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Sarmah PB, Ehsanullah SA, Sarmah BD. Long-term follow-up and outcomes of percutaneous nephron-sparing surgery for upper tract urothelial carcinoma. Indian J Urol 2020; 36:276-281. [PMID: 33376263 PMCID: PMC7759167 DOI: 10.4103/iju.iju_93_20] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2020] [Revised: 06/18/2020] [Accepted: 07/16/2020] [Indexed: 11/04/2022] Open
Abstract
Introduction Upper tract urothelial carcinoma (UTUC) is uncommon, accounting for 5%-10% of all urothelial carcinomas. Current standard of care for localized disease consists of radical nephroureterectomy (RNU) which leads to loss of half the patient's functioning nephrons. Percutaneous nephron-sparing surgery (PCNSS) is an alternative minimally-invasive approach in selected cases where nephron preservation is desired. The long-term outcomes of this procedure at a single center are described. Methods All patients undergoing PCNSS, with the operation carried out by a single surgeon, were included. Equipment used was a standard 26Ch resectoscope through a 30Ch Amplatz sheath, with all patients receiving postoperative intrapelvic Mitomycin. Data for each patient were collected on patient age; tumor size at diagnosis; grade; stage; oncological recurrence; requirement for subsequent RNU; and overall survival. Primary outcomes were disease recurrence and overall mortality, and secondary outcome was rate of subsequent RNU. Results Fifteen patients in total underwent PCNSS, 14 were diagnosed with UTUC; benign leiomyoma was proven in one patient and excluded from final analysis. Overall survival at 5 and 10 years was 92.9% and 78.6%, respectively, with disease-specific mortality at 10 years of 7.1% (one patient who developed metastatic carcinoma); 21.4% of patients had recurrent ipsilateral UTUC and all required subsequent RNU for this indication. No patients had seeding of the percutaneous tract. Conclusion PCNSS for UTUC is a feasible approach to consider in carefully selected patients who agree to intensive follow-up, even for higher grade tumors. Where recurrent UTUC occurs, further management options still exist for disease treatment.
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Affiliation(s)
- Piyush Bhargav Sarmah
- Department of Urology, Birmingham Heartlands Hospital, University Hospitals of Birmingham, Birmingham, UK
| | - Syed Ali Ehsanullah
- Department of Urology, Birmingham Heartlands Hospital, University Hospitals of Birmingham, Birmingham, UK
| | - Bhupendra Dev Sarmah
- Department of Urology, Birmingham Heartlands Hospital, University Hospitals of Birmingham, Birmingham, UK
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Irwin BH, Berger AK, Brandina R, Stein R, Desai MM. Complex percutaneous resections for upper-tract urothelial carcinoma. J Endourol 2010; 24:367-70. [PMID: 20218882 DOI: 10.1089/end.2009.0181] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND AND PURPOSE Percutaneous endoscopic resection is a viable treatment option for upper-tract urothelial carcinoma (UC) in selected patients. We present our experience with patients who underwent percutaneous resections for complex urothelial tumors. PATIENTS AND METHODS Patients who were undergoing percutaneous treatment for UC were identified within a prospectively maintained database at a single institution. Charts were reviewed to identify complex patients (n = 16) who met the following criteria: (a) tumor size >2.5 cm (n = 8), (b) preoperative creatinine level >3.0 mg/dL (n = 3), or (c) anatomic variant (cystectomy/urinary diversion [n = 2]; autotransplanted kidney [n = 1]; ipsilateral partial nephrectomy [n = 1]; distal ureterectomy [n = 1]). Demographic, operative, and oncologic data were captured. Recurrence-free, cancer-specific, and overall survivals were calculated and compared with a control group of noncomplex cases (n = 23). RESULTS No difference was found in mean age (69.7 +/- 10.8 years vs 69.8 +/- 11.2 years), complication rate (6.3% vs 7.1%), or change in creatinine level (1.53 mg/dL to 1.51 mg/dL vs 1.88 mg/dL to 1.57 mg/dL) between noncomplex and complex cases. The incidences of high-grade tumors (55% vs 71%), invasive tumors (15% vs 20%), solitary kidney (82% vs 92%), contralateral nephroureterectomy (52% vs 60%), and history of bladder cancers (47% vs 38%) were similar between the two groups. Median follow-up was 36 months. No difference was seen in cancer-specific survival (P = 0.98) or recurrence-free survival (P = 0.39). An improved trend in overall survival (P = 0.20) was seen in the noncomplex patients when compared with the complex group. CONCLUSIONS These findings suggest that patients with large tumors, poor renal function, and significant anatomic variations may be well served by endoscopic treatment for upper-tract UC when indicated.
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Affiliation(s)
- Brian H Irwin
- Steven B. Streem Center for Endourology, Glickman Urological and Kidney Institute, Cleveland Clinic Foundation, Cleveland, Ohio 44195, USA
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Tomaszewski JJ, Smaldone MC, Ost MC. The Application of Endoscopic Techniques in the Management of Upper Tract Recurrence After Cystectomy and Urinary Diversion. J Endourol 2009; 23:1265-72. [DOI: 10.1089/end.2009.0049] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Jeffrey J. Tomaszewski
- Department of Urology, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Marc C. Smaldone
- Department of Urology, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Michael C. Ost
- Department of Urology, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
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Rastinehad AR, Smith AD. Bacillus Calmette-Guérin for upper tract urothelial cancer: is there a role? J Endourol 2009; 23:563-8. [PMID: 19335155 DOI: 10.1089/end.2008.0164] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Since the first reported case of using adjuvant topical immunotherapy utilizing bacillus Calmette-Guérin (BCG) was published by Herr and associates, several institutions have utilized numerous agents for topical infusion therapies (BCG, Mitomycin, Epirubicin, Thiotepa or combination therapy of BCG/INF) as adjuncts in the treatment of upper tract papillary transitional cell carcinoma. A comprehensive review of the current data in the treatment of upper tract transitional cell carcinoma (Ta/T1 disease) with adjuvant BCG therapy was completed. Currently, the efficacy of adjuvant BCG therapy was not demonstrated.
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Affiliation(s)
- Ardeshir R Rastinehad
- Department of Urology, North Shore-Long Island Jewish Health System, New Hyde Park, New York 11040, USA.
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Smaldone MC, Ost MC. Percutaneous resection of upper tract transitional cell carcinoma in a solitary kidney after cystectomy and continent orthotopic urinary diversion. J Endourol 2008; 22:2087-9; discussion 2095. [PMID: 18811551 DOI: 10.1089/end.2008.9739] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Marc C Smaldone
- Department of Urology, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania 15213, USA.
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Williams SK, Denton KJ, Minervini A, Oxley J, Khastigir J, Timoney AG, Keeley FX. Correlation of upper-tract cytology, retrograde pyelography, ureteroscopic appearance, and ureteroscopic biopsy with histologic examination of upper-tract transitional cell carcinoma. J Endourol 2008; 22:71-6. [PMID: 18315477 DOI: 10.1089/end.2007.9853] [Citation(s) in RCA: 82] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
PURPOSE To determine the accuracy of radiographic studies, ureteroscopy, biopsy, and cytology in predicting the histopathology of upper-tract transitional cell carcinoma (TCC). MATERIALS AND METHODS From 1998 to 2006, 46 upper-tract lesions were diagnosed ureteroscopically and underwent nephroureterectomy, and 30 of them were subjected to direct ureteroscopic inspection and biopsy. Fresh samples were delivered to the cytopathology laboratory and histology samples were prepared whenever visible tissue was present. Radiological, ureteroscopic, cytology, and biopsy data were compared to the actual grades and stages of these 30 surgical specimens. RESULTS Retrograde ureteropyelography was suggestive of malignancy in 29 of 30 cases, but did not predict the grade or stage accurately. Cytology was positive for malignancy in 21 of 30 cases (70%). Grading of ureteroscopic specimens was possible in all cases. At nephroureterectomy two cases were found to have no tumor (T(0)). Of the remaining 28 cases, the biopsy grade proved to be identical in 21 (75%). Grade 1 or 2 ureteroscopic specimens had a low-stage (T(0), T(a), or T(1)) tumor in 17 of 25 (68%); in contrast, 3 of 5 (60%) high-grade specimens had invasive tumor (T(2) or T(3)). For patients with grade 2 ureteroscopic specimens, combining exfoliated cell cytology and biopsy grade improved the accuracy in predicting high-stage and high-grade disease. CONCLUSIONS This study confirms previous findings that ureteroscopic inspection and biopsy provides accurate information regarding the grade and stage of upper-tract TCC. Combining exfoliated cell cytology improves the predictive power of biopsy grade 2 disease for high-risk specimen grade and stage. Our data suggest that ureteroscopic findings may predict muscle invasion.
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Arancibia MF, Bolenz C, Michel MS, Keeley FX, Alken P. The modern management of upper tract urothelial cancer: surgical treatment. BJU Int 2007; 99:978-81. [PMID: 17437429 DOI: 10.1111/j.1464-410x.2007.06705.x] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- Mario Fernández Arancibia
- Department of Urology, University Hospital Mannheim, Faculty of Clinical Medicine Mannheim, University of Heidelberg, Mannheim, Germany
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Argyropoulos AN, Tolley DA. Upper urinary tract transitional cell carcinoma: current treatment overview of minimally invasive approaches. BJU Int 2007; 99:982-7. [PMID: 17437430 DOI: 10.1111/j.1464-410x.2007.06870.x] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Chew BH, Pautler SE, Denstedt JD. Percutaneous Management of Upper-Tract Transitional Cell Carcinoma. J Endourol 2005; 19:658-63. [PMID: 16053354 DOI: 10.1089/end.2005.19.658] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
The gold standard treatment for supravesical urothelial carcinoma has been open radical nephroureterectomy based on the premise that this cancer is a field defect. However, nephroureterectomy is an extensive procedure that may not be tolerated by all patients. Percutaneous and ureteroscopic approaches have been utilized in an attempt to avoid the potential morbidity associated with traditional open surgery. This review provides an update on percutaneous management of upper-tract urothelial transitional-cell cancer based on a review of the pertinent literature.
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Affiliation(s)
- Ben H Chew
- Division of Urology, Department of Surgery, University of Western Ontario, London, Ontario, Canada
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Johnson GB, Fraiman M, Grasso M. Broadening experience with the retrograde endoscopic management of upper urinary tract urothelial malignancies. BJU Int 2005; 95 Suppl 2:110-3. [PMID: 15759354 DOI: 10.1111/j.1464-410x.2005.05210.x] [Citation(s) in RCA: 36] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- G B Johnson
- Department of Urology, St. Vincent's Hosptial, New York Medical College, New York, New York, USA
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Affiliation(s)
- M T Gettman
- Department of Urology, Mayo Clinic, Rochester, MN 55905, USA
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12
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Murphy DP, Gill IS, Streem SB. Evolving management of upper-tract transitional-cell carcinoma at a tertiary-care center. J Endourol 2002; 16:483-7. [PMID: 12396441 DOI: 10.1089/089277902760367449] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
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.
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Affiliation(s)
- David P Murphy
- Urological Institute, The Cleveland Clinic Foundation, 9500 Euclid Avenue, Cleveland, OH 44195, USA.
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Liatsikos EN, Dinlenc CZ, Kapoor R, Smith AD. Transitional-cell carcinoma of the renal pelvis: ureteroscopic and percutaneous approach. J Endourol 2001; 15:377-83; discussion 397. [PMID: 11394449 DOI: 10.1089/089277901300189385] [Citation(s) in RCA: 55] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
There are a variety of publications advocating the ureteroscopic or the percutaneous approach for the treatment of transitional cell carcinoma of the renal pelvis. The diagnostic tool of choice for the upper urinary tract and collecting system is the flexible ureteroscope. One of the major concerns about ureteroscopic management of renal disease initially was the lack of flexibility of the instruments and therefore the inability to deal with demanding sites. The advent of new ureteroscopic techniques, as well as the continuous evolution of the technology, have paved the way for safe and effective access to the upper urinary tract. In the hands of an experienced urologist, such procedures can provide reliable treatment options for small upper urinary tract lesions. Coupling minimal morbidity with ever-improving optics and flexibility, the ureteroscope of today leaves no area of the urinary tract unseen. In patients with bulky tumors or in whom easy access and resection is not possible ureteroscopically, the percutaneous approach to the renal pelvis, although more invasive, provides a better working environment. Clearly, the most difficult aspect of ureteroscopic access to the lower pole is not just visibility but the loss of deflection caused by passage of various instruments through the working channel. Direct access via percutaneous approach with a large resectoscope avoids these problems.
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Affiliation(s)
- E N Liatsikos
- Department of Urology, Albert Einstein College of Medicine, Long Island Jewish Medical Center, New Hyde Park, New York 11042, USA
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