Definitive tumor resection and percutaneous bacille Calmette-Guérin for management of renal pelvic transitional cell carcinoma in solitary kidneys

The Role of Local Agents for the Treatment of Localized Upper Tract Urothelial Carcinoma: A Review of the Current Evidence

Kidney-sparing surgery (KSS) for upper urinary tract urothelial carcinoma (UTUC) is a promising alternative to radical nephroureterectomy, especially for low-risk cases. However, due to the established risk of ipsilateral UTUC recurrence caused by the implantation of floating neoplastic cells after endoscopic resection, adjuvant endocavitary (endoureteral) instillations have been proposed. Instillation therapy may be also used as primary treatment for UTUC. The two most studied drugs that have been evaluated in both the adjuvant and primary setting of endocavitary instillation are mitomycin C and Bacillus Calmette-Guerin. The current paper provides an overview of the endocavitary treatments for UTUC, focusing on methods of administration, novel formulations, oncologic outcomes (in terms of endocavitary recurrence and progression), as well as on complications. In particular, the role of UGN-101 as a primary chemoablative treatment of primary noninvasive, endoscopically unresectable, low-grade, UTUC has been analysed. The drug achieved a complete response rate of 58% after the induction cycle, with a durable response independently of the maintenance cycle. The cumulative experience on the role of UUT instillation therapy appears encouraging; however, no definitive conclusions can be drawn about its therapeutic benefit. Given the current state of the art, any decision to administer adjuvant endoureteral therapy for UTUC should be carefully weighed against the potential adverse events. Nevertheless, newer investigations that improve visualization during ureteroscopy, genomic characterization, novel drugs and innovative strategies of improved drug delivery are under evaluation. The landscape of KSS for the treatment of the UTUC is evolving and seems promising.

Outcomes of endoscopic management of upper tract urothelial carcinoma

While radical nephroureterectomy (RNU) remains the gold-standard treatment for upper tract urothelial carcinoma (UTUC), a growing volume of literature surrounding endoscopic, organ-sparing procedures has developed over the past few decades. Based on this, endoscopic management of UTUC has gained acceptance as a standard of care approach, particularly among those with low-risk disease or with imperative indications for organ preservation. As a rare disease, however, data is mostly restricted to retrospective single institution series with relatively small numbers. Therefore, comparative outcomes of endoscopic management to RNU remain incompletely defined. Furthermore, the comparative utility of endoscopic approaches (ureteroscopy versus percutaneous resection) and topical therapy following resection lacks prospective analysis. In this article we review the available literature on endoscopic management of UTUC.

Future strategies to enhance kidney preservation in upper urinary tract urothelial carcinoma

Though radical nephroureterectomy remains the gold standard treatment for high grade or invasive disease in upper tract urothelial cancer (UTUC), kidney-sparing surgery has become preferred for low risk disease, in order to minimize morbidity and preserve renal function. Many methods exist for endoscopic management, whether via an antegrade percutaneous or retrograde ureteroscopic approach, including electroresection, laser ablation, and fulguration. There has been an increase in use of adjuvant intracavitary therapy, predominantly using mitomycin and bacillus Calmette-Guerin (BCG), to reduce recurrence after primary endoscopic management for noninvasive tumors, although efficacy remains questionable. Intraluminal BCG has additionally been used for primary treatment of CIS in the upper tract, with around 50% success. Newer investigations include use of narrow band imaging or photodynamic diagnosis with ureteroscopy to improve visualization during diagnosis and treatment. Genomic characterization may improve selection for kidney-sparing surgery as well as identify actionable mutations for systemic therapy. The evolution in adjuvant management has seen strategies to increase the dwell time and the urothelial contact of intraluminal agents. Lastly, chemoablation using a hydrogel for sustained effect of mitomycin is under investigation with promising early results. Continued expansion of the armamentarium available and better identification and characterization of tumors ideal for organ-sparing treatment will further improve kidney preservation in UTUC.

Intracavitary therapies for upper tract urothelial carcinoma

INTRODUCTION

While radical nephroureterectomy remains the gold-standard for upper tract urothelial carcinoma (UTUC), there is a growing push for organ-sparing therapy in low-risk disease. Herein we review the use of intracavitary topical therapy for treatment of UTUC. Areas covered: A PubMed search was performed for studies pertaining to upper tract urothelial carcinoma, with 236 articles reviewed, and distilled for content pertinent to intracavitary therapy for UTUC. Topics discussed include agents used for management of UTUC, most commonly BCG, as well as techniques for administration. Additionally, we review the evidence for curative treatment for Cis versus adjuvant therapy for Ta/T1 disease. Finally, we discuss emerging technologies to improve agent delivery and efficacy in the upper tract. Expert commentary: No significant advances have occurred in topical management of UTUC in the past 2 decades. However, advances in diagnostic techniques such as modern ureteroscopes, and improved diagnostic imaging at the time of ureteroscopy may help improve our patient selection. Additional advances in topical therapy focused on increasing the duration of contact between agent delivered and the upper tract urothelium offer hope that a new leap forward in topical therapy is on the horizon.

Which is best method for instillation of topical therapy to the upper urinary tract? An in vivo porcine study to evaluate three delivery methods

Purpose:

To compare the staining intensity of the upper urinary tract (UUT) urothelium among three UUT delivery methods in an in vivo porcine model.

Materials and methods:

A fluorescent dye solution (indigo carmine) was delivered to the UUT via three different methods: antegrade perfusion, vesico-ureteral reflux via in-dwelling ureteric stent and retrograde perfusion via a 5F open-ended ureteral catheter. Twelve renal units were tested with 4 in each method. After a 2-hour delivery time, the renal-ureter units were harvested en bloc. Time from harvesting to analysis was also standardised to be 2 hours in each arm. Three urothelium samples of the same weight and size were taken from each of the 6 pre-defined points (upper pole, mid pole, lower pole, renal pelvis, mid ureter and distal ureter) and the amount of fluorescence was measured with a spectrometer.

Results:

The mean fluorescence detected at all 6 predefined points of the UUT urothelium was the highest for the retrograde method. This was statistically significant with p-value less than <0.05 at all 6 points.

Conclusions:

Retrograde infusion of UUT by an open ended ureteral catheter resulted in highest mean fluorescence detected at all 6 pre-defined points of the UUT urothelium compared to antegrade infusion and vesico-ureteral reflux via indwelling ureteric stents indicating retrograde method ideal for topical therapy throughout the UUT urothelium. More clinical studies are needed to demonstrate if retrograde method could lead to better clinical outcomes compared to the other two methods.

Comparison of 3 upper tract anticarcinogenic agent delivery techniques in an ex vivo porcine model

OBJECTIVE

To evaluate the degree of urothelial exposure using 3 upper tract delivery techniques in an ex vivo porcine model, to determine the optimal modality to locally deliver topical anticarcinogenic agents in patients with upper tract urothelial carcinoma.

MATERIALS AND METHODS

An indigo carmine solution was infused into en bloc porcine urinary tracts to test the 3 techniques: antegrade infusion via nephrostomy tube, reflux via indwelling double-pigtail stent, and retrograde administration via a 5F open-ended ureteral catheter. Nine renal units (3 per delivery method) were used. After a 1-hour dwell time, the urinary tracts were bivalved and photographed. Each renal unit was evaluated by 3 blinded reviewers who estimated the total percentage of stained urothelial surface area using a computer-based area approximation system. In addition, as a surrogate for exposure adequacy, a validated equation was used to calculate the staining intensity at 6 predetermined locations in the upper tract, with lower values representing more efficient staining.

RESULTS

Mean percent of surface area stained for the nephrostomy tube, double-pigtail stent, and open-ended ureteral catheter groups was 65.2%, 66.2%, and 83.6%, respectively (P = .002). Mean staining intensities were 40.9, 33.4, and 20.4, respectively (P = .023).

CONCLUSION

Our results suggest that retrograde infusion via open-ended ureteral catheter is the most efficient method of upper tract therapy delivery. Larger studies using in vivo models should be performed to further validate these findings and potentially confirm this method as optimal for delivery of topical anticarcinogenic agents in upper tract urothelial carcinoma.

Mitomycin C instillation following ureterorenoscopic laser ablation of upper urinary tract carcinoma

Introduction:

Instillation of Mitomycin C (MMC) should prevent implantation of cancer cells released during endoscopic treatment and prevent recurrences as seen in carcinoma of the bladder.

Aim:

To develop and evaluate a protocol for a single dose MMC instillation following Holmium: YAG laser ablation of upper urinary tract transitional cell carcinoma (UUT-TCC).

Setting and Design:

A single institute prospective study.

Materials and Methods:

MMC instillations protocol was designed and offered to patients between August 2005 and April 2011. Following tumor ablation, MMC was instilled into upper urinary tract (UUT) over 40 minutes. All the patients were regularly followed up.

Results:

Twenty UUT units (19 patients) were managed for UUT-TCCs using our MMC protocol. Two UUT units had G1pTa tumors, 14 had G2pTa, 2 had G3pTa, and 2 had G3pT1. At a mean follow-up of 24 months (range 1-72 months), 13/20 (65%) of the UUT units remained cancer-free, 3 (15%) UUT units developed stricture and were treated with endoscopic dilatation, only 1 (5%) of these developed long-term complications. None of the patients developed postoperative renal impairment or systemic side-effects.

Conclusions:

Using a set standard protocol, MMC can safely be instilled into the UUT after TCC ablation with minimal complications or side effects, good preservation of renal function, and with a low recurrences rate comparable to the literature.

Conservative management of upper tract transitional cell carcinoma

Aim

Our aim was to review the current literature describing the endoscopic management of upper tract transitional cell carcinoma (TCC).

Materials and Methods

Review of published, peer-reviewed articles relating the primary ureteroscopic or percutaneous management of upper tract TCC was performed using the MEDLINE database.

Results

Historically, the gold-standard management for upper tract TCC consists of nephroureterectomy with excision of a bladder cuff. The employment of endoscopic management with these neoplasms was initially instituted in individuals with imperative indications, including bilateral disease, solitary kidney, and/or renal insufficiency. For individuals treated with ureteroscopy, recurrence rates range from 30 to 71% and cancer-specific survival rates from 50 to 93%. Results are dependent primarily on tumor grade and stage. In individuals with low-stage, low-grade tumors treated percutaneously, recurrence rates, and cancer-specific survival rates are 18-33% and 94-100%, respectively. Adjuvant therapy has been employed with thiotepa, mitomycin, and BCG, but none have been able to demonstrate a statistically significant difference in recurrence or cancer-specific survival rates.

Conclusions

Endoscopic management is a safe and effective treatment alternative to nephroureterectomy in the management of upper tract TCC. Survival outcomes are comparable, but renal preservation therapy offers the advantage of reduced morbidity, complications, and the potential for better quality of life. Recurrence and disease progression are not uncommon and underscore the need for strict tumor surveillance.

Comprehensive management of upper tract urothelial carcinoma

Urothelial carcinoma of the upper urinary tract represents only 5% of all urothelial cancers. The 5-year cancer-specific survival in the United States is roughly 75% with grade and stage being the most powerful predictors of survival. Nephroureterectomy with excision of the ipsilateral ureteral orifice and bladder cuff en bloc remains the gold standard treatment of the upper urinary tract urothelial cancers, while endoscopic and laparoscopic approaches are rapidly evolving as reasonable alternatives of care depending on grade and stage of disease. Several controversies remain in their management, including a selection of endoscopic versus laparoscopic approaches, management strategies on the distal ureter, the role of lymphadenectomy, and the value of chemotherapy in upper tract disease. Aims of this paper are to critically review the management of such tumors, including endoscopic management, laparoscopic nephroureterectomy and management of the distal ureter, the role of lymphadenectomy, and the emerging role of chemotherapy in their treatment.

Urothelial-Cell Carcinoma and Solitary Kidney: Outcomes with Renal-Sparing Management

PURPOSE

To review our experience with renal-sparing approaches for upper-tract transitional-cell carcinoma (UT-TCC) associated with solitary kidneys.

PATIENTS AND METHODS

Ten patients with UT-TCC associated with solitary kidneys who were managed with renal-sparing approaches from 2000 to 2004 were identified. Patient data were gathered retrospectively, and a patient interview was conducted. A literature review was performed, and our results were compared with those from selected other authors. The mean follow-up was 33 months.

RESULTS

Eight patients (80%) developed recurrence after initial treatment necessitating further intervention. The average number of procedures was nine per patient, and an average of two cycles of topical therapy was given. At the end of the follow-up period, 6 patients (60%) were disease free. Of these 6 patients, 2 (33%) required interval nephroureterectomy because of disease progression in one and renal insufficiency leading to dialysis in the other. Metastatic disease occurred in four patients during the surveillance interval, including one patient with a nephrostomy-site recurrence. Three patients died from their disease during the follow-up period, and one patient remained alive after chemotherapy. The overall survival rate was 70% at 33 months. Of the living patients, 6 (86%) could be reached for comment, and all were very satisfied with their renal-sparing management.

CONCLUSIONS

Renal-sparing approaches remain an option in motivated patients with solitary kidneys and UT-TCC. Patients should realize that management tends to involve multiple procedures that are associated with potential morbidity, entails lifetime follow-up, and often requires long-term nephrostomy access for topical treatment or relief of obstruction. Long-term patient quality-of-life and cancer-specific outcomes for renal- sparing management compared with quality-of-life and survival on dialysis are unknown.

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.

Transitional cell carcinoma of the ureter and renal pelvis

Transitional cell carcinoma (TCC) of ureter and renal pelvis is relatively uncommon. Smoking, occupational carcinogens, analgesic abuse, Balkan nephropathy are the risk factors. Cytogenetic studies revealed that the most frequent aberration is the partial or complete loss of chromosome 9. Approximately 20-50% of patients with upper urinary tract (UUT) TCC have bladder cancer at some point on their course, whereas the incidence of UUT TCC after primary bladder cancer is 0.7-4%. Excretory urography and retrograde pyelography are the conventional diagnostic tools; however, ureteropyeloscopy combined with cytology and biopsy is more accurate. Grade and stage of the disease have the most significant impact on survival. Nephroureterectomy with bladder cuff excision has been the mainstay of treatment. Local resection may be appropriate for distal ureteral lesions especially when the disease is low grade and stage. Advances in endourology have made it possible to treat many tumors conservatively. Ureteroscopic and to a certain extent percutaneous surgical approaches are widely used today especially in patients with low grade, low stage disease. Endoscopic close surveillance is mandatory for these patients. Adjuvant topical therapies appear to be safe but confirmation of any benefits awaits the results of further large studies. More recently, laparoscopic techniques have become a viable alternative to open surgery, but long term cancer control data are lacking. Aggressive surgical resection does not affect the outcome of patients with advanced disease. Adjuvant radiotherapy is ineffective, and systemic chemotherapy results in a low complete response rate for patients with metastases.

Percutaneous management of renal pelvic urothelial tumors: long-term followup

PURPOSE

We present the long-term outcome of percutaneous resection of renal urothelial tumor.

MATERIALS AND METHODS

A total of 24 patients underwent primary percutaneous resection of renal urothelial tumor. Patients with low stage pT0-1 disease were treated primarily with percutaneous surgery. All pelvicaliceal tumors were taken for biopsy and treated with percutaneous resection. Patients with multi-segmental pelvicaliceal system involvement, stage greater than pT1, high grade histology or additional ureteral tumors were considered for nephroureterectomy. Topical chemotherapy (mitomycin C or epirubicin) was administered via nephrostomy tube or intravesical instillation after Double-J stent (Medical Engineering Corp., New York, New York) insertion. Surveillance included upper tract cytology, nephroscopy or fiberoptic ureterorenoscopy. Long-term followup was correlated with histopathology.

RESULTS

Of the 24 cases 2 had squamous cell carcinoma, 5 had grade III transitional cell carcinoma, 15 had grade I to II transitional cell carcinoma and 2 had no tumor. Control was established with initial percutaneous resection in 18 (75%) cases and second look nephroscopy in 4. Early recurrences were detected by excretory urography (IVP) in 3 cases, small pelvic recurrences by IVP in 2, fiberoptic ureterorenoscopy in 2 and bladder tumors by flexible cystoscopy in 3 after 1 year. A total of 10 nephroscopies were performed in 5 cases, 24 flexible uretereorenoscopies in 9 and IVP in 6. Three synchronous, grade I bladder tumors were managed conventionally. All patients with high grade disease died of malignancy except one (with no further treatment) and 6 of the 15 patients with low grade noninvasive transitional cell carcinoma underwent nephroureterectomy during followup either due to progression of disease, concomitant tumor or complications. Two patients with solitary kidneys died of renal failure unrelated to malignancy. High grade tumors or tumors greater than T1 were treated with nephroureterectomy early during management. There was no perioperative mortality and 9 (60%) of the low grade cases the kidneys were preserved at a mean followup +/- SD of 64 +/- 15 months. All excised tracks from patients who underwent nephroureterectomy and the renal fossae were free of tumor on histopathological examination.

CONCLUSIONS

Percutaneous resection of transitional cell tumor should be considered primarily in patients with early stage disease excluding tumors crossing caliceal infundibula, ureteropelvic junction tumor, tumor extending over multiple calices and synchronous ureteral tumors. The long-term outcome of low grade tumors is good and they should be managed by either form of minimally invasive surgery. Nephron sparing is possible in a large percentage of low grade disease but high grade tumors should be treated with nephroureterectomy.

Transitional-cell carcinoma of the renal pelvis: ureteroscopic and percutaneous approach

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.

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.

Continuous antegrade infusion of adriamycin as adjuvant therapy for upper tract urothelial malignancies

OBJECTIVES

To evaluate the feasibility, efficacy, and toxicity of antegrade chemotherapy delivered continuously as adjuvant treatment for patients with upper tract transitional cell carcinoma.

METHODS

During a 6-year interval, 12 patients with upper tract transitional cell malignancies underwent continuous antegrade intraluminal infusion chemotherapy (CAIIC) with adriamycin. After placement of percutaneous access and surgical treatment of the primary lesion, patients received 5-day cycles of CAIIC. Patients received between two and four treatment cycles at 2-week intervals. After therapy, patients with no evidence of residual disease were then monitored long-term with retrograde pyelography and upper tract cytology.

RESULTS

Twelve patients underwent a total of 35 5-day cycles of CAIIC. No patient experienced hematologic and/or local/regional toxicity during or after drug infusion. Three patients were treated for upper tract carcinoma in situ, and 9 patients had discrete exophytic tumors. Two patients died (treatment unrelated) before a final assessment of therapeutic outcome, leaving 10 patients available for evaluation of the therapeutic response. One patient with carcinoma in situ and 5 of 7 patients with discrete upper tract tumors remained disease free after surgery and adjuvant therapy. Both patients with discrete tumors in whom therapy failed had residual gross disease after primary surgical treatment.

CONCLUSIONS

CAIIC using adriamycin was well tolerated for periods of up to 5 days over multiple cycles. Early data suggest a limited efficacy in treating patients with gross residual disease. The efficacy of this approach in preventing the recurrence of upper tract disease after surgical ablation awaits further assessment.

Ureteroscopic approach to upper-tract urothelial tumors

Transitional-cell carcinoma (TCC) of the upper urinary tract has traditionally been managed by nephroureterectomy, whereas nephron-sparing surgery has been reserved for those few patients with solitary kidneys or bilateral lesions. However, with the introduction of improved diagnostic and therapeutic technology, including smaller ureteroscopes and working instruments, and the concomitant ease of surveillance, ureteroscopic treatment of upper-tract urothelial tumors has become a reasonable alternative to open operative intervention in patients requiring conservative management. Furthermore, as preoperative grading and staging have improved, ureteroscopic treatment of upper-tract urothelial tumors is assuming an increasingly important role in the management of some patients who might have otherwise been treated with a nephroureterectomy. The technique of ureteroscopic resection is described in detail.

13-year experience with percutaneous management of upper tract transitional cell carcinoma

PURPOSE

We determined the immediate and long-term results of percutaneous management of upper trace transitional cell carcinoma in regard to rates of tumor recurrence and preservation of renal function.

MATERIALS AND METHODS

Since July 1985, 12 men and 5 women 50 to 86 years old (mean age 72.2) years old underwent percutaneous management of upper tract transitional cell carcinoma. Of the patients 12 (71%) had a solitary kidney and 1 was treated bilaterally. In 16 of the 18 treated renal units (89%) definitive percutaneous resection of the tumor was followed by 6 weekly percutaneous installations of bacillus Calmette-Guerin.

RESULTS

Complete resection was accomplished in 17 of the 18 renal units. Of the 18 renal units 15 (83.3%) had documented stage pTa lesions and 14 (77.8%) had grade 1/3 or 2/3 disease. Followup for all patients ranged from 1.7 to 75.5 months (mean 20.5). At the latest followup 11 patients (64.7%) are alive with no evidence of disease, and 6 (35.3%) died, 3 of whom (17.6%) had metastatic transitional cell carcinoma. Of the 13 patients undergoing treatment to solitary kidneys or bilaterally followup ranged from 1.7 to 75.5 months (mean 23.6). Serum creatinine ranged from 1.1 to 3.5 mg./dl. (mean 1.6) before percutaneous tumor resection and from 1.1 to 2.2 mg./dl. (mean 1.6) at the latest followup. Only 1 of these 13 patients (7.7%) with a solitary kidney has required dialysis. Ipsilateral local recurrence developed in 6 of the 18 renal units (33%), and in 4 of these 6 patients (67%) the tumor was grade 2/3 or 3/3 at initial resection. These recurrences were treated endoscopically in 4 patients, 3 of whom are currently without evidence of disease, and with nephroureterectomy in 2. Of the 17 patients only 1 (5.9%) with high grade (3/3), invasive (pT2) primary tumor at initial resection died of locally persistent or recurrent disease.

CONCLUSIONS

Percutaneous management of upper tract transitional cell carcinoma is technically feasible and applicable in a significant number of patients in whom nephron sparing management is otherwise warranted. In carefully selected patients the results are at least comparable to other forms of "conservative" management in terms of tumor control and preservation of renal function.