 to pT3). Tumors were pathologically up staged to pT1+ (range pT1 to pT3) in 10 of the 22 cases (45%) in which ureteroscopic biopsy stage was Ta. Tumor location did not affect diagnostic accuracy.

CONCLUSIONS

This multi-biopsy ureteroscopic approach provided the tissue diagnosis of urothelial carcinoma in 89% of cases and predicted exact histopathological grade in 78%. Although it is not accurate as a staging modality, multi-biopsy ureteroscopy may assess lamina propria invasion in two-thirds of cases.

Results of conservative treatment of upper urinary tract transitional cell carcinoma

BACKGROUND

The treatment preserving the kidney for upper urinary tract tumor is still controversial. The indications and results of conservative treatment remain to be elucidated. Experiences of this type of treatment are reported.

METHODS

Between April 1981 and March 1998, 14 patients with upper urinary tract transitional cell carcinoma were treated with renal preserving methods. Five were elective and nine were imperative cases. Treatments performed were partial nephrectomy, partial ureterctomy with or without adjuvant chemotherapy, endoscopic tumor resection and topical bacillus Calmette-Guerin instillation in one, 10, two and one patient, respectively.

RESULTS

Crude and cause-specific 5 year-survival rates were 91.7 and 100%, respectively. Of 14 patients, five had bladder recurrences, but ipsilateral local recurrence developed in only one patient. Two patients died from metastasis of transitional cell carcinoma 61 and 89 months after initial treatment. The lesions of carcinoma in situ were well controlled with topical bacillus Calmette-Guerin therapy.

CONCLUSION

The results of conservative treatment for upper urinary tract tumor were satisfactory and local excision can be indicated for low grade, solitary tumors located in the distal ureter.

Frequent recurrence of superficial bladder tumors in the periorificial region: possible predictor for delayed appearance of invasive intramural ureteric cancer

Two cases of invasive lower ureteric cancer developed following frequent recurrence of superficial bladder tumors in the region of the ureteral orifice. The cancer focus could not be identified in the intramural ureter prior to intravenous urography which revealed hydronephrosis. When bladder tumors repeatedly develop near the ureteric orifice, careful investigations such as ureteral catheterization with a small brush for cytology or ureteroscopy are necessary for the early detection of invasive disease.

Conservative surgery for ureteral tumor associated with horseshoe kidney

PURPOSE

We demonstrate the successful conservative management of a ureteral tumor in a horseshoe kidney.

MATERIALS AND METHODS

A patient with low grade transitional cell carcinoma of the left lower ureter had asymptomatic horseshoe kidney. Biopsy specimen revealed low grade tumor in the lower urinary tract that was associated with a congenital abnormality. The patient underwent total ureterectomy with bladder cuff excision and ileal ureteral interposition.

RESULTS

With this technique renal function was preserved without resection through the isthmus of the kidney. The patient has no evidence of recurrent disease after 20-month followup by cytology, computerized tomography, excretory urogram and cystoscopy.

CONCLUSIONS

Organ preserving surgery is an alternative to total nephroureterectomy in lower ureteral tumors in select patients.

Modified "pluck" nephroureterectomy for upper urinary tract disorders: combined endourologic and open approach

Nephroureterectomy is the standard surgical approach for upper urinary tract transitional-cell carcinoma (TCC) and many other conditions. In 1952, a modification of the conventional method was described in which a transurethral resection of the ureteral meatus and intramural ureter is undertaken until the remaining ureter has no attachment to the bladder. The resected area and the distal tip of the ureter are coagulated, and the ureter is removed in continuity with the kidney through a single flank incision. Since January 1990, we have performed 12 nephroureterectomies with this technique (9 men and 3 women with an average age of 61.8 years, ranging from 35 to 73). Six of them were operated on for a TCC of the upper urinary tract, and the postoperative follow-up of these patients was from 6 to 54 months (mean 18.6). Within the follow-up period, tumor has not recurred either at the resected trigonal area or in the retroperitoneum, and only one patient has had a tumor distant from the site of ureteric resection. One patient with bladder TCC, who had a suspect kidney mass on the left side detected by CT, underwent nephroureterectomy with this technique. Five patients had primary renal disorders and upper tract calculous problems, in which nephroureterectomy was required. After the transurethral resection, an indwelling catheter was left in the bladder for 4 days. We believe that our experience confirms the feasibility of this technique in order to improve and simplify nephroureterectomy. Therefore, we recommend the modified "pluck" technique in all patients who are candidates for an operation requiring nephroureterectomy, as it gives considerable benefit to the patient.

Diagnostic accuracy of ureteroscopic biopsy in upper tract transitional cell carcinoma

PURPOSE

Our aim was to determine the accuracy of ureteroscopic biopsies and cytological techniques compared to open surgical specimens of upper tract transitional cell carcinoma.

MATERIALS AND METHODS

From 1985 to 1995, 51 cases of upper tract transitional cell carcinoma were diagnosed ureteroscopically and distal ureterectomy or nephroureterectomy was performed. Each patient underwent direct ureteroscopic inspection and biopsy. Fresh samples were delivered to the cytopathology laboratory, where they were examined using cytospin and smear. A cell block was prepared when visible tissue was present. Grades of ureteroscopic biopsies were compared to grades and stages of surgical specimens in 42 cases.

RESULTS

Cytological evaluation was positive for malignancy in 48 of the 51 cases (94.1%). Grading of ureteroscopic specimens was possible in 42 cases (82.4%). Transitional cell carcinoma grade on ureteroscopy accurately predicted tumor grade and stage in the surgical specimens. Of 30 low or moderate grade ureteroscopic specimens 27 (90%) proved to be low or moderate grade transitional cell carcinoma in the surgical specimens, while 11 of the 12 high grade ureteroscopic specimens (91.6%) proved to be high grade transitional cell carcinoma (p < 0.0001). Of 30 low or moderate grade ureteroscopic specimens 26 (86.6%) had a low stage (Ta or T1) tumor. In contrast, 8 of 12 high grade ureteroscopic specimens (66.7%) had invasive tumor (stage T2 or T3) in the surgical specimen (p = 0.0006).

CONCLUSIONS

Ureteroscopic inspection and biopsy combined with cytological techniques provide accurate information regarding grade and stage of upper tract transitional cell carcinoma.

The dangerous ureter

Seven patients with recurring transitional cell carcinoma of the urinary bladder were treated with repeated transurethral resections of these tumors and were given adjuvant intravesical chemotherapy or bacillus-Calmette Guerin (BCG) vaccine. Carcinoma either in the ureters or renal pelves subsequently developed in these patients. Unfortunately, 2 patients had inoperable tumors when the diagnosis was confirmed. When treating patients with recurring carcinoma of the urinary bladder, the possibility of upper urinary tract tumors developing must always be considered. Hence, the necessity of frequent urinary and ureteral cytology examinations proceeding to excretory urography, retrograde pyelograms, computerized tomography (CT) scans of the upper tracts, or ureteroscopy as may be necessary to locate small tumors or to diagnose carcinoma in situ.

Routine excretory urography in follow-up of superficial transitional cell carcinoma of bladder

To determine cost-effective guidelines for the follow-up of patients with superficial transitional cell carcinoma of the bladder (STCCAB), we reviewed clinical histories, pathology reports, and intravenous pyelography results in 84 patients with Stage Ta or T1 disease. In 4 patients (4.8%) subsequent upper tract tumors developed with an average interval from initial presentation to the development of upper tract disease of 5.4 years. Three of these patients were treated successfully. We recommend upper tract surveillance in this group of patients with intravenous pyelography at diagnosis and every twenty-four months thereafter, or selection of those patients who are at high risk for development of upper tract disease (i.e., ureteral-vesical reflux) with voiding cystourethrography one month following each resection of tumors near a ureteral orifice. Refluxing patients should then either undergo surgical repair of their reflux or yearly pyelography.

Carcinoma of the ureter: a clinicopathologic study of 49 cases

We reviewed 49 patients with urothelial tumors of the ureter: 33 male and 16 female patients with a mean age of 64.8 and 66.3 years, respectively. Median followup was 83 months. Gross hematuria was present in 29 patients and a silent kidney was found in 21. The majority of the tumors were in the distal ureter and approximately 50 per cent of the patients had synchronous or asynchronous urothelial tumors. The majority of the patients had low grade, low stage tumors (75 per cent). A total of 21 patients underwent local resection and none died of tumor. Only 1 of these 21 patients had an ipsilateral recurrence. Nephroureterectomy was performed in 24 patients and 5 of them died of ureteral tumor, including 4 in whom periureteral tumor growth initially was recorded. The prognosis of patients with papillomas or grades 1 to 3, stages Pa to P1 ureteral tumors was excellent and a conservative approach is recommended for these patients. Abuse of combination analgesics containing phenacetin, phenazone and caffeine may be a risk factor for development of ureteral tumors.

Laser treatment of ureteral tumors

Ureteroscopic laser coagulation was performed in 20 patients. In 4 of these patients endoscopic treatment was judged to be incomplete and biopsy demonstrated a muscle invasive tumor in 3 and a poorly differentiated tumor in 1. Therefore, segmental resection or nephroureterectomy followed. In the other 16 patients laser treatment alone (8) or in conjunction with electroresection (8) eradicated the tumor successfully. All of these were stage Ta or T1 and grade 1 or 2 tumors. Three recurrences (after 12, 24 and 49 months) were detected within a medium observation period of 13.8 months and could be eradicated easily with the laser, since these tumors were small. A ureteral stricture developed at the treatment site once in the "laser only" group and 3 times in the group with laser treatment and electroresection. Endoscopic laser coagulation seems to be a promising treatment modality for selected small ureteral tumors. Electroresection has a high risk for development of a ureteral stricture. Regular retrograde ureteropyelography is mandatory for follow-up.

Prognostic variables in patients with transitional cell carcinoma of the renal pelvis and proximal ureter

Recent technological advances in urological endoscopic surgery of the renal pelvis and proximal ureter via ureteroscopy or percutaneous nephroscopy have made it possible to consider parenchymal-sparing procedures in patients with transitional cell carcinoma. To define the role of these procedures in the management of renal pelvic or proximal ureteral transitional cell carcinoma we analyzed retrospectively 31 patients who underwent nephroureterectomy for transitional cell carcinoma of the renal pelvis and/or proximal ureter. High grade upper urinary tract transitional cell carcinoma and a history of metachronous or synchronous bladder transitional cell carcinoma were independent adverse prognostic factors. However, patients with low grade upper urinary tract transitional cell carcinoma and no evidence of a urothelial field change had a 100 per cent 5-year survival rate. It would appear that parenchymal-sparing endoscopic techniques should be regarded with caution in patients with either high grade transitional cell carcinoma of the renal pelvis and proximal ureter or a history of bladder cancer.

Primary carcinoma of the upper urinary tract

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

In situ management of renal tumors: renal cell carcinoma and transitional cell carcinoma

In the last 8 years 15 patients with malignant neoplasms in functionally solitary kidneys underwent in situ excision of the tumor with preservation of renal parenchyma. Of 10 patients with renal cell carcinoma 8 underwent partial nephrectomy, 1 had a central wedge resection and 1 had enucleation of 3 tumors. After followup of 6 months to 4.7 years 6 patients are free of disease. One patient died of metastatic cancer and 1 of cardiovascular disease. Of 5 patients with transitional cell carcinoma of the kidney (including 2 with parenchymal invasion) 2 underwent partial nephrectomy and 3 underwent extensive resection of renal pelvic lesions. After followup of 6 months to 7 years 2 patients are alive, 2 died of metastatic disease and 1 died of metastatic bladder carcinoma. Only 1 of the 5 patients had locally recurrent tumor. These data demonstrate the efficacy of in situ management of renal tumors in selected patients with solitary kidneys or compromised renal function.

Oncologic imaging: kidney and ureter

Malignant cancers of the kidney and ureter account for only 2-3% of all neoplasms in man. However, early diagnosis and treatment can have a profound effect on patient prognosis and survival. This article seeks to amalgamate a large body of information related to the pathology or primary renal tumors and metastatic disease with current imaging strategies to assist the clinician and enhance his understanding of the wide variety of modern imaging techniques available. Current tumor staging classifications are presented and the various imaging strategies are keyed to detection, definition and treatment options for tumors of the renal parenchyma and ureter. The strengths and limitations of all available imaging modalities are reviewed. An optimal approach to the imaging work up is developed with regard to availability, evolving technology and most importantly, cost efficacy. The controversies and conflicts in imaging and treatment options are explored while constructing a step by step approach that will be both flexible and utilitarian for the clinician faced with daily oncologic management choices.

A comparison of clinical course with blood group antigen testing by specific red cell adherence and immunoperoxidase in ureteral and renal pelvic tumors

Specimens of transitional cell carcinoma of the ureter and renal pelvis from 20 patients were tested for blood group antigenicity using immunoperoxidase and specific red cell adherence methods. The results of antigen testing were correlated with tumor stage and grade as well as the subsequent clinical course of the patients. The specific red cell adherence test was negative in 80 per cent and the immunoperoxidase test was negative in 40 per cent of all tumors. Of the 4 patients with positive specific red cell adherence tests 3 had high grade (II to III), invasive tumors as did 7 of 12 with tumors that were positive by immunoperoxidase testing. Blood group antigen testing did not prove helpful in predicting the clinical course of our patients. In addition, a careful review of previously published data does not support the conclusion that blood group antigen testing is a valuable predictor of upper tract tumor aggressiveness.