Nephroureterectomy: Rationale in the Management of Transitional Cell Carcinoma of the Upper Urinary Tract

Significant predictors of contralateral upper tract recurrence after radical nephroureterectomy for upper tract urothelial carcinoma

OBJECTIVES

To investigate the significant predictors of contralateral upper tract recurrence after radical nephroureterectomy for upper tract urothelial carcinoma.

METHODS

Between January 2001 and December 2015, 548 patients with upper tract urothelial carcinoma who underwent radical nephroureterectomy in a single institution were included in this retrospective cohort study. Several clinicopathological characteristics and outcomes were explored. The crucial end-point was the diagnosis of contralateral upper tract recurrence after radical nephroureterectomy.

RESULTS

Of the 548 patients, the median age was 68 years (range 24-93 years), and the median follow-up time after radical nephroureterectomy was 41 months (range 8-191 months). Contralateral upper tract recurrence occurred in 28 patients (5.1%). The median time period between radical nephroureterectomy and contralateral upper tract recurrence was 15.4 months (range 3.4-52.4 months). In the multivariate analysis, preoperative estimated glomerular filtration rate <30 mL/min/1.73 m² (hazard ratio 3.08, P = 0.003) and tumor multifocality (hazard ratio 2.16, P = 0.043) were independent risk factors.

CONCLUSION

Preoperative estimated glomerular filtration rate <30 and tumor multifocality are significant predictors of contralateral upper tract recurrence after radical nephroureterectomy for upper tract urothelial carcinoma.

Marital status does not affect the cancer-specific survival of patients with upper tract urothelial carcinoma treated with nephroureterectomy: a propensity score matching study

Background:

The purpose of this study was to investigate the relationship between marital status and the prognosis of patients with upper tract urothelial carcinoma (UTUC) treated with nephroureterectomy (NU).

Methods:

Patients with UTUC who received NU treatment were identified from the Surveillance, Epidemiology, and End Results (SEER) database between 2004 and 2015. Kaplan–Meier curves and Cox regression were used to analyze the effect of marital status on cancer-specific survival (CSS), and 1:1 propensity score matching (PSM) was performed for married and unmarried patients to explore further the effect of marital status on patients with UTUC.

Results:

Among 1565 eligible patients, 960 (61.3%) were married and 605 (38.7%) were unmarried, of which 146 (9.3%) were divorced/separated, 306 (19.6%) were widowed, and 153 (9.8%) were single. Multivariate Cox regression analysis showed that marital status was not an independent risk factor for patients with UTUC treated with NU. After stratification by grade and SEER stage, multivariate analysis showed that there was no significant difference in 5-year CSS between divorced/separated, widowed, and single patients compared with married patients in different grades and SEER stages. In addition, after PSM analysis, marital status was still not an independent risk factor for patients with UTUC treated with NU.

Conclusion:

For patients with UTUC treated with NU, marital status has no prognostic effect on CSS.

Risk factors and survival outcomes of metachronous contralateral upper tract urothelial carcinoma

Because population-based risk estimates for metachronous contralateral UTUC are lacking. In this study, we aimed to evaluate the risk and survival of metachronous contralateral upper tract urothelial carcinoma (UTUC) on a large population-based level. A total of 23,075 patients were identified from the Surveillance, Epidemiology, and End Results database (1973–2015), 144 (0.6%) patients developed metachronous contralateral UTUC (median of 32 months after diagnosis). The cumulative incidence at 10, 20, and 30 years of follow-up was 1.1%, 1.6%, and 2.6%, respectively. We applied Fine and Gray’s competing risk regression model to determine the risk factors of a new contralateral, metachronous UTUC. The competing risk regression model demonstrated that older age (hazard ratio [HR] 0.75; 95% CI 0.67–0.85) and larger tumor size (HR 0.61; 95% CI 0.39–0.97) were associated with a significantly decreased risk of metachronous contralateral UTUC. However, bladder cancer presence was an independent risk factor for the development of contralateral tumors (HR 2.42; 95% CI 1.73–3.37). In addition, we demonstrated developing contralateral UTUC was not associated with poor prognosis by using Kaplan–Meier and multivariable analysis. Our findings suggest that metachronous contralateral UTUC is comparatively rare, and has not impact on survival. Importantly, patients with younger age, small tumours, and the presence of bladder cancer were more likely to develop a contralateral tumor, which may provide a rationale for lifelong surveillance in high-risk patients.

An Unusual Case of Three Synchronous Tumors in a Young Woman

The occurrence in the same young patient of three synchronous tumors deriving from different embryogenic tissues and without a clear correlation with a common etiopathogenic factor is very unusual. We report a case of a Caucasian woman submitted to wide resection of a large retroperitoneal liposarcoma and right radical nephrectomy for suspected tumor infiltration. Histological examination of the right ureter and renal pelvis showed the presence of a multifocal urothelial carcinoma that was clinically asymptomatic. Two months later, during follow-up, chest X-ray and computed tomography documented a coin lesion of the upper left lung, confirmed by positron emission tomography. This nodule was surgically removed and examined histologically, resulting in a diagnosis of sclerosing hemangioma. The patient is alive without evidence of recurrent disease.

Comparison of clinicopathologic characteristics, epigenetic biomarkers and prognosis between renal pelvic and ureteral tumors in upper tract urothelial carcinoma

Background

There's no consensus about the difference between renal pelvic and ureteral tumors in terms of clinical features, pathological outcomes, epigenetic biomarkers and prognosis.

Methods

The data of 341 patients with renal pelvic tumors and 271 patients with ureteral tumors who underwent radical nephroureterectomy between 1999 and 2011 were retrospectively reviewed. The clinicopathologic features, gene promoters methylation status and oncologic outcomes were compared. Regression analysis was performed to identify oncologic prognosticators.

Results

Patients with ureteral tumors were relatively older (p = 0.002), and had higher likelihood of pre-operative renal insufficiency (p < 0.001), hypertension (p = 0.038) and hydronephrosis (P < 0.001), while in patients with renal pelvic tumors gross hematuria was more prevalent (p < 0.001). Renal pelvic tumors tended to exhibit non-organ-confined disease (p = 0.004) and larger tumor diameter (p = 0.001), while ureteral tumors had a higher likelihood of exhibiting high grade (p < 0.001) and sessile architecture (p = 0.023). Hypermethylated gene promoters were significantly more prevalent in renal pelvic tumors (p < 0.001), specifically for TMEFF2, GDF15, RASSF1A, SALL3 and ABCC6 (all p < 0.05). Tumor location failed to independently predict cancer-specific survival, overall survival, intravesical or contralateral recurrence (all p > 0.05), while gene methylation status was demonstrated to be an independent prognostic factor.

Conclusion

Renal pelvic tumors and ureteral tumors exhibited significant differences in clinicopathologic characteristics and epigenetic biomarkers. Gene promoter methylation might be an important mechanism in explaining distinct tumor patterns and behaviors in UTUC.

CT of Carcinoma of the Renal Pelvis

CT in 28 histologically proven carcinomas of the renal pelvis (pTa-2, n = 12; pT3–4, n = 16) in 26 patients was evaluated retrospectively. Twenty-four of 28 tumors could be identified at CT, 17/28 at urography, and 12/14 at retrograde pyelography. Nineteen tumors appeared as a discrete intrapelvic mass with an attenuation close to that of the kidney on noncontrast scans. There was slight to moderate enhancement of the tumors following i.v. contrast medium injection but they appeared hypodense relative to the renal parenchyma. Five tumors caused only a diffuse obliteration of the renal sinus. Criteria to define peripelvic tumor growth are proposed, i.e. tumors obliterating fat planes or abutting of renal parenchyma should not be regarded as signs of extrapelvic extension, while inhomogeneous attenuation of peripelvic fat and renal parenchyma (in the absence of other explanation) should, or if the tumor mass is seen interdigitizing with surrounding structures. Thickening of Gerota's fascia or septa in the perirenal space are unspecific findings. With CT we were able to differentiate tumors confined to the renal pelvic wall from those with more advanced disease including metastases in 22 of 26 patients.

A systematic review and meta-analysis of oncological and renal function outcomes obtained after segmental ureterectomy versus radical nephroureterectomy for upper tract urothelial carcinoma

OBJECTIVE

To perform a systematic review and meta-analysis of the comparative studies reporting oncological and renal function outcomes of segmental ureterectomy (SU) versus radical nephroureterectomy (RNU) for upper tract urothelial carcinomas (UTUC).

MATERIALS AND METHODS

A literature search on Pubmed, Embase, and the Cochrane library was conducted according to the PRISMA guidelines, and a meta-analysis was performed to assess cancer-specific survival (CSS), overall survival (OS), recurrence-free survival (RFS), intravesical recurrence free survival (IVRFS) and surgery-related variations in estimated glomerular filtration rate (eGFR).

RESULTS

A total of 11 retrospective studies with 3963 patients who underwent either SU (n = 983; 24.8%) or RNU (n = 2980; 75.2%) were included. Although patients treated with SU were more likely to be diagnosed with favorable pathological features, the meta-analysis of unadjusted data revealed no significant difference between both groups in terms of CSS (HR 0.90, p = 0.33) and OS (HR 0.98, p = 0.93). Accordingly, the meta-analysis of adjusted data confirmed equivalent CSS (HR = 0.90, p = 0.47) between SU and RNU. Similarly, no significant difference was found in terms of RFS (HR 1.06, p = 0.72) and IVRFS (HR 1.35, p = 0.39). However, a significant decreased risk of impaired renal function was observed after SU when compared to RNU (mean eGFR difference = 9.32 ml/1.73 m², p = 0.007).

CONCLUSION

Although adverse patient and tumor characteristics were not equally balanced between treatment arms, our systematic review and meta-analysis supports similar oncological outcomes between SU and RNU, with better preservation of renal function after SU. As such, SU should be preferably used as the first-line treatment for low-risk ureter tumors, while considered for selected cases of high-risk disease.

Laparoscopic nephroureterectomy for upper tract urothelial carcinoma - Update

Upper urinary tract urothelial carcinomas (UTUCs) are uncommon and account for only 5%-10% of urothelial carcinomas. Pyelocaliceal tumors are about twice as common as ureteral tumors. Sixty percent of UTUCs are invasive at diagnosis. Radical nephroureterectomy, including the excision of the distal ureter and bladder cuff is standard of care for treatment of localized UTUCs, because of the high potential for recurrence, multifocality, and progression. Since first laparoscopic nephroureterectomy (LNU) was introduced by Clayman et al. in 1991 and improvement of laparoscopic technique and equipment, LNU has been reported to be equivalent to conventional open method. We reviewed the current literature of patients with UTUCs treated by LNU focusing on technical aspects, peri-operative and oncological outcomes. Laparoscopic radical nephroureterectomy offers the advantages of minimally invasive surgery without deteriorating the oncological outcome for treatment of UTUCs. Indications tend to increase as operator skills increase. Indications for laparoscopic or open nephroureterectomy are in principle the same. The basic requirement for laparoscopic surgery in UTUCs is to achieve benefits of minimal invasive surgery and maintain oncologic principles.

Predictive role of preoperative hydronephrosis on poor pathological outcomes and prognosis in upper tract urothelial carcinoma patients: Experience from a nationwide high-volume center in China

To validate the predictive value of preoperative hydronephrosis (HN) with regard to clinicopathological outcome and prognosis in a large cohort of upper tract urothelial carcinoma (UTUC) patients, a retrospective analysis was conducted using the clinicopathological data of 520 consecutive patients treated between 2000 and 2010 at a nationwide high-volume center in China. Preoperative computed tomography or magnetic resonance imaging scans were evaluated for the presence of ipsilateral HN, and the associations between HN and pathological outcomes, patient survival and urinary tract recurrences were assessed. Ipsilateral HN was present in 271 patients (52.1%). Preoperative HN was associated with advanced age (P=0.007), sessile tumor architecture (P<0.001), ureteral location (P<0.001), higher tumor stage (P<0.001) and higher histological grade (P=0.002). Univariate and multivariate analyses revealed that poorer cancer-specific survival (CSS) and overall survival (OS) times were correlated with preoperative HN (P=0.004 and P=0.009, respectively). The 5-year CSS and OS rates for patients with HN were 86.9 and 86.2%, respectively, compared to 93.3 and 91.9% for patients without HN. For patients with muscle-invasive disease, HN remained a risk factor for poor CSS and OS (P=0.009 and P=0.012, respectively). No association was identified between HN and bladder recurrence (P=0.552) or the development of contralateral upper tract carcinoma (P=0.164). The findings indicated that preoperative HN is prevalent in UTUC. The presence of preoperative HN predicted poorer pathological outcomes and was a significant risk factor affecting survival. The evaluation of HN may be informative for decisions concerning surgical options, and the presence of HN should raise the possibility of employing an aggressive treatment approach.

Contralateral upper tract urothelial carcinoma after nephroureterectomy: the predictive role of DNA methylation

Background

Aberrant methylation of genes is one of the most common epigenetic modifications involved in the development of urothelial carcinoma. However, it is unknown the predictive role of methylation to contralateral new upper tract urothelial carcinoma (UTUC) after radical nephroureterectomy (RNU). We retrospectively investigated the predictive role of DNA methylation and other clinicopathological factors in the contralateral upper tract urothelial carcinoma (UTUC) recurrence after radical nephroureterectomy (RNU) in a large single-center cohort of patients.

Methods

In a retrospective design, methylation of 10 genes was analyzed on tumor specimens belonging to 664 consecutive patients treated by RNU for primary UTUC. Median follow-up was 48 mo (range: 3–144 mo). Gene methylation was accessed by methylation-sensitive polymerase chain reaction, and we calculated the methylation index (MI), a reflection of the extent of methylation. The log-rank test and Cox regression were used to identify the predictor of contralateral UTUC recurrence.

Results

Thirty (4.5%) patients developed a subsequent contralateral UTUC after a median follow-up time of 27.5 (range: 2–139) months. Promoter methylation for at least one gene promoter locus was present in 88.9% of UTUC. Fewer methylation and lower MI (P = 0.001) were seen in the tumors with contralateral UTUC recurrence than the tumors without contralateral recurrence. High MI (P = 0.007) was significantly correlated with poor cancer-specific survival. Multivariate analysis indicated that unmethylated RASSF1A (P = 0.039), lack of bladder recurrence prior to contralateral UTUC (P = 0.009), history of renal transplantation (P < 0.001), and preoperative renal insufficiency (P = 0.002) are independent risk factors for contralateral UTUC recurrence after RNU.

Conclusions

Our data suggest a potential role of DNA methylation in predicting contralateral UTUC recurrence after RNU. Such information could help identify patients at high risk of new contralateral UTUC recurrence after RNU who need close surveillance during follow up.

Nomogram predicting renal insufficiency after nephroureterectomy for upper tract urothelial carcinoma in the Chinese population: exclusion of ineligible candidates for adjuvant chemotherapy

OBJECTIVES

To report the decline of renal function after radical nephroureterectomy (RNU) in upper tract urothelial carcinoma (UTUC) patients and to develop a nomogram to predict ineligibility for cisplatin-based adjuvant chemotherapy (AC).

METHODS

We retrospectively analyzed 606 consecutive Chinese UTUC patients treated by RNU from 2000 to 2010. We chose an eGFR of 60 and 45 ml/min/1.73 m(2) as cut-offs for full-dose and reduced-dose AC eligibility.

RESULTS

Median eGFR for all patients before and after surgery was 64 and 49 ml/min/1.73 m(2) (P < 0.001). The proportion of patients ineligible to receive full-dose and reduced-dose AC changed from 42% to 74% and from 20% to 38.1%. Older age (OR = 1.007), preoperative eGFR (OR = 0.993), absence of hydronephrosis (OR = 0.801), smaller tumor size (OR = 0.962), and tumor without multifocality (OR = 0.876) were predictive for ineligibility for full-dose AC. Preoperative eGFR (OR = 0.991), absence of hydronephrosis (OR = 0.881), tumor located in renal pelvis (OR = 1.164), and smaller tumor size (OR = 0.969) could predict ineligibility for reduced-dose AC. The c-index of the two models was 0.757 and 0.836. Postoperative renal function was not associated with worse survival.

CONCLUSIONS

Older age, lower preoperative eGFR, smaller tumor size, tumor located in renal pelvis, and absence of hydronephrosis or multifocality were predictors of postoperative renal insufficiency.

Degree of hydronephrosis predicts adverse pathological features and worse oncologic outcomes in patients with high-grade urothelial carcinoma of the upper urinary tract

OBJECTIVE

To evaluate degree of hydronephrosis (HN) as a surrogate for adverse pathological features and oncologic outcomes in patients with high-grade (HG) and low-grade (LG) upper tract urothelial carcinomas (UTUCs).

METHODS

We retrospectively reviewed 141 patients with localized UTUCs that underwent extirpative surgery at a tertiary referral center. Preoperative imaging was used to evaluate presence and degree of ipsilateral HN. We evaluated degree of HN (none/mild vs. moderate/severe), pathological findings, and oncologic outcomes.

RESULTS

HG UTUC was present in 113 (80%) patients, muscle-invasive disease (≥pT2) in 49 (35%), and non-organ-confined disease (≥pT3) in 41 (29%). At a median follow-up of 34 months, 49 (35%) patients experienced intravesical recurrence, 28 (20%) developed local/systemic recurrence, and 24 (17%) died of UTUC. HN was graded as none/mild in 77 (55%) patients and moderate/severe in 64 (45%). In patients with HG UTUC, but not LG, degree of HN was associated with advanced pathological stage (P<0.001), positive lymph nodes (P = 0.01), local/systemic recurrence-free survival (hazard ratio [HR] = 5.5, P = 0.02), and cancer-specific survival (HR = 5.2, P = 0.02). On multivariable analysis of preoperative factors, degree of HN in patients with HG UTUC was associated with muscle invasion (HR = 9.3; 95% CI: 3.08-28.32; P<0.001), non-organ-confined disease (HR = 4.5; 95% CI: 1.66-12.06; P = 0.003), local/systemic recurrence-free survival (HR = 2.5; 95% CI: 1.07-5.64; P = 0.04), and cancer-specific survival (HR = 2.6; 95% CI: 1.05-6.22; P = 0.04).

CONCLUSIONS

Degree of HN can serve as a surrogate for advanced disease and predict worse oncologic outcomes in HG UTUC. Degree of HN was not predictive of intravesical or local/systemic recurrence in LG UTUC.

Risk factors and treatment outcomes of new contralateral upper urinary urothelial carcinoma after nephroureterectomy: the experiences of a large Chinese center

OBJECTIVE

To explore the risk factors and treatment outcomes of contralateral new upper tract urothelial carcinoma (UTUC) after nephroureterectomy in a large single-center cohort of UTUC patients.

METHODS

A retrospective analysis of the clinicopathological data of 509 consecutive patients treated by nephroureterectomy from 2000 to 2010 at a high-volume center in China was conducted.

RESULTS

Thirty-five patients (6.9%) were found to develop contralateral UTUC. Gross hematuria was a common symptom, and aristolochic acid (AA) containing Chinese herbs was identified as an underlying cause. In multivariate analysis, renal transplant recipients (HR = 16.507) and preoperative renal insufficiency (HR = 2.523) were independent risk factors. No correlation was found in the clinical and pathological characteristics of primary and subsequent contralateral UTUC. A second round of nephroureterectomy should be performed on renal transplant patients, whereas patients who are older, exhibit relatively better renal function, and have tumors that are single, located in the ureter and small size could be treated with nephron-sparing surgery. No survival difference was detected between the two treatment groups, and developing contralateral UTUC was not associated with worse survival.

CONCLUSION

Contralateral UTUC is comparatively rare, and gross hematuria is a common symptom. Renal transplant history and renal insufficiency are independent risk factors, and prophylactic contralateral nephroureterectomy is considered for uremic UTUC patients with proper renal replacement treatment or renal transplant recipients. These features are likely related to the mechanisms of multifocality of UTUC, and the potential correlation with AA remains to be elucidated. Tumor characteristics and renal function are informative for the decisions concerning surgical options for contralateral UTUC.

Pattern and risk factors of intravesical recurrence after nephroureterectomy for upper tract urothelial carcinoma: a large Chinese center experience

BACKGROUND/PURPOSE

There is currently no consensus about the pattern and risk factors of bladder recurrence after nephroureterectomy, especially in the Chinese population. We evaluated the pattern and risk factors based on data from a large Chinese center.

METHODS

The clinical and pathological data of 438 patients with upper tract urothelial carcinoma (UTUC), who underwent nephroureterectomy at Peking University First Hospital, Beijing, China between 2000 and 2010, was retrospectively analyzed. Univariate analysis by log-rank test and multivariate analysis by Cox proportional hazards regression model were used to determine the independent risk factors.

RESULTS

A total of 135 patients (30.8%) developed intravesical recurrence within a median follow-up of 45 months (range: 12-144 months). The median interval of bladder recurrence was 15 months (range: 2.0-98.0 months), and the two peaks for recurrence were 4-6 months and 17-19 months. Lower tumor grade, tumor multifocality, concomitant carcinoma in situ (CIS) and tumors located in the lower ureter were significant risk factors by univariate and multivariate analysis. A risk-scoring system was developed and a significant difference was found between different risk evaluations. Patients with concomitant CIS tended to develop a late bladder recurrence. One hundred and eighteen patients (87.4%) received transurethral resection after bladder tumor recurrence.

CONCLUSION

Lower tumor grade, tumor multifocality, concomitant CIS and tumors located in the lower ureter tend to be predictive for bladder recurrence after nephroureterectomy, although the underlying mechanism is not fully elucidated, and the scoring system could help risk stratification. Most recurrent tumors could be treated by transurethral resection and there were two peaks for recurrence, which is probably related to the mechanisms and may be unique to the Chinese population.

Robot-assisted reconstructive surgery for ureteral malignancy: analysis of efficacy and oncologic outcomes

BACKGROUND AND PURPOSE

There have been previous reports of the use of robotic technology for the surgical treatment of ureteral neoplasms such as transitional-cell carcinoma. These have lacked long-term follow-up, been isolated cases, or focused on only the distal ureter. This investigation examines a series of mid and distal ureteral neoplasms managed with surgeon controlled robotic techniques at a tertiary care medical center. We present perioperative data and long-term follow-up, with emphasis on oncologic outcomes.

PATIENTS AND METHODS

This series includes six consecutive patients who have undergone robot-assisted surgical extirpation of mid and distal ureteral malignancies since 2008. Four patients underwent robot-assisted distal ureterectomy with ureteroneocystostomy, and two underwent midureter segmental excision with ureteroureterostomy. Patient demographics, intraoperative data, final pathology results, and oncologic follow-up were reviewed retrospectively.

RESULTS

Total mean operative time was 268.5 minutes, including the cystoscopy and change of position component of the procedure; mean estimated blood loss was 72.5 mL, and the mean length of stay was 1.8 days. All four patients who underwent distal ureterectomy also had excisions of the ipsilateral bladder cuff-three needed a psoas hitch to facilitate the ureteroneocystostomy. Final pathology results revealed four cases of transitional-cell carcinoma, one case of ureteral carcinoma in situ, and one case of non-Hodgkin diffuse-type B-cell lymphoma. The only complication was a small hydrocele in one patient. All patients underwent standard surveillance protocol, with a recurrence in the bladder developing in one patient. Ureteral obstruction did not develop in any patient postoperatively. Mean length of follow-up was 33 months.

CONCLUSIONS

Robot-assisted surgery is well suited for the complex reconstruction of the mid and distal ureter after excision of low-grade malignant lesions. This series demonstrates that this surgical approach offers excellent intermediate-term oncologic outcomes with preservation of ipsilateral renal function. We believe that robotic surgery may be considered as a first-line option for the minimally invasive excision and reconstruction of low-grade, localized ureteral malignancy in selected patients at centers with experienced teams.

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.

Small endoscopic biopsies of the ureter and renal pelvis: pathologic pitfalls

Technical advances in endoscopic equipment have led to increased ureteroscopic biopsies of the upper urinary tract, resulting in limited biopsy material. We retrospectively reviewed 76 consecutive mid-upper ureter and renal pelvis biopsies submitted for consultation from January 2004 to January 2009, where follow-up was obtainable. There were 49 (64.5%) males and 27 (35.5%) females. Thirty-nine (51.3%) of the biopsies were from the ureter with the remaining 37 (48.7%) from the renal pelvis. The mean age was 70 years for males and 71 for females (range: 24 to 89). At consultation, the most common diagnoses were benign urothelium (n=25, 32.9%); atypical (n=17, 22.4%); low-grade noninvasive papillary urothelial carcinoma (n=10, 13.2%); and high-grade noninvasive papillary urothelial carcinoma (n=8, 10.5%). In cases where a definitive diagnosis could not be reached on expert review, it was mainly because of the limited size of the biopsy, absence of papillary fronds, crush artifact, and distorted architecture. There were 7 major discrepancies between the outside and second opinion diagnosis, where all of the cases were initially diagnosed as an urothelial neoplasm, yet was non-neoplastic upon review. Strips of urothelium without well-developed fibrovascular cores, polypoid ureteritis/pyelitis, and reactive urothelium mimicked urothelial neoplasms. In 5 of these 7 cases, there was no gross lesion suspicious of a tumor present according to the urologist. Overall, 33 of the 44 (75%) cases with a mass noted by the urologist or by radiography was found to have a neoplasm at follow-up. Conversely, 24 of the 32 (75%) cases without a grossly suspected tumor had no neoplasm at follow-up. The association between the histologic presence of a neoplasm at follow-up and the presence of a clinically suspected tumor was highly significant (P<0.0001). Pathologists need to recognize that in almost 1 of the 4 renal pelvic/ureteral biopsies a definitive diagnosis cannot be made because of the inadequate tissue. Caution must be exercised in the evaluation of these limited specimens, especially in the absence of a clinically suspected tumor.

[Predictive factors of metachronous bladder neoplasm after nephroureterectomy]

PURPOSE

To determine prognostic factors of bladder recurrence in patients with upper urinary tract (UUT) urothelial carcinoma, who underwent nephroureterectomy.

MATERIAL AND METHODS

Patients (N = 51) with UUT transitional cell carcinoma who underwent nephroureterectomy. A retrospective and prospective observational cohort study was made during the period 1995-2007, at Arquitecto Marcide Hospital, Ferrol Health Area, La Coruña. Differences between groups with and without recurrence were analized by means of chi-squared test in qualitative variables and t-Student and U Mann-Whitney test in quantitative variables. Kaplan-Meier methodology was used in order to predict bladder recurrence free survival (BRFS), developing a multivariate Cox regression model to identify variables related to bladder recurrence.

RESULTS

Mean age of patients was 68.51 +/- 12.11 (24-86). Histological grade distribution was as follows: 7 G1 (13.72%), 20 G2 (39.21%), 23 G3 (45.10%) and 1 undetermined case (1.97%). With regard to pT category, 19 cases were pT1 (37.25%), 12 pT2 (23.53%), 19 pT3 (37.25%) y 1 case undetermined (1.97%). Bladder recurrence was detected in 16 patients during follow-up (31.37%). 70.59% of recurrences were identified during first two years of follow-up. Differences related to follow-up period, presence of obstructive uropathy, microscopic growth pattern and tumour multifocality, were observed between patients without and with bladder recurrence. BRFS rates at 1, 2, 5 and 10 years were 85.10%, 67.90%, 56.60% y 31.80%, respectively. BRFS was significantly modified by tumour location (p = 0.019) and tumour multifocality (p = 0.002). Multivariate analysis showed that tumour multifocality was an independent factor in the prediction of bladder recurrence (RR = 7.35; 95% CI = 1.57-34.45; p = 0.011).

CONCLUSIONS

The development of bladder recurrence after nephroureterectomy was observed in 31.37% of patients in our study, detecting most of events during the first two years of follow-up. Tumour multifocality in UUT constitutes the most important risk factor for the development of bladder recurrence.

Lymphovascular invasion predicts poor outcome of urothelial carcinoma of renal pelvis after nephroureterectomy

OBJECTIVE

To evaluate the significance of lymphovascular invasion (LVI) to predict cancer-specific survival (CSS) in patients with renal pelvic urothelial carcinoma (UC).

PATIENTS AND METHODS

In all, 76 patients with primary renal pelvic UC were treated by nephroureterectomy (NU). Inclusion criteria included nonmetastatic renal pelvic UC with no previous history of bladder cancer, concomitant ureteric lesion, or neoadjuvant chemotherapy. Age, gender, adrenalectomized or not, pathological T stage, grade, and LVI were examined by univariate and multivariate analyses to determine which were independent risk factors.

RESULTS

In all, 38 men and 38 women were included with a mean (range) age of 66 (41-93) years. The median (range) follow-up was 48 (15-88) months. At follow-up, eight cancer-related deaths (10.5%) were censored, and 66 patients (85.9%) were alive and disease-free. LVI was the only significant predictor of CSS in the univariate and multivariate analyses.

CONCLUSIONS

Adrenal metastases from primary renal pelvic UCs were rare. The present results suggest that ipsilateral adrenalectomy is not necessary during radical NU for treating patients with renal pelvic UCs. LVI appears to be a better prognostic factor for predicting poor outcome of renal pelvic UC than pT stage or tumour grade when using the current tumour-nodes-metastases staging system.

CKD as a risk factor for bladder recurrence after nephroureterectomy for upper urinary tract urothelial carcinoma

BACKGROUND

The aim of this study is to examine chronic kidney disease (CKD) as a risk factor for bladder recurrence and cancer-specific and total mortality in a cohort of patients with upper urinary tract (UUT) urothelial carcinoma (UC) treated by means of nephroureterectomy.

STUDY DESIGN

Cohort study.

SETTINGS & PARTICIPANTS

150 patients with primary UC of the ureter or renal pelvis treated by means of nephroureterectomy at a single center.

PREDICTOR

Presence and severity of CKD according to preoperative markers of kidney damage, estimated glomerular filtration rate calculated using the Modification of Diet in Renal Disease Study equation, and other covariates.

OUTCOMES & MEASUREMENTS

Subsequent bladder recurrences, cancer-specific survival, and overall survival.

RESULTS

Of 150 patients, 37 (25%) had no CKD, 71 patients (47%) had CKD stages 1 to 4, and 42 patients (28%) had CKD stage 5. 41 (27%) and 31 patients (21%) reported exposure to herbal medicine or tobacco use, respectively. During a mean follow-up of 4 years, 53 patients (35%) developed bladder recurrence and 27 (18%) died, of whom 14 (9.3%) died of cancer. Overall 5-year bladder recurrence-free and cancer-specific survival rates were 62% and 89%, respectively (n = 150). Risks of bladder recurrence were 2.43 (95% confidence interval, 1.00 to 5.93) and 3.95 (95% confidence interval, 1.59 to 9.80), greater in patients with CKD stages 1 to 4 and CKD stage 5 compared with patients without CKD, respectively. Ureteral involvement of the primary tumor (hazard ratio, 1.97; 95% confidence interval, 1.12 to 3.48) also was associated significantly with an increased rate of bladder recurrence. The risk of death from all causes or UC was not significantly greater in patients with CKD stages 1 to 4 or CKD stage 5 compared with those without CKD. Higher tumor stage (pT2 to 4) was associated significantly with overall death (hazard ratio, 5.15; 95% confidence interval, 1.84 to 14.48).

LIMITATIONS

A retrospective study in an area of high incidence of both UUT-UC and CKD.

CONCLUSIONS

Advancing CKD stage of patients and positive ureteral involvement of the primary tumor (especially in the lower ureter) are associated with greater risk of subsequent bladder recurrence in patients with UUT-UC treated by means of radical surgery.

Impact of the extent of regional lymphadenectomy on the survival of patients with urothelial carcinoma of the upper urinary tract

PURPOSE

We determined the impact of the extent of regional lymphadenectomy on survival in patients with urothelial carcinoma of the upper urinary tract.

MATERIALS AND METHODS

Between January 1989 and January 2006, 169 patients with nonmetastatic urothelial carcinoma of the upper urinary tract underwent curative surgery. We previously reported the primary sites of nodal metastases in urothelial carcinoma of the upper urinary tract. Nodal sites where the incidence of metastases was 30% or more were considered regional lymph nodes. When all primary sites were resected, this was considered complete lymphadenectomy. Regional lymphadenectomy without the removal of all primary sites was considered incomplete lymphadenectomy. We retrospectively analyzed the influence of the extent of lymphadenectomy on patient survival.

RESULTS

A total of 45 patients (26.6%) underwent complete lymphadenectomy. Lymphadenectomy was performed in an additional 36 patients (21.3%) but it was incomplete. Lymphadenectomy was not performed in 88 patients. Cancer specific survival did not significantly differ between the groups when all patients were analyzed. However, patient survival significantly depended on the extent of lymphadenectomy when we focused on patients with T stage pT3 or higher. Patient survival was likely to improve when the number of lymph nodes removed increased. Multivariate analysis showed that complete lymphadenectomy was a significant prognostic factor for cancer specific survival (p = 0.009) as well as T stage (pT3 or less p = 0.0004) and tumor grade (G3 p = 0.0001).

CONCLUSIONS

Although further investigation is required to make a definite conclusion, the extent of lymphadenectomy may significantly influence its therapeutic effect, especially for patients with advanced disease.

Primary site and incidence of lymph node metastases in urothelial carcinoma of upper urinary tract

OBJECTIVES

To determine the primary site and incidence of lymph node metastases in urothelial carcinoma of the upper urinary tract.

METHODS

From January 1989 to October 2005, we treated 181 patients with urothelial carcinoma of the upper urinary tract. The findings of the imaging studies when lymph node metastasis was diagnosed and the pathologic examination findings of the nodal specimens were analyzed. If multiple nodal metastases were present, the largest lymph node was considered the primary site.

RESULTS

Of the 181 patients, 42 (23.2%) had nodal involvement. Lymphatic metastasis was confirmed pathologically in 23 patients and 19 were clinically considered to have nodal metastasis without pathologic diagnosis because these patients died of the disease with deterioration of nodal involvement during follow-up. In tumors of the right renal pelvis, the primary metastatic sites were the right renal hilar, paracaval, and retrocaval nodes. Tumors of the upper two thirds of the right ureter primarily metastasized to the retrocaval and inter-aortocaval nodes. In tumors of the left renal pelvis, the primary sites were the left renal hilar and para-aortic nodes. Tumors of the upper two thirds of the left ureter primarily metastasized to the para-aortic nodes. Tumors of the lower ureter primarily metastasized inferiorly to the aortic bifurcation.

CONCLUSIONS

Lymphadenectomy for urothelial carcinoma of the right renal pelvis and upper two thirds of the ureter should include a relatively wide area, compared with regional lymph nodes conventionally addressed, encompassing the paracaval, retrocaval, and inter-aortocaval nodes.

[Conservative treatment of upper urinary tract tumors]

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

Laparoscopic Nephroureterectomy with Bladder-Cuff Resection: Techniques and Outcomes

Advancements in minimally invasive instrumentation and technique have provided the impetus to performing urologic procedures with reduced perioperative morbidity, shorter hospital stays, and, most importantly, efficacious oncologic results. At multiple centers of excellence, laparoscopic nephroureterectomy (LNU) has evolved into a new standard for the management of upper-tract transitional-cell carcinoma (TCC) that is not amenable to endoscopic resection. An LNU may be performed via a transperitoneal or retroperitoneal approach together with excision of the distal ureter and a bladder cuff. Analysis of present-day studies comparing LNU with open techniques demonstrates equivalent oncologic outcomes. In addition, those patients undergoing LNU fare better than their counterparts having open surgery with respect to hospital stay, analgesic requirements, and convalescence. With multiple options for excision of a cuff of bladder, a consensus has not been established. However, LNU has emerged as the new standard of care for the treatment of upper- tract TCC. Review of the techniques and outcomes of LNU from the minimally invasive urology community are described.

Outcomes of hand-assisted laparoscopic nephroureterectomy for managing upper urinary tract transitional cell carcinoma—China Medical University Hospital experience

OBJECTIVES

To report our experience with hand-assisted laparoscopic nephroureterectomy (HALNU) to treat upper urinary tract transitional cell carcinoma (TCC). In addition, we report the treatment of 4 patients with upper urinary tract TCC and synchronous superficial urinary bladder TCC by HALNU and simultaneous transurethral resection of bladder tumor (TURBT).

METHODS

We retrospectively reviewed 33 patients who had undergone HALNU. Recovery was evaluated according to the Eastern Cooperative Oncology Group performance status. Four patients had concomitant superficial urinary bladder cancer and underwent simultaneous TURBT at the beginning of surgery. We compared our data with those of our open surgery group and previously published data.

RESULTS

Partial recovery had occurred by 1 week and complete recovery by 4 weeks postoperatively. Conversion to open surgery was required in 2 (6%) of the 33 patients. The complication rate was 24% (8 of 33) without any mortality. The recurrence rate of urinary bladder TCC was 6% (2 of 33). Both patients with recurrent tumor were treated successfully by TURBT and bacille Calmette-Guérin instillation. All 4 patients with synchronous superficial urinary bladder TCC had undergone simultaneous transurethral resection of bladder tumor, and all 4 were disease free at the last follow-up visit.

CONCLUSIONS

Hand-assisted procedures are appropriate for surgeons with limited experience with laparoscopic surgery. In our study, the convalescence of patients was excellent, and the postoperative results were compatible with those of previous studies. To treat upper urinary tract TCC with synchronous urinary bladder TCC, HALNU and TURBT together seems to be a safe and efficient technique.

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.

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

OBJECTIVES

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

METHODS

Review of the literature using Medline.

RESULTS

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

CONCLUSIONS

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

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.

Evolving management of upper-tract transitional-cell carcinoma at a tertiary-care center

BACKGROUND AND PURPOSE

Traditional management of upper-tract transitional-cell carcinoma (TCC) has been open nephroureterectomy. Minimally invasive options, including laparoscopic and endoscopic techniques, are being applied with increasing frequency, however. To assess the impact of these techniques on the current management of upper-tract TCC, we reviewed our experience managing this problem over the last 3 years.

PATIENTS AND METHODS

Since January 1998, 84 patients underwent definitive management of upper-tract TCC using open, laparoscopic, or endoscopic techniques. This study group includes 57 men and 27 women with a mean age of 69.9 years.

RESULTS

Fifty-three patients (63.9%) were treated by laparoscopic nephroureterectomy. Twelve patients (14.5%) were treated endoscopically, with percutaneous resection in 7 patients and ureteroscopic resection in 5 patients. The indications for nephron-sparing management in these 12 patients included solitary kidneys in 6 patients, significant comorbidities in 4 patients, and bilateral disease in 1 patient. Endoscopic management was elective in one patient. Nineteen patients (22.9%) underwent open surgical procedures consisting of nephroureterectomy in 16 patients and distal ureterectomy with reimplantation in 3 patients.

CONCLUSIONS

Advances in laparoscopy and endourology are significantly impacting the definitive management of upper-tract TCC. Patients with a normal contralateral kidney are currently offered laparoscopic nephroureterectomy, while those with an absent or functionally compromised contralateral kidney are generally managed with endoscopic resection. Although minimally invasive techniques have demonstrated advantages regarding postoperative pain, hospital stay, and return to regular activities, only critical long-term follow-up regarding rates of local and distant recurrence will determine the ultimate role of these techniques.

Totally endoscopic management of upper tract transitional-cell carcinoma

BACKGROUND AND PURPOSE

Nephron-sparing therapy arose spurred by efforts to delay dialysis for patients with renal insufficiency or solitary kidneys. As technology has improved, complete endoscopic ablation of tumor via the holmium and Nd:YAG lasers has proven efficacious for cancer control. We have extended ureteroscopic treatment to patients with normal contralateral kidneys given the proper indications. For required extirpative therapy in cases of uncontrolled cancer, laparoscopic nephroureterectomy is rapidly becoming popular and appears to lend the same tumor control as open surgery while significantly lessening morbidity. We reviewed our experience with endourologic treatment and propose an algorithm for the management of upper tract TCC.

PATIENTS AND METHODS

Over the period from August 1998 to May 2000, 70 patients underwent ureteroscopic evaluation, treatment, or both for TCC. During the same period, 24 patients had a hand-assisted laparoscopic nephroureterectomy (HALNU) performed. A thorough chart review was performed to determine pathologic data and management decision-making.

RESULTS

Of the 70 patients evaluated ureteroscopically, 46 were examined for the first time, while the remaining 24 patients were already on the surveillance protocol. Of the 46 initially evaluated patients, 18 were referred for HALNU. Fifteen other patients were placed on surveillance. Of the 24 patients already on surveillance, only 1 required HALNU. The most common reasons for nephroureterectomy were bulky tumors that were ureteroscopically unresectable, high-grade disease, and patient preference.

CONCLUSIONS

The combination of ureteroscopy and laparoscopy has made the management of upper tract TCC totally endoscopic, providing decreased morbidity while maintaining cancer control.

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.

Percutaneous endoscopic management of urothelial tumors of the renal pelvis

Although nephroureterectomy remains the reference standard for the treatment of transitional cell cancer of the renal pelvis, advances in technology and techniques have made percutaneous management of select lesions feasible. We report our technique of staged percutaneous resection of a large renal pelvic transitional cell cancer.

Laparoscopic nephroureterectomy for the treatment of transitional cell carcinoma of the upper urinary tract

OBJECTIVES

To establish the safety and efficacy of laparoscopic and laparoscopic-assisted nephroureterectomy.

METHODS

Since 1993, 25 patients with a minimum of 12 months of follow-up underwent nephroureterectomy using a total laparoscopic or laparoscopic-assisted technique. Four patients had specimen morcellation for tissue removal. All patients had regular follow-up with physical examinations, interval cystoscopy, and radiographs, depending on the metastatic potential of the tumor. Retrospective chart review was performed and assessed for operative time, blood loss, tumor pathologic stage, complications, and outcome. One patient was excluded because of an open conversion due to multiple previous abdominal surgeries and failure to progress.

RESULTS

The mean operating time was 329 minutes but decreased with experience. The median hospital stay was 4 days. Tumor stage was directly related to tumor grade. Associated bladder tumors (prior history or recurrent tumors) occurred in 50% of the patients. Ipsilateral ureteral stump site recurrence occurred in 1 patient. Although no port site seeding occurred, 1 patient, whose tumor was discovered histologically after laparoscopic pyeloplasty for presumed benign disease, developed recurrence in the renal fossa and metastatic disease. Two patients developed liver metastasis.

CONCLUSIONS

Total laparoscopic and laparoscopic-assisted nephroureterectomy are acceptable alternatives to open surgery in the treatment of transitional cell carcinoma of the upper urinary tract. Tumor morcellation did not appear to adversely affect patient outcome. As with open nephroureterectomy, tumor grade is the most important prognostic indicator of local, bladder, and metastatic recurrence. No port site seeding was observed in either the total laparoscopic or laparoscopic-assisted groups.

Prospective comparison between hand-assisted laparoscopic and open surgical nephroureterectomy for urothelial cell carcinoma

OBJECTIVES

To prospectively compare open surgical and the new hand-assisted approach to laparoscopic nephroureterectomy for urothelial cell carcinoma. Previous retrospective studies have suggested that standard laparoscopic nephroureterectomy provides a briefer convalescence than open surgical nephroureterectomy.

METHODS

Between March 1997 and September 1999, 16 hand-assisted laparoscopic and 11 open surgical nephroureterectomies were performed, without randomization. Validated questionnaires were prospectively administered preoperatively and 2 and 6 weeks postoperatively.

RESULTS

The operative time was longer with the laparoscopic approach (320 versus 199 minutes, P <0.001), but the hospital stay was shorter (3.9 versus 5.2 days, P = 0.03). Patient recovery favored the laparoscopic group with regard to time to drive (17.1 versus 37.7 days), time to normal, nonstrenuous activity (18.2 versus 38.1 days), and the mental component score of the SF-12 survey at 6 weeks (57.1 versus 43.0) (P <0.05 for all). Minor complications occurred in 19% of the laparoscopic and 45% of the open surgical procedures; major complications occurred in 19% of laparoscopic and 27% of open surgical procedures (P >0.1 for both). Cancer control was similar between both groups. The mean operating room cost was 56% more for the laparoscopic group (P <0.001), but the overall hospital cost was only 8% greater (P >0.3).

CONCLUSIONS

Hand-assisted laparoscopic nephroureterectomy is a safe and effective alternative to an open surgical approach. Indexes of patient recovery suggest that patient convalescence is less than after an open surgical nephroureterectomy. Increased operative costs may be offset by a shorter hospital stay and fewer complications, resulting in similar overall hospital costs.

Laparoscopic radical nephroureterectomy

Because of the high rate of ipsilateral multifocal disease and the low incidence of contralateral disease, upper tract transitional-cell carcinoma has historically been treated with radical nephroureterectomy. This operation has been performed laparoscopically in many medical centers, with various techniques. The difficult concept has always been handling of the distal ureter and bladder cuff. A technique involving transvesical laparoscopy-assisted transurethral dissection with low pressure that mimics the open procedure is used at the Cleveland Clinic. The reported mean operative times range from 2.6 to 8.3 hours, with the longest time being reported from one of the earliest series. Although the cost of laparoscopic nephroureterctomy is higher than that of the open procedure by about 24%, this figure does not include the societal costs of the longer convalescence after the latter operation. Longer follow-up will be required to learn whether the laparoscopic method is as effective from an oncologic standpoint as open surgery.

Primary percutaneous approach to upper urinary tract transitional cell carcinoma

The optimal approach to upper tract TCC remains to be redefined. A routine nephroureterectomy for every filling defect in the upper urinary system, even in the case of a normal contralateral kidney, constitutes an unnecessary mutilation in more than two thirds of the cases. Nephroureterectomy does not reduce the need for a long-term cystoscopic follow-up because of the high rate of bladder tumor recurrence that may happen years later after nephroureterectomy. Relying solely on radiography and cytology, lacking sensitivity and specificity, to recommend a nephroureterectomy is against the principles of oncologic surgery, especially now that preoperative histologic proof is easy to obtain endoscopically without compromising cancer control. Ureteroscopy, rigid and flexible, provides a complete assessment of the upper urinary system. Biopsy specimens taken with ureteroscopy may be sufficient for grading but less adequate for staging of the tumor. The authors reserve ureteroscopy for ureteral tumors and small (< 1.5 cm) single tumors of the renal pelvis. They approach large or multiple tumors of the renal pelvis percutaneously, in which a full histologic assessment is possible along with a complete resection of the tumor. The decision on the therapeutic approach is made only after the final pathologic report is reviewed. Grade I and grade II superficial disease (Ta, T1) can be treated endoscopically with minimal morbidity and with an efficiency comparable with the standard more invasive nephroureterectomy (Table 5). The indications for endourologic treatment in these cases can be extended safely beyond a solitary kidney or a high surgical risk to include any healthy individual with a normal contralateral kidney who is willing to commit to a rigorous lifelong follow-up. Patients with grade II T1 lesions require a more vigilant follow-up. For grade III Ta disease, more caution should be exercised in selecting these patients for elective endourologic management. When criteria of good prognosis are found, such as absence of carcinoma in situ, presence of diploidy, low p53 expression and a single-tumor, endoscopic management can be offered [table: see text] with a closer follow-up and resorting always to immediate nephroureterectomy at the first evidence of upstaging. Because of the high incidence of recurrence and progression, elective endourologic management for grade III T1 tumors is not recommended. Endoscopic conservative surgery still can be offered in the cases of a solitary kidney or chronic renal insufficiency or for poor surgical candidates. Patients with localized stages (T2, T3) TCC should be offered immediate nephroureterectomy. The authors do not expect adequate endoscopic extirpation with muscle invasive tumors. Although the tissue removed may include deep layers, deep resection is precluded by the thin renal pelvic wall and the associated risk for perforation. Patients with more extensive disease (T3, T4) have a bad prognosis regardless of the form of therapy. Achieving local control percutaneously while preserving as many nephrons as possible for the future chemotherapy can be a reasonable option.

Prognostic significance of p27Kip1 and Ki-67 expression in carcinoma of the renal pelvis and ureter

OBJECTIVE

To determine the significance of p27(Kip1) (p27) for tumour behaviour and prognosis of patients with transitional cell carcinoma (TCC) of the renal pelvis and ureter.

PATIENTS AND METHODS

Using immunohistochemical staining, the relationship was evaluated between p27 protein level (low < 50%, high > 50%) and the Ki-67 labelling index (low < 30%, high > 30%) and clinicopathological features of 37 consecutive Japanese patients with TCC of the renal pelvis and ureter.

RESULTS

Low levels of p27 correlated with higher tumour stage (P < 0.05) and positive lymph node metastases (P < 0.05). There was no significant association between p27 staining and the grade and tumour proliferation as assessed by the Ki-67 index. A high Ki-67 index correlated with higher grade and stage (P < 0.05). Kaplan-Meier plots of survival rate in patients with low or high p27 staining showed that low levels correlated with a shorter disease-free and overall survival (P < 0.001 and P < 0.01, respectively). Similarly, patients with a high Ki-67 index had lower disease-free and overall survival than those with a low Ki-67 index (P < 0.01 and P < 0.05, respectively). The Cox proportional hazards model showed that a low level of p27 was an independent predictor of a shorter disease-free (P < 0.01) and overall survival (P < 0.05) on univariate analysis, but not of overall survival on multivariate analysis. A high Ki-67 index was an independent prognostic marker for shorter disease-free survival on univariate and multivariate analysis (P < 0.01) and for overall survival on multivariate analysis (P < 0.05). In those with a high Ki-67 index, increased p27 staining was associated with a better prognosis than decreased staining for disease-free and overall survival (log-rank test, P < 0. 01 and P < 0.05, respectively).

CONCLUSIONS

The finding that a low level of p27 is associated with tumour invasion and unfavourable prognosis indicates that p27 may be a useful prognostic marker for survival in upper urinary tract cancer.