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

Oncologic results of nephron sparing endoscopic approach for upper tract low grade transitional cell carcinoma in comparison to nephroureterectomy - a case control study

Background

There is paucity of data as to the results of the endoscopic approach in comparison to the golden standard of nephro-ureterectomy in elective, low grade TCC, patients. Our purpose is to report our results of a nephron sparing approach compared to nephro-ureterectomy in those patients.

Methods

From a retrospective data base we identified 25 patients and 23 patients who underwent a nephron sparing ureterosocpic resection and nephro-reterectomy for low grade UT-TCC, respectively. The endoscopic technique included endoscopic tumor biopsy followed by primary resection and/or fulguration. The nephron sparing group was followed by bi-annual ureteroscopy and upper tract imaging, timely cystoscopy and urine cytology collection. Data for overall and disease related mortality, bladder and ureteral TCC recurrence and renal function are reported in both groups.

Results

Median follow - up time was 26 months. 11 (44%) patients developed bladder recurrence at a median period of 9 months after initial ureteroscopy, compared to 9 (39%) in the NUx group (P < 0.05). Recurrent ureteral low grade TCC was observed in 9 patients (median: 9 months). All were treated endoscopicaly successfully. Renal function remained stable in the nephron sparing group. No disease related mortality was recorded in the nephron-sparing group while one patient died of his disease following NUx.

Conclusions

Disease related mortality following a nephron sparing endoscopic approach or nephroureterectomy for low grade upper tract TCC is excellent. However, the nephron sparing approach is associated with a relatively high rate of ureteral and bladder recurrence. Therefore, a stringent follow-up protocol is required.

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.

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.

Robot-Assisted Laparoscopic Distal Ureterectomy and Ureteral Reimplantation with Psoas Hitch

For midureteral and distal-ureteral tumors not amenable to endoscopic resection, distal ureterectomy with ureteral reimplantation is a treatment option. When ureteral length is insufficient for direct reimplantation, additional length can be gained with either a psoas hitch or a Boari flap. We describe our technique for robot-assisted laparoscopic distal ureterectomy and ureteral reimplantation with psoas hitch.

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.

Surveillance and management of recurrence for upper tract transitional cell carcinoma

Surveillance of treated upper tract TCC must be tailored to each patient based on individual tumor characteristics. Important risk factors include tumor stage, grade, and multifocality. Molecular markers for TCC may assist in future surveillance strategies, but for now remain experimental. Improvements in imaging eventually may provide the sensitivity needed to determine tumor stage, which would make both initial and recurrence management decisions much more accurate. Initial surgical treatment will influence surveillance when it pertains to superficial disease treated conservatively with either open segmental resection or, now more commonly, with endoscopic resection. Patients treated in this manner require vigilant surveillance of the ipsilateral ureter. Direct visualization in combination with cytology currently appears to be the most effective method, using the same timelines as those used for bladder TCC. Prospective studies concerning surveillance protocols for upper tract TCC would certainly provide more evidence for the current recommendations. However, the evidence does show that upper tract TCC behaves biologically much in the same fashion as does bladder TCC. In light of this fact, the current recommendations are meant to suggest following a patient after treatment for upper tract TCC in a manner similar to that used to follow a patient after treatment of bladder TCC, with individual strategies based on tumor characteristics. For superficial disease, the technology now exists to moniter a patient after endoscopic resection of an upper tract tumor in exactly the same manner used to follow a patient after endoscopic resection of a bladder tumor.