Ureteroscopic Treatment of Pelvic Renal Tumor in a Solitary Kidney with Orthotopic Neobladder

Experience with 45 Consecutive Patients with Neobladders Undergoing Retrograde Ureteroscopy for Upper Tract Abnormalities

Introduction

In this study we reviewed the feasibility, technique, complications and outcomes of retrograde ureteroscopy in patients with orthotopic neobladders.

Methods

We retrospectively reviewed our retrograde ureteroscopic experience in patients with orthotopic ileal neobladder diversions. Data were collected and analyzed regarding patient characteristics, indications, technique, success and complications of the procedure.

Results

Between 1995 and 2013, 45 patients with neobladders underwent 77 retrograde ureteroscopy sessions on 97 renal units for filling defects (47 cases), urothelial thickening (9), calculi (4), positive cytology (27) and/or positive fluorescence in situ hybridization (15) on followup. The ureter and renal pelvis were successfully instrumented in 78 of 97 units (80.4%), with 85.3% success in Hautmann-type neobladders (75 renal units attempted), 50% in Studer-type neobladders (8 renal units attempted) and 71.4% in unascertained-type neobladders (14 renal units attempted). Causes of failure involved the inability to locate the ureteral orifice (8 cases), to cannulate the orifice (6 cases) or to advance the ureteroscope due to tortuosity (5 cases). Among the successful attempts with appropriately documented findings 35.9% of cases with filling defects (39) were confirmed malignant and 61.5% were confirmed benign by ureteroscopy. All cases with a positive cytology (23) and 85.7% of cases with positive fluorescence in situ hybridization (14) were confirmed malignant by retrograde ureteroscopy, and 2 of the 4 cases of calculi were successfully managed retrogradely.

Conclusions

Retrograde ureteroscopic evaluation of upper tract abnormalities is feasible and practical in patients with orthotopic neobladders. Identification and cannulation of the ureteral orifice are challenging, particularly in tortuous situations, but difficulties can be overcome with fluoroscopic techniques. Retrograde ureteroscopy avoids the morbidity of percutaneous access with minimal complications.

Endourologic management of upper tract transitional cell carcinoma following cystectomy and urinary diversion

Traditionally, nephroureterectomy is the gold standard therapy for upper tract recurrence of transitional cell carcinoma (TCC) following cystectomy and urinary diversion. With advances in endoscopic equipment and improvements in technique, conservative endourologic management via a retrograde or antegrade approach is technically feasible with acceptable outcomes in patients with bilateral disease, solitary renal units, chronic renal insufficiency, or significant medical comorbidities. Contemporary studies have expanded the utility of these techniques to include low-grade, low-volume disease in patients with a normal contralateral kidney. The aim of this report is to review the current outcomes of conservative management for upper tract disease and discuss its application and relevance in patients following cystectomy with lower urinary tract reconstruction.