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

Conditional Intravesical Recurrence-Free Survival Rate After Radical Nephroureterectomy With Bladder Cuff Excision for Upper Tract Urothelial Carcinoma

Background

To evaluate the conditional intravesical recurrence (IVR)–free (IVRF) survival rate in patients with upper tract urothelial carcinoma (UTUC) who had no history of bladder cancer and no concomitant bladder cancer. Hence, we aimed to analyze a relatively large number of patients with UTUC who underwent radical nephroureterectomy with bladder cuff excision (RNUx).

Methods

We retrospectively analyzed the data of 1,095 patients with UTUC who underwent RNUx. Their baseline characteristics, bladder tumor history, and UTUC features were analyzed to evaluate oncological outcomes. To determine the factors affecting IVR, surgical modality, use of preoperative ureteroscopy, TNM stage, and pathological outcomes were evaluated. Multivariable Cox regression analyses were performed to evaluate the factors affecting IVR. Conditional IVRF survival rate was analyzed using Kaplan–Meier curves.

Results

Among the 1,095 patients, 462 patients developed IVR, and the mean time to the development of IVR was 13.08 ± 0.84 months after RNUx. A total of 30.74% of patients with IVR and 15.32% of those without IVR had a history of bladder cancer (p < 0.001). Multivariable analysis showed that a history of bladder cancer, multifocal tumors, use of preoperative ureteroscopy, extravesical bladder cuffing method, lymph node involvement, positive surgical margins, and use of adjuvant chemotherapy were determined to be risk factors for IVR. The conditional IVRF rate was 74.0% at 12 months after RNUx, 87.1% at 24 months after RNUx, 93.6% at 36 months after RNUx, and 97.3% at 60 months after RNUx. The median IVRF survival period was 133.00 months for all patients. In patients with IVRF at 24 months after RNUx, only ureteroscopy was an independent risk factor for IVR [hazard ratio (HR) 1.945, p = 0.040]. In patients with IVRF at ≥36 months, there was no significant factor affecting IVR.

Conclusions

Active IVR assessment is required until 36 months after RNUx. In addition, patient education and regular screening tests, such as urine analysis and cytology, are required for patients with IVRF for ≥36 months.

Effects of Complete Bladder Cuff Removal on Oncological Outcomes Following Radical Nephroureterectomy for Upper Tract Urothelial Carcinoma

Purpose

This study aimed to evaluate the effects of bladder cuff method on oncological outcomes in patients who underwent radical nephroureterectomy (RNU) for upper tract urothelial carcinoma.

Materials and Methods

The records of 1,095 patients treated with RNU performed at our hospital between 1994 and 2018 were retrospectively reviewed; 856 patients with no bladder tumor history were enrolled in the present study. The management of bladder cuff was divided into two categories: extravesical ligation (EL) or transvesical resection (TR). Survival was analyzed using the Kaplan-Meier method and Cox regression analyses were performed to determine which factors were associated with intravesical recurrence (IVR)–free survival (IVRFS), cancer-specific survival (CSS), and overall survival (OS).

Results

The mean patient age was 64.8 years and the median follow-up was 37.7 months. Among the 865 patients, 477 (55.7%) underwent the TR and 379 (44.3%) the EL. Significantly higher IVRFS (p=0.001) and OS (p=0.013) were observed in the TR group. In multivariable analysis, IVR, CSS, and OS were independently associated with the EL. Among 379 patients treated with the EL, eight underwent remnant ureterectomy. Based on radical cystectomy–free survival, significant difference was not observed between the two groups. However, significantly higher IVRFS was observed in the TR group when the tumor was located in the renal pelvis.

Conclusion

Intramural complete excision of the distal ureter during RNU should be the gold standard approach compared with EL for the management of distal ureter in terms of oncological outcomes.

Long-term oncological outcomes of the Agarwal loop-ligation technique for management of the distal ureter during laparoscopic radical nephroureterectomy

OBJECTIVES

To describe the Agarwal loop-ligation technique for the management of the distal ureter during laparoscopic radical nephroureterectomy (LRNU) for upper tract urothelial carcinoma (UTUC) and report on long-term oncological outcomes.

PATIENTS AND METHODS

In the Agarwal loop-ligation technique, the distal ureteric stump is controlled using endoscopic Endoloop^® or PolyLoop^® ligation to ensure en bloc excision of the bladder cuff and prevent spillage of upper tract urine into the perivesical space. A retrospective review of the medical records of 76 patients who underwent the Agarwal loop-ligation technique for UTUC at participating centres from July 2004 to December 2017 was performed. Data collected included demographics, perioperative, and long-term oncological outcomes. Survival was calculated using Kaplan-Meier survival analyses.

RESULTS AND LIMITATIONS

A total of 76 patients were included. The median age was 71.5 years and median operative time was 4.3 h. The intramural ureter and bladder cuff were completely excised in all patients. Distal surgical margins were clear in all, with only two patients found to have tumour extending to the circumferential surgical margin. There were no cases of perivesical recurrence or port-site metastasis. The 5-year bladder, local, and contralateral recurrence-free survival was 59.6%, 89.0% and 93.5%, respectively. Metastasis-free survival at 5-years was 73.5%. The 5-year overall survival and cancer-specific survival rates were 70.3% and 84.7%, respectively.

CONCLUSIONS

We have described the Agarwal loop-ligation technique for the management of the distal ureter in LRNU. This technique complies with oncological principles outlined in the European Association of Urology guidelines, which minimises tumour spillage. Long-term oncological outcomes are satisfactory, with no cases of perivesical recurrence detected in this series.

Assessing the impact of different distal ureter management techniques during radical nephroureterectomy for primary upper urinary tract urothelial carcinoma on oncological outcomes: A systematic review and meta-analysis

OBJECTIVES

To assess the oncological outcomes of several distal ureter management techniques in patients administered with radical nephroureterectomy (RNU) for primary upper urinary tract urothelial carcinoma (UTUC).

METHODS

A systematic search of PubMed, EMBASE, and the Cochrane Library was conducted to identify studies comparing outcomes following RNU under various surgical methods for bladder cuff management. Standard cumulative analyses of hazard ratios (HRs) with 95% confidence intervals (CIs) were performed using Review Manager (5.3).

RESULTS

Nine studies involving 4683 patients were selected based upon eligibility criteria. Meta-analysis of cancer-specific survival (CSS) and overall survival (OS) revealed no significant differences among intravesical incision of the bladder cuff (IVBC), extravesical incision of the bladder cuff (EVBC) and transurethral incision of the bladder cuff (TUBC) techniques. However, the IVBC technique appeared to have better recurrence-free survival (RFS) (HR = 1.37, p < 0.01) and intravesical recurrence-free survival (IRFS) (HR = 1.45, p < 0.01) compared with non-IVBC methods, including both TUBC and EVBC. When studies involving patients with bladder tumour history were excluded, the pooled statistic appeared to confirm that IVBC was associated with improved IRFS (HR = 1.25, p = 0.03) compared with EVBC and TUBC. No significant difference was found between the EVBC and TUBC groups (HR = 1.81, p = 0.32).

CONCLUSIONS

The findings suggest that IVBC is associated with improved oncologic outcomes and that it may be recommended for distal ureter management. However, caution must be taken because this recommendation is based upon a very limited number of clinical studies. Further research with enhanced outcome data collection and improved reporting is required to confirm these findings.

Distal Ureter Management During Nephroureterectomy: Evidence from a Systematic Review and Cumulative Analysis

INTRODUCTION AND OBJECTIVES

Standard of care in upper tract urothelial cancer is nephroureterectomy with bladder cuff excision (BCE). However, alternative techniques such as transurethral incision/resection have been used to simplify distal ureterectomy. The optimum strategy is unclear, and current guidelines do not specify a gold standard technique. The objective of this study was to perform a systematic review of the literature, to compare BCE and transurethral distal ureter methods.

MATERIALS AND METHODS

A Cochrane and PRISMA-guided systematic literature search was conducted on English language articles from January 2000 to present, reporting on centers' experience with either BCE or transurethral distal ureterectomy. A cumulative meta-analysis comparison between the two procedures was performed. Primary outcome was intravesical recurrence. Secondary outcomes were local/distant recurrence, surgical margins, and disease-specific mortality (DSM). Groups were compared using chi-square analysis.

RESULTS

In total, 66 studies were included after excluding 1795. BCE and transurethral groups contained 6130 and 1183 patients, respectively. Mean/median age ranged from 57.5 to 75.2 years, and follow-up from 6.1 to 78 months. Level of evidence was low, with high risk of bias and small sample size (<100 patients) in 41 (62%) and 52 (79%) studies, respectively. Baseline cancer demographic analysis identified significantly higher rates of high grade, advanced stage, node-positive and carcinoma in situ disease in the BCE group. However, intravesical recurrence (23.6% vs 28.7%, p = 0.0002) and local/distant recurrence (17.9% vs 21.6%, p = 0.02) were significantly lower than the transurethral group. No difference was seen regarding surgical margins (3.1% vs 2.4%, p = 0.27) or DSM (16.8% vs 14.3%, p = 0.06).

CONCLUSIONS

No prospective, randomized comparisons exist for distal ureterectomy at nephroureterectomy. In this analysis, patients undergoing BCE had more advanced disease burden compared with the transurethral group. Despite this, the BCE group had statistically lower intravesical and local/distant recurrence. Further prospective research should be encouraged to identify gold standard ureter management.

Laparoscopic nephroureterectomy with laser endoscopic transuretral disinsertion in lateral decubitus: progressive adaptation to retroperitoneocopic approach

BACKGROUND

The ureteral disinsertion with bladder cuff technique continues to evolve. We present the endoscopic laser transurethral technique combined with a transperitoneal and retroperitoneal laparoscopic approach in lateral decubitus, without patient repositioning, for treating urothelial carcinomas of the upper urinary tract.

MATERIALS AND METHODS

We present 3 laparoscopic nephroureterectomies: 1 transperitoneal and 2 retroperitoneal. Disinsertion was performed in lateral decubitus using a flexible cystoscope and a 365-μm holmium laser fiber. The endoscopic technique was progressively adapted to 3-port and single-port retroperitoneoscopic approaches. Before laparoscopic handling of the kidney, ureter was clamped below the tumour. The endoscopic technique was then started. Both approaches were simultaneously employed.

RESULTS

Nephroureterectomies were achieved performing en bloc endoscopic disinsertion of the bladder cuff and ensuring a closed system comparable to open technique. The second case required reconversion due to technical problems and extension of the surgical time. No relapses were diagnosed during follow-up.

CONCLUSION

Results are comparable to open surgery, technique ensured compliance to oncology principles, enabled disinsertion in lateral decubitus and avoid patient repositioning saving surgical time. The results reflect the benefits of minimally invasive surgery in all cases.

Surgical management for upper urinary tract transitional cell carcinoma (UUT-TCC): a systematic review

Surgical management of upper urinary tract transitional cell carcinoma (UUT-TCC) has significantly changed over the past two decades. Data for several new surgical techniques, including nephron-sparing surgery (NSS), is emerging. The study systematically reviewed the literature comparing (randomised and observational studies) surgical and oncological outcomes for various surgical techniques MEDLINE, EMBASE, Cochrane Library, CINAHL, British Nursing Index, AMED, LILACS, Web of Science, Scopus, Biosis, TRIP, Biomed Central, Dissertation Abstracts, ISI proceedings, and PubMed were searched to identify suitable studies. Data were extracted from each identified paper independently by two reviewers (B.R. and B.S.) and cross checked by a senior member of the team. The data analysis was performed using the Cochrane software Review manager version 5. Comparable data from each study was combined in a meta-analysis where possible. For dichotomous data, odds ratios with 95% confidence intervals (CIs) were estimated based on the fixed-effects model and according to an intention-to-treat analysis. If the data available were deemed not suitable for a meta-analysis it was described in a narrative fashion. One randomised control trial (RCT) and 19 observational studies comparing open nephroureterectomy (ONU) and laparoscopic NU (LNU) were identified. The RCT reported the LNU group to have statistically significantly less blood loss (104 vs 430 mL, P < 0.001) and mean time to discharge (2.30 vs 3.65 days, P < 0.001) than the ONU group. At a median follow-up of 44 months, the overall 5-year cancer-specific survival (CSS; 89.9 vs 79.8%) and 5-year metastasis-free survival rates (77.4 vs 72.5%) for the ONU were better than for LNU, respectively, although not statistically significant. A meta-analysis of the observational studies favoured LNU group for lower urinary recurrence (P < 0.001) and distant metastasis. The meta-analyses for local recurrence for the two groups were comparable. One retrospective study comparing ONU with a percutaneous approach for grade 2 disease reported no significant differences in CSS rates (53.8 vs 53.3 months). Three retrospective studies compared NSS and radical NU, and reported no significant differences in overall CSS and recurrence-free survival between the two approaches. Five retrospective studies compared various techniques of en bloc excision of the lower ureter. No technique was reported to be better (operative and oncological) than any other. This review concludes that there is a paucity of good quality evidence for the various surgical approaches for UUT-TCC. The techniques have been assessed and reported in many retrospective single-centre studies favouring LNU for better perioperative outcomes and comparable oncological safety. The reported observational studies data is further supported by one RCT.

Upper urinary tract urothelial cell carcinoma: location as a predictive factor for concomitant bladder carcinoma

OBJECTIVE

To investigate the existence of predictive factors for concomitant, primary UUT-UCC and BC. Upper urinary tract urothelial cell carcinoma (UUT-UCC) is a pan-urothelial disease of the transitional epithelial cells. Although several studies have shown the association of bladder recurrence following UUT-UCC, little is known on the incidence of concomitant UUT-UCC and bladder cancer (BC) without previous BC.

MATERIALS AND METHODS

A retrospective review of 673 patients diagnosed and treated for UUT-UCC was performed. Patients with history of BC were excluded. We investigated age, sex, location of the upper tract tumor (calyx, renal pelvis, upper ureter, mid-ureter, lower ureter), multifocality, clinical symptoms, tumor grade and pathological stage. Contingency tables and chi-square test were used for categorical variables and analysis of variance (ANOVA) for quantitative variables.

RESULTS

450 patients eligible for inclusion were identified. Of these, 76 (17 %) presented concomitant primary UUT-UCC and BC. Location of primary UUT-UCC was in calyx and/or renal pelvis in 25 patients (34 %), upper ureter 8 (11 %) and lower ureter 37 (49 %). In 6 patients (8 %), data were missing. Concomitant BC was found in 10, 18, and 33 % of patients with primary caliceal/renal pelvis, upper ureter and lower ureter UUT-UCC, respectively. On multivariate analysis, location of UUT-UCC was the only predictive factor for concomitant bladder tumor (OR: 1.7; 95 % CI, 1.007-2.906 p = 0.047).

CONCLUSIONS

Our findings suggest that the possibility of concomitant BC in primary diagnosed patient with UUT-UCC is as high as 33 % and mainly depends on upper tract tumor location.

Surgical management for upper urinary tract transitional cell carcinoma

BACKGROUND

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

OBJECTIVES

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

SEARCH STRATEGY

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

SELECTION CRITERIA

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

DATA COLLECTION AND ANALYSIS

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

MAIN RESULTS

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

AUTHORS' CONCLUSIONS

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

Does the surgical technique for management of the distal ureter influence the outcome after nephroureterectomy?

Study Type - Therapy (case series) Level of Evidence 4 What's known on the subject? and What does the study add? The resection of the distal ureter and its orifice is an oncological principle during radical nephroureterectomy which is based on the fact that it represents a part of the urinary tract exposed to a considerable risk of recurrence. After removal of the proximal part it is hardly possible to image or approach it by endoscopy during follow-up. Recent publications on survival after nephroureterectomy do not allow the conclusion that removal of distal ureter and bladder cuff are useless. Several techniques of distal ureter removal have been described but they are not equivalent in term of oncological safety. • The standard treatment of upper urinary tract urothelial carcinomas (UUT-UCs) must obey oncological principles, which consist of a complete en bloc resection of the kidney and the ureter, as well as excision of a bladder cuff to avoid tumour seeding. • The open technique is the 'gold standard' of treatment to which all other techniques developed are necessarily compared, and various surgical procedures have been described. • The laparoscopic stapling technique maintains a closed system but risks leaving behind the ureteric and bladder cuff segments. • Transvesical laparoscopic detachment and ligation is a valid approach from an oncological stance but is technically difficult. The major inconvenience of the transurethral resection of the ureteric orifice and intussusception techniques is the potential for tumour seeding. • Management of the distal ureter via the robot-assisted laparoscopic method is technically feasible, but outcomes from these procedures are still preliminary. • Therefore, prospective comparative studies with more thorough explorations of these techniques are needed to solve the dilemma of the management of the distal ureter during nephroureterectomy. However, bladder cuff excision should remain the standard of care irrespective of the stage of the disease.

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.

[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.

Comparative outcomes following endoscopic ureteral detachment and formal bladder cuff excision in open nephroureterectomy for upper urinary tract transitional cell carcinoma

PURPOSE

The introduction of laparoscopic nephroureterectomy highlights the need for the critical appraisal of approaches to the distal ureter at surgery for upper tract transitional cell carcinoma. We compared differences after endoscopic ureteral detachment and open bladder cuff excision in nephroureterectomy.

MATERIALS AND METHODS

A total of 138 patients underwent open nephroureterectomy for upper urinary tract transitional cell carcinoma from 1982 to 2005 with a median followup of 43 months. Of these patients 90 underwent endoscopic ureteral detachment and 48 underwent bladder cuff excision. Demographic, perioperative and oncological outcome data were collected in all cases. Statistical analyses were performed using the Student t test, chi-square and log rank tests, and logistic and Cox regression.

RESULTS

Mean operative duration was significantly lower in the endoscopic detachment group than in the bladder cuff group (p <0.01). There were 49 (54.4%) bladder recurrences in the endoscopic detachment group, of which 8 (16.3%) were muscle invasive and 3 (3.3%) developed at the resection site. There were 23 (47.9%) bladder recurrences in the bladder cuff group, of which 3 (13.0%) were muscle invasive and 2 (4.2%) developed at the resection site. All 5 resection site tumors occurred after excision of muscle invasive distal ureteral tumors and 4 of these had positive margins. There were no differences in recurrence-free survival or disease specific survival between the groups. Operation subtype did not predict oncological outcome on univariate or multivariate analysis.

CONCLUSIONS

Endoscopic ureteral detachment reduces operative duration and is associated with equivalent oncological outcomes compared with open bladder cuff excision in nephroureterectomy. Caution should be exercised in patients with low ureteral tumors.

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.

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Transitional-Cell Carcinoma Recurrence Rate after Nephroureterectomy in Patients Who Undergo Open Excision of Bladder Cuff v Transurethral Incision of the Ureteral Orifice

BACKGROUND AND PURPOSE

The gold standard treatment for upper-tract transitional-cell carcinoma is radical nephroureterectomy, but management of the distal ureter is not standardized. Two treatment options to detach the distal ureter are open cystotomy (OC) and excision of a bladder cuff or transurethral incision of the ureteral orifice (TUIUO). We compared the clinico-pathologic outcomes of these two techniques.

PATIENTS AND METHODS

Hospital records were reviewed on all 51 patients who had undergone open or laparoscopic nephroureterectomy at our institution between 1 January 1990 and 30 June 2005. Patient demographics, intraoperative parameters, and pathology data were collected. The mean follow-up was 23.2 months (range 4.5-75 months) and 22.1 months (range 1-50 months) for the OC and TUIUO groups, respectively. There were no significant differences in sex, age at operation, American Society Anesthesiologists risk score, previous transitional-cell tumors, pathologic tumor grade and stage, or metastatic disease status in the two groups.

RESULTS

Five patients had an unplanned incomplete ureterectomy. The bladder recurrence rates were similar in the OC group (22.2%; 6/27) and the TUIUO group (26.3%; 5/19). There were no pelvic recurrences in either group. Four of the five patients who had an incomplete ureterectomy had tumor recurrences, three in the form of metastatic disease.

CONCLUSION

Management of the distal ureter by TUIUO in appropriate patients offers the same rate of bladder recurrence as OC. Incomplete ureterectomy results in a significantly higher rate of recurrence, often associated with the development of metastatic disease.

[Bladder neoplasm after nephroureterectomy for upper urinary tract tumor. Does distal ureter surgery influx on the evolution?]

OBJECTIVE

To compare evolution in patients with urothelial upper tract tumor (UUTT) in whom we performed the classic open approach to the distal ureter with those in whom whe performed the endoscopic approach. We study the bladder recurrences in each group and the factors which may influx on the evolution.

MATERIAL AND METHODS

Retrospective review of nephroureterectomies in our department in the last 20 years. Group A (n:24): double incision (lumbar and pelvic incision), Group B (n:29): endoscopical approach of the distal ureter and classic lumbar incision. A descriptive study is first performed in which we review: sex, and patients age, background transuretral resection of bladder tumor (TURBT), UUTT side, and UUTT location (calices, pelvis or urether). Pathological stage and tumor grade are also exposed. Secondly, a review of the bladder recurrences in each group is performed. In order to find differences between de groups we used the Fisher's Exact test.

RESULTS

We observed that in terms of bladder recurrence there is a statistically significant difference between the two groups favoring Group B (p < 0.036), which means that there are less bladder recidives when perform endoscopic approach of distal ureter. Noneless due to the groups inhomogeneity in tumor stage, grade, and location, this differences seem to be associated to these sigues, more than to the approach to the ureter as an independant variable. In that concerning to the eventual relationship between bladder recidive and background of previous TURBT, we have not found any differences between the two groups but there are statystically significant difference in the global series. The small number of recurrences (13) does not allow us to establish a well based conclusion on this issue, but it seems that the background of previous TURBT is an important factor that may influx in posterior bladder recurrences.

CONCLUSIONS

In our results, endoscopic approach of distal ureter in nephroureterectomy for UUTT does seems to positively influx in the posterior chance of bladder recurrences. But the studied sample is small and the two groups have not been aleatorized because of ethical reasons. May the low number of cases affect the test's statistical potency. It seems that previous TURBT may conditionate these recurrences, as we show in global serie. It should be necessary a prospective and statistically analised multicenter trial to understand if distal ureter approach influx on the evolution of these tumors.

[Radical laparoscopic nephroureterectomy]

As with the increasingly common presence of laparoscopic surgery in renal adenocarcinoma, the same situation is also occurring with radical management of tumours of the upper urothelium. In this type of clinical condition, it is important to emphasize the different ways to mobilise the distal ureter (with transuretral resection or unroofing, pure laparoscopy, or open), and to take into account that this tumour has the highest risk of implantation at the ports of entry. Here, we conduct a literature review and up-date of the different approaches to the distal urethra.

Upper Urinary Tract Cancer: Location is Correlated with Prognosis

OBJECTIVES

Evaluate prognostic information of anatomical location in patients with upper tract transitional cell carcinoma (UTTCC).

METHODS

Retrospective analysis of 149 upper tract transitional cell carcinoma (UTTCC) patients from a single institute treated surgically between 1988 and 2003.

RESULTS

Transmural tumor growth (pT3 or pT4) was less common in distally located tumors (33%) compared to mid (44%), proximal ureter (75%) or pyelum tumors (41%). Tumor stage was the best predictor of disease specific survival. Distally located tumors had a significantly better survival than proximally located cancers (median survival 53 months versus 16 months for tumors in the proximal ureter). Bladder cancer was found in 73 (49%) patients. Invasive UTTCC were less likely to be associated bladder cancer (RR 0.66, 95%CI 0.43-0.98). In a multivariate analysis both tumor stage and location in the upper tract were predictive of disease specific survival after UTTCC diagnosis.

CONCLUSION

Tumor location in the proximal upper tract predicts stage-independent poor prognosis in patients with UTTCC.

Laparoscopic nephroureterectomy for upper urinary tract transitional cell carcinoma: is it better than open surgery?

OBJECTIVE

In 1991, laparoscopic nephroureterectomy has been introduced as a treatment option for upper tract transitional cell carcinoma. Based on the review of the current literature and personal experience we want to analyze the actual results of this technique in comparison to open surgery.

MATERIALS AND METHODS

We performed a MEDLINE/PubMed search and reviewed the literature on laparoscopic and open nephroureterectomy between 1991 and 2004 (n = 1365 patients) including the results of 45 patients who underwent either laparoscopic (n = 23) or open nephroureterectomy (n = 21) during the same period of time at the Klinikum Heilbronn. Demographic, perioperative and follow-up data were compared.

RESULTS

The analysis revealed a slightly longer OR-time (276.6 vs. 220.1 min), and significantly lower blood loss (240.9 vs. 462.9 ml) in the laparoscopic series. No differences of minor (12.9 vs. 14.1%) or major complication rate (5.6 vs. 8.3%) were observed. All nine comparative studies revealed a significant dose reduction of the morphine-equivalents after laparoscopy. In all ten comparative series the hospital stay was shorter after laparoscopy, but only in 6 series the difference was statistically significant. The frequency of bladder recurrence (24.0 vs. 24.7%), local recurrence (4.4 vs. 6.3%), and distant metastases (15.5% vs. 15.2) did not differ significantly in both groups. The actual disease-free two-year survival rates (75.2 vs. 76.2%) were similar. The five-year survival rates averaged 81.2% in the three laparoscopic (n = 113 pat.) and 61% in the ten open series (n = 681 pat.) Six port site metastases were reported in 377 (1.6%) analyzed patients occurring 3 to 12 months following laparoscopy.

CONCLUSION

Open radical nephroureterectomy still represents the golden standard for the management of upper tract transitional cell carcinoma, however, laparoscopic radical nephroureterectomy offers the advantages of minimally invasive surgery without deteriorating the oncological outcome. In case of advanced tumors (pT3,N+) open surgery is still recommended.

Bladder Tumor Recurrence after Primary Surgery for Transitional Cell Carcinoma of the Upper Urinary Tract

OBJECTIVE

Primary transitional cell carcinoma (TCC) of the upper urinary tract represents 6-8% of all TCC cases. Nephroureterectomy with removal of a bladder cuff is the treatment of choice. The rates of TCC recurrence in the bladder after primary upper urinary tract surgery described in the literature range between 12.5 and 37.5%. In a retrospective analysis we examined the occurrence of TCC after nephroureterectomy for upper tract TCC in patients without a previous history of bladder TCC at the time of surgery.

METHODS

Between 1990 and 2002, 29 patients underwent primary nephroureterectomy for upper tract TCC. The mean age of the patients was 69.5 years. In 5 cases upper urinary tract tumors were multilocular, in the remaining cases unilocular in the renal pelvis (n=12) or the ureter (n=12). The follow-up was available for 29 patients with a mean follow-up of 3.37 (0.1-11.2) years.

RESULTS

11/29 (37.9%) patients had TCC recurrence with 9/11 patients having bladder TCC diagnosed within 2.5 years (0.9-6.0) after nephroureterectomy. 13/29 patients are alive without TCC recurrence, 3/29 patients died due to systemic TCC progression and 5/29 died of unrelated causes without evidence of TCC recurrence.

CONCLUSION

Our data indicate a high incidence of bladder TCC after nephroureterectomy for primary upper tract TCC of up to 6 years after primary surgery. Because of the high incidence of bladder TCC within the first 3 years of surgery, careful follow-up is needed over at least this period.

Stripping technique for endoscopic management of distal ureter during nephroureterectomy: Experience of 32 procedures

OBJECTIVES

To assess the results of the stripping technique for endoscopic management of the distal ureter during nephroureterectomy.

METHODS

Since 1995, 32 patients have undergone open nephroureterectomy involving stripping of the distal ureter for upper urinary tract carcinoma. After endoscopic placement of a Chevassu ureteral catheter, nephrectomy was performed using a lumbotomy approach. The catheter tip was tied to the top of the ureteral extremity. At the end of the intervention, the catheter was pulled out transurethrally to intussuscept the distal ureter. Endoscopic resection through the bladder muscular wall was performed around the everted ureteral orifice, then the distal ureter was stripped and removed with a bladder cuff.

RESULTS

The mean operative time was 180 minutes, and the mean blood loss was 220 mL. The stripping failed in 6 patients (18.7%), requiring an iliac incision. The reasons for failure were a retained ureter in 5 cases and ureteral breakage in 1 case. The mean duration of urethral catheterization was 5 days, and the mean hospital stay was 8 days. The complication rate was 3.1%. At a median follow-up of 35.2 months, 9 patients (28.1%) had experienced recurrence: 6 with superficial bladder tumors, 2 with renal fossa recurrence, and 1 with asynchronous liver metastases. The disease-specific mortality rate was 9.4%.

CONCLUSIONS

These results confirm that the stripping technique for endoscopic management of the distal ureter during open nephroureterectomy is a simple and safe procedure.

Tumores de urotelio superior

OBJECTIVE

To evaluate diagnostic techniques, treatment and follow-up in 94 patients affected of upper urinary tract tumor.

PATIENTS AND METHOD

From 1978 to december 2002 we operated 105 patients due to upper urinary tract tumor, although only 94 are valid for analysis. Mean age was 65 years and 85% were man. Haematuria was the most frequent symptom.

RESULTS

Urography (93%), ecography (77%) and CT (67%) were the most used diagnostic techniques. Pelvic tumor was the most frequent (71%) and total nephroureterectomy including bladder cuff the chosen treatment (76.4%). Previous or simultaneous bladder tumor was observed in 23% cases and delayed in 30%. With a mean follow-up of 76 months the patient survival is 53%.

CONCLUSIONS

Due to the high frequence of previous, simultaneous or delayed bladder tumors, the upper urinary tract tumor should be considered as a panurothelial disease, worsening the outcome of this kind of tumors.