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Yang H, Liu Z, Wang Y, Li J, Li R, Wang Q, Hu C, Jiang H, Wu H, Song L, Bai Y. Olaparib is effective for recurrent urothelial carcinoma with BRCA2 pathogenic germline mutation: first report on olaparib response in recurrent UC. Ther Adv Med Oncol 2020; 12:1758835920970845. [PMID: 33240400 PMCID: PMC7675892 DOI: 10.1177/1758835920970845] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2020] [Accepted: 10/08/2020] [Indexed: 11/25/2022] Open
Abstract
Urothelial carcinoma (UC) is a common malignancy of the lower and upper urinary tract. Recurrent UC has poor prognosis due to delayed diagnosis and a lack of clinical management guidance, especially for upper urinary tract UC. Patients with germline or somatic BRCA1/2 mutations are a special population in UC. No evidence is available so far on the effectiveness of poly ADP-ribose polymerase inhibitor (PARPi) in this population. Here, we report a 60-year-old female patient diagnosed with left ureter high-grade UC. Recurrent lesions were found 20 months after radical surgery. Computed tomography (CT) examination showed a slightly high-density soft tissue mass (3.2 × 3.1 cm) on the left posterior wall of the abdomen (waist), soft tissue mass adjacent to the left inner wall of the pelvis (3.2 × 4.2 cm), and multiple enlarged lymph nodes to the left of abdominal aorta. A next-generation sequencing (NGS)-based 605-gene panel detected a novel BRCA2 pathogenic germline mutation c.1670T>A (p.L557*), and a series of somatic insertion and deletion (INDEL) mutations of BRCA1, RB1, and JAK2, and single nucleotide variation (SNV) mutations of TP53, KMT2D, MET, ROS1, and IL7R. The above lesions were reduced significantly or disappeared (partial response, PR) after a 3-month Olaparib treatment, and the patient’s general condition remained well. In conclusion, this study proved for the first time that PARPi was effective for UC treatment in patients carrying germline BRCA2 pathogenic mutations, providing new treatment options for such patients. In addition, the circulating tumor DNA (ctDNA) test can be used for drug selection and response monitoring in UC treatment.
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Affiliation(s)
- Hong Yang
- Department of Urology, The Third Affiliated Hospital of Kunming Medical University, Tumor Hospital of Yunnan Province, Kunming, Yunnan, P.R. China
| | - Zhimin Liu
- Department of Urology, The Third Affiliated Hospital of Kunming Medical University, Tumor Hospital of Yunnan Province, Kunming, Yunnan, P.R. China
| | - Yufang Wang
- HaploX Biotechnology, Co., Ltd., Shenzhen, Guangdong, P.R. China
| | - Jun Li
- Department of Urology, The Third Affiliated Hospital of Kunming Medical University, Tumor Hospital of Yunnan Province, Kunming, Yunnan, P.R. China
| | - Ruiqian Li
- Department of Urology, The Third Affiliated Hospital of Kunming Medical University, Tumor Hospital of Yunnan Province, Kunming, Yunnan, P.R. China
| | - Qilin Wang
- Department of Urology, The Third Affiliated Hospital of Kunming Medical University, Tumor Hospital of Yunnan Province, Kunming, Yunnan, P.R. China
| | - Chen Hu
- Department of Urology, The Third Affiliated Hospital of Kunming Medical University, Tumor Hospital of Yunnan Province, Kunming, Yunnan, P.R. China
| | - Haiyang Jiang
- Department of Urology, The Third Affiliated Hospital of Kunming Medical University, Tumor Hospital of Yunnan Province, Kunming, Yunnan, P.R. China
| | - Hongyi Wu
- Department of Urology, The Third Affiliated Hospital of Kunming Medical University, Tumor Hospital of Yunnan Province, Kunming, Yunnan, P.R. China
| | - Lele Song
- HaploX Biotechnology, Co., Ltd. 8th Floor, Auto Electric Power Building, Songpingshan Road, Nanshan District, Shenzhen, Guangdong 518057, P.R. China
| | - Yu Bai
- Department of Urology, The Third Affiliated Hospital of Kunming Medical University, Tumor Hospital of Yunnan Province, Kunming, Yunnan 650118, P.R. China
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Kwon SY, Ko YH, Song PH, Kim BH, Kim BS, Kim TH. The Remaining Ipsilateral Ureteral Orifice Provokes Intravesical Tumor Recurrence After Nephroureterectomy for Upper Tract Urothelial Carcinoma: A Multicenter Study With a Mid-Term Follow-Up. Urology 2020; 145:166-171. [DOI: 10.1016/j.urology.2020.06.083] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2020] [Revised: 06/26/2020] [Accepted: 06/30/2020] [Indexed: 11/16/2022]
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Dursun F, Pan MM, Morgan M, Gonzalez RR, Satkunasivam R. 532 nm green-light laser vaporization of upper tract urothelial carcinoma. BMC Urol 2020; 20:172. [PMID: 33115473 PMCID: PMC7594425 DOI: 10.1186/s12894-020-00744-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2020] [Accepted: 10/15/2020] [Indexed: 12/12/2022] Open
Abstract
Background Endoscopic management of low risk upper tract urothelial carcinoma (UTUC) may be considered in select clinical scenarios, which allows sparing the morbidity of radical nephroureterectomy while achieving acceptable oncological outcomes and preservation of kidney function. Herein, we present a case with UTUC in a solitary kidney managed with 532 nm laser vaporization through a percutaneous approach. Case presentation The patient in this video (Additional file 1) is an 85-year-old woman who presented with a bulky tumor in the collecting system of a congenital solitary left kidney, which was a biopsy proven low grade urothelial carcinoma. Prior to the procedure, a lower pole percutaneous nephrostomy tube was successfully placed under sedation by Interventional Radiology. The procedure was done in a prone split leg position. The mass, which was predominantly localized to the renal pelvis was efficiently vaporized with the 532 nm laser in a systematic manner with continuous irrigation of normal saline through the cystoscope. The patient was discharged home on postoperative day 2 with the nephroureterostomy catheter open to drainage. This catheter was subsequently clamped and removed two weeks later without complications. Follow up uretroscopy showed excellent treatment response and the patient remains well without complications. Conclusion This case report details the potential utility of 532 nm laser vaporization of UTUC, however, ongoing studies are required to demonstrate peri-operative safety and durable oncologic efficacy.
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Affiliation(s)
- F Dursun
- Department of Urology, Houston Methodist Hospital, 6560 Fannin Street, Suite 2100, Houston, TX, 77030, USA
| | - M M Pan
- Scott Department of Urology, Baylor College of Medicine, Houston, TX, USA
| | - M Morgan
- Department of Urology, Houston Methodist Hospital, 6560 Fannin Street, Suite 2100, Houston, TX, 77030, USA
| | - R R Gonzalez
- Department of Urology, Houston Methodist Hospital, 6560 Fannin Street, Suite 2100, Houston, TX, 77030, USA
| | - R Satkunasivam
- Department of Urology, Houston Methodist Hospital, 6560 Fannin Street, Suite 2100, Houston, TX, 77030, USA.
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Abstract
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.
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Affiliation(s)
- John J Knoedler
- Division of Urology, Penn State Milton S. Hershey Medical Center, Hershey, PA, USA
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Knoedler JJ, Raman JD. Intracavitary therapies for upper tract urothelial carcinoma. Expert Rev Clin Pharmacol 2018; 11:487-493. [PMID: 29634361 DOI: 10.1080/17512433.2018.1461560] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
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.
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Affiliation(s)
- John J Knoedler
- a Department of Surgery, Division of Urology , Penn State Hershey Surgical Specialties , Hershey , PA , USA
| | - Jay D Raman
- a Department of Surgery, Division of Urology , Penn State Hershey Surgical Specialties , Hershey , PA , USA
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Abstract
A select group of patients with upper tract urothelial carcinoma (UTUC) may meet indications for endoscopic management. Strategies for disease management are provided, based on a comprehensive review of the data using PubMed and Medline databases and marrying this with our experience with endoscopic management of UTUC. Endoscopic management of UTUC via retrograde or antegrade approaches is a viable treatment option for appropriately selected patients with low-risk UTUC, including those with low-grade, low-volume, and solitary tumors. However, recurrence risk limits these procedures to compliant patients under a vigilant surveillance program. Efficacious adjuvant therapies are needed to reduce local recurrences.
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Affiliation(s)
- Firas G Petros
- Department of Urology, UT MD Anderson Cancer Center, 1515 Holcombe Boulevard, Houston, TX 77030, USA
| | - Roger Li
- Department of Urology, UT MD Anderson Cancer Center, 1515 Holcombe Boulevard, Houston, TX 77030, USA
| | - Surena F Matin
- Department of Urology, UT MD Anderson Cancer Center, 1515 Holcombe Boulevard, Houston, TX 77030, USA.
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Raman JD, Park R. Endoscopic management of upper-tract urothelial carcinoma. Expert Rev Anticancer Ther 2017; 17:545-554. [DOI: 10.1080/14737140.2017.1326823] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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Szarvas T, Módos O, Horváth A, Nyirády P. Why are upper tract urothelial carcinoma two different diseases? Transl Androl Urol 2016; 5:636-647. [PMID: 27785420 PMCID: PMC5071198 DOI: 10.21037/tau.2016.03.23] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
In the last few years growing evidence highlighted the differences between upper tract urothelial carcinoma (UTUC) and urothelial bladder carcinoma (UBC) which cannot be explained solely by their different anatomical location. The aim of this review was to summarize current progress in UTUC research and to underline the differences and similarities between UTUC and UBC by focusing on epidemiology, etiology, staging and risk factors as well as on surgical and medical management. UBC and UTUC sharing common risk factors such as smoking and aromatic amines, while aristolochic acid exposure or familiar Lynch syndrome are rather specific for UTUC. The grading of UBC and UTUC are identical, but inherent from their different anatomical locations, there are some differences between their stage classifications. As an example, in contrast to UBC where a clear recommendation for pT3 subclassification exists, in UTUC current research aims to define an adequate subclassification for pelvic pT3 cases aiming to provide a better risk stratification. The primary treatment for both UBC and UTUC is surgery. Similarly to UBC, UTUC patients at high risk of disease progression are treated by radical surgery. However, because of the inaccurate preoperative or transurethral staging of UTUC, many radical nephroureterectomies are performed unnecessarily. Preoperative prediction of pathological stage or patients' prognosis may reduce this overtreatment by selecting patients for nephron-sparing surgery. To this end, predictive models combining histological and molecular features together with imaging data may be used. The antegrade or retrograde instillation of BCG or mitomycin C, as topical agents is feasible after conservative treatment of UTUC or for the treatment of CIS. However, the prognostic significance of lymph node positivity in UTUC seems to be similar to that of UBC, the therapeutic benefit of lymph node dissection (LND) in UTUC has not been firmly established yet. In addition, the number of lymph nodes to be removed and the sequence of lymphadenectomy also remain to be defined. Systemic neoadjuvant and adjuvant chemotherapies appear to have beneficial effect on UTUC survival, however, this has to be confirmed by large prospective studies. Due to the intensive research of the last few years, our knowledge on UTUC has been largely improved, but many questions remained to be answered. Further research on the molecular background of UTUC holds the potential to identify prognostic or predictive markers which, together with imaging and histologic data, may help to overcome the inaccuracy of ureteroscopic endoscopy and may therefore help to improve therapeutic decision-making. Further, prospective studies should confirm the benefit of LND and adjuvant chemotherapy. Considering the low incidence of UTUC, conduction of such studies is difficult and may only be performed in a multicenter setting.
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Affiliation(s)
- Tibor Szarvas
- Department of Urology, Semmelweis University, Budapest, Hungary; ; Department of Urology, University Hospital of Essen, University of Duisburg-Essen, Essen, Germany
| | - Orsolya Módos
- Department of Urology, Semmelweis University, Budapest, Hungary
| | - András Horváth
- Department of Urology, Semmelweis University, Budapest, Hungary
| | - Péter Nyirády
- Department of Urology, Semmelweis University, Budapest, Hungary
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9
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Risk-adapted strategy for the kidney-sparing management of upper tract tumours. Nat Rev Urol 2015; 12:155-66. [DOI: 10.1038/nrurol.2015.24] [Citation(s) in RCA: 59] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
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Huang LH, Hung SW, Ou YC, Chiu KY. Nephron-sparing surgery with autotransplantation for high-grade upper urinary tract urothelial carcinoma in a patient with solitary kidney. UROLOGICAL SCIENCE 2014. [DOI: 10.1016/j.urols.2013.08.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
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11
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Audenet F, Rouprêt M, Houédé N, Colin P. Traitements non chirurgicaux des tumeurs de la voie excrétrice supérieure : état-de-l’art pour le rapport annuel de l’Association française d’urologie. Prog Urol 2014; 24:1030-40. [DOI: 10.1016/j.purol.2014.07.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2014] [Revised: 06/27/2014] [Accepted: 07/06/2014] [Indexed: 11/26/2022]
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12
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Yang B, Sun W. Percutaneous nephroscopic resection of pyelocaliceal transitional cell carcinoma in solitary kidney. Urol Ann 2014; 6:91-3. [PMID: 24669134 PMCID: PMC3963355 DOI: 10.4103/0974-7796.127027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2012] [Accepted: 07/21/2012] [Indexed: 11/16/2022] Open
Abstract
Percutaneous approaches to upper tract urothelial cancers have been performed in patients unsuitable for radical nephroureterectomy. We present two cases of transitional cell carcinoma involving the renal pelvis in either functional or anatomical solitary kidney, which were successfully treated by percutaneous nephroscopic resection using monopolar electrocautery.
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Affiliation(s)
- Bo Yang
- Department of Urology, The Second Affiliated Hospital of Dalian Medical University, Shahekou District, Dalian, Liaoning Province, China
| | - Weibing Sun
- Department of Urology, The Second Affiliated Hospital of Dalian Medical University, Shahekou District, Dalian, Liaoning Province, China
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13
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Bachir BG, Kassouf W. Efficacy of instillations with chemotherapy or immunotherapy following endoscopic resection for upper tract urothelial carcinoma. Expert Rev Anticancer Ther 2014; 12:63-75. [DOI: 10.1586/era.11.193] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
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14
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Kapoor A, Allard CB, Black P, Kassouf W, Morash C, Rendon R. Canadian guidelines for postoperative surveillance of upper urinary tract urothelial carcinoma. Can Urol Assoc J 2013; 7:306-11. [PMID: 24319507 DOI: 10.5489/cuaj.1578] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Affiliation(s)
- Anil Kapoor
- Division of Urology, McMaster University, Hamilton, ON
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16
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Abstract
OBJECTIVES To review the diagnosis, treatment, and nursing management of patients with urothelial cancers. DATA SOURCES PubMed, Ovid MEDLINE, Text books, and clinical experience. CONCLUSION Progress is being made in the surgical and systemic management of urothelial cancers, and the oncology nurse is in a position to make an impact on patient education and overall quality of life. IMPLICATIONS FOR NURSING PRACTICE Nursing care begins at pre-diagnostic testing and continues through treatment for metastatic disease. Nurses must be knowledgeable about diagnostic tests, treatment options, and the quality-of-life implications of associated surgeries and/or treatments to support and guide patients. Education should be comprehensive, addressing not only treatment side effects but also long-term implications on patients' lives and lifestyles.
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Affiliation(s)
- Allison Tyler
- Cleveland Clinic Taussig Cancer Institute, 9500 Euclid Ave., Desk R33, Cleveland, OH 44915, USA.
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Upper urinary tract instillations in the treatment of urothelial carcinomas: a review of technical constraints and outcomes. World J Urol 2012; 31:45-52. [DOI: 10.1007/s00345-012-0949-3] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2012] [Accepted: 09/07/2012] [Indexed: 10/27/2022] Open
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Upper tract urothelial carcinoma: current treatment and outcomes. Urology 2012; 79:749-56. [PMID: 22469572 DOI: 10.1016/j.urology.2011.12.024] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2011] [Revised: 11/26/2011] [Accepted: 12/15/2011] [Indexed: 01/12/2023]
Abstract
The reference standard treatment of upper tract urothelial carcinoma is open radical nephroureterectomy. Many centers have advocated less-invasive treatment modalities. We reviewed contemporary treatments of upper tract urothelial carcinoma and their outcomes. A MEDLINE search was conducted for all relevant published data during the past 15 years. Endoscopic management is feasible for low-grade disease with strict surveillance protocols. Radical nephroureterectomy remains the reference standard for upper tract urothelial carcinoma. The intermediate-term oncologic outcomes are similar between the laparoscopic and open approaches. Controversies still exist regarding the optimal management of the distal ureter, the utility of topical therapy, and the role of lymphadenectomy.
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Adamis S, Varkarakis J. Minimally invasive approach in the management of upper- urinary-tract tumours. ACTA ACUST UNITED AC 2012; 45:381-7. [PMID: 22070534 DOI: 10.3109/00365599.2011.590999] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
OBJECTIVE Nephroureterectomy with bladder cuff excision has been the gold standard treatment for upper tract transitional cell carcinoma (UTTCC) for more than 60 years. However, endoscopic treatment of urothelial tumours of renal pelvis and ureter is gaining acceptance as a conservative treatment modality. MATERIAL AND METHODS A review in the English language of the Medline and Pub Med databases was performed using the keywords upper urinary tract transitional cell carcinoma and endoscopic management. There was a particular emphasis on treatment outcomes from published series. RESULTS Endoscopic treatment of UTTCC alone for high-grade tumours is not advised owing to high rates of both local recurrence and disease progression, while many authors do not recommend primary endoscopic management of UTTCC in elective situations if pathological analysis and tumour grade cannot be obtained. CONCLUSION Endourological management of UTTCC has become an accepted treatment option in highly selected patients, provided long-term close surveillance to detect and treat recurrences is ensured.
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Affiliation(s)
- Stefanos Adamis
- 2nd Department of Urology, University of Athens, Medical School, Sismanoglion Hospital, Athens, Greece.
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Cutress ML, Stewart GD, Zakikhani P, Phipps S, Thomas BG, Tolley DA. Ureteroscopic and percutaneous management of upper tract urothelial carcinoma (UTUC): systematic review. BJU Int 2012; 110:614-28. [DOI: 10.1111/j.1464-410x.2012.11068.x] [Citation(s) in RCA: 165] [Impact Index Per Article: 13.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
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Preoperative T Categorization and Prediction of Histopathologic Grading of Urothelial Carcinoma in Renal Pelvis Using Diffusion-Weighted MRI. AJR Am J Roentgenol 2011; 197:1130-6. [DOI: 10.2214/ajr.10.6299] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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22
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Abstract
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.
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Raymundo EM, Lipkin ME, Bañez LB, Mancini JG, Zilberman DE, Preminger GM, Inman BA. Third Prize: The Role of Endoscopic Nephron-Sparing Surgery in the Management of Upper Tract Urothelial Carcinoma. J Endourol 2011; 25:377-84. [DOI: 10.1089/end.2010.0276] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Eliza M. Raymundo
- Department of Surgery-Urology, Duke University Medical Center, Durham, North Carolina
| | - Michael E. Lipkin
- Department of Surgery-Urology, Duke University Medical Center, Durham, North Carolina
| | - Lionel B. Bañez
- Department of Surgery-Urology, Duke University Medical Center, Durham, North Carolina
| | - John G. Mancini
- Department of Surgery-Urology, Duke University Medical Center, Durham, North Carolina
| | - Dorit E. Zilberman
- Department of Surgery-Urology, Duke University Medical Center, Durham, North Carolina
| | - Glenn M. Preminger
- Department of Surgery-Urology, Duke University Medical Center, Durham, North Carolina
| | - Brant A. Inman
- Department of Surgery-Urology, Duke University Medical Center, Durham, North Carolina
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24
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Abstract
With the development of techniques for percutaneous access and equipment to disintegrate calculi, percutaneous nephroscopic surgery is currently used by many urologists and is the procedure of choice for the removal of large renal calculi and the management of diverticula, intrarenal strictures, and urothelial cancer. Although it is more invasive than shock wave lithotripsy and retrograde ureteroscopic surgery, percutaneous nephroscopic surgery has been successfully performed with high efficiency and low morbidity in difficult renal anatomies and patient conditions. These advantages of minimal invasiveness were rapidly perceived and applied to the management of ureteropelvic junction obstruction, calyceal diverticulum, infundibular stenosis, and urothelial cancer. The basic principle of endopyelotomy is a full-thickness incision of the narrow segment followed by prolonged stenting and drainage to allow regeneration of an adequate caliber ureter. The preferred technique for a calyceal diverticulum continues to be debated. Excellent long-term success has been reported with percutaneous, ureteroscopic, and laparoscopic techniques. Each approach is based on the location and size of the diverticulum. So far, percutaneous ablation of the calyceal diverticulum is the most established minimally invasive technique. Infundibular stenosis is an acquired condition usually associated with inflammation or stones. Reported series of percutaneously treated infundibular stenosis are few. In contrast with a calyceal diverticulum, infundibular stenosis is a more difficult entity to treat with only a 50-76% success rate by percutaneous techniques. Currently, percutaneous nephroscopic resection of transitional cell carcinoma in the renal calyx can be applied in indicated cases.
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Affiliation(s)
- Tae-Kon Hwang
- Department of Urology, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
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25
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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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26
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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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Lasers in percutaneous renal procedures. World J Urol 2009; 28:135-42. [PMID: 19488759 DOI: 10.1007/s00345-009-0423-z] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2009] [Accepted: 05/10/2009] [Indexed: 10/20/2022] Open
Abstract
INTRODUCTION Since the invention of lasers in 1960, they have been increasingly used in medicine. In this review paper, the types of lasers used in urology, in addition to their applications to percutaneous renal surgery will be reviewed. Specifically, use of lasers in the percutaneous management of renal stones, upper tract transitional cell carcinoma and stricture will be reviewed. MATERIALS AND METHODS Pubmed was searched for citations since 1966. The following terms were used: "lasers", "calculi", "endopyelotomy", and "transitional cell carcinoma". RESULTS Due to its minimal depth of penetration, holmium laser has proven to be safe and efficacious. It is currently the primary energy source for flexible instrumentation, and also has demonstrated efficacy in percutaneous lithotripsy (faster than ultrasonic lithotripsy and safer than electrohydraulic lithotripsy). Holmium laser been used for antegrade endopyelotomy and percutaneous resection of upper tract transitional cell carcinoma. CONCLUSIONS Holmium laser is safer than other lasers and has become the gold standard for laser lithotripsy for flexible instrumentation. It has been used successfully in the percutaneous management of renal stones, ureteropelvic junction obstruction, and upper tract transitional cell carcinoma. Holmium laser is an alternative energy source to conventional lithotripters and electrocautery for endopyelotomy and resection of upper tract transitional cell carcinoma.
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Endourologic management of upper tract transitional cell carcinoma following cystectomy and urinary diversion. Adv Urol 2008:976401. [PMID: 19125199 PMCID: PMC2610406 DOI: 10.1155/2009/976401] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2008] [Revised: 09/28/2008] [Accepted: 11/03/2008] [Indexed: 11/29/2022] Open
Abstract
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.
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Ost MC, Okeke Z, VanderBrink BA, Rastinehad A, Kavoussi LR, Siegel DN, Smith AD. Totally bloodless percutaneous renal surgery. J Endourol 2008; 22:2241-4. [PMID: 18937588 DOI: 10.1089/end.2008.9701] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
INTRODUCTION We evaluated the feasibility of intraoperative transarterial balloon occlusion of renal artery as a novel technique to reduce blood loss in high-risk patients undergoing complex percutaneous renal surgery (PRS). METHODS Four patients (staghorn calculi: n=2, renal pelvis TCC: n=1, ureteropelvic junction obstruction: n=1) underwent transfemoral arteriography prior to PRS. The renal artery was identified and an occluding balloon was inflated in the main renal artery. The kidney was intermittently allowed to perfuse with heparinized saline. Percutaneous renal access was obtained under fluoroscopic guidance by the urologist. Multiple tracts were established as needed to perform the procedure. The arterial occluding balloon was taken down at the completion of PRS and renal angiography repeated through the established angiographic catheter to identify any vascular injury. RESULTS Subjective improved visualization was attributed to decreased bleeding. Blood loss was less than 500 cc. Post-PRS intraoperative angiography revealed no active bleeding vessels requiring embolization. Two of the four patients presented with delayed renal hemorrhage over 10 days later requiring angiography and selective embolization with cessation of bleeding. All vascular abnormalities identified on repeat angiogram were not present on immediate post-PRS angiography. CONCLUSIONS Intraoperative balloon occlusion of renal artery is feasible and safe in patients undergoing complex PRS. Vascular control improves intraoperative endoscopic visibility while reducing intraoperative blood loss in patients at high risk for bleeding. However, these patients can still be at risk for delayed hemorrhage as iatrogenic vascular abnormalities, which can cause bleeding, can take time to develop and not be evident immediately post PRS.
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Affiliation(s)
- Michael C Ost
- Department of Urology, The University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
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A 20-year experience with percutaneous resection of upper tract transitional carcinoma: is there an oncologic benefit with adjuvant bacillus Calmette Guérin therapy? Urology 2008; 73:27-31. [PMID: 18929398 DOI: 10.1016/j.urology.2008.06.026] [Citation(s) in RCA: 79] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2007] [Revised: 05/12/2008] [Accepted: 06/01/2008] [Indexed: 12/14/2022]
Abstract
OBJECTIVES To determine whether there is an oncologic benefit of adjuvant bacillus Calmette Guérin (BCG) after resection of upper tract transitional cell carcinoma (UTTCC). METHODS A total of 133 renal units (RU) treated by percutaneous resection for UTTCC between 1985 and 2005 were retrospectively analyzed. Forty-four RU were excluded because of carcinoma in situ, high grade/stage, metastatic disease present at initial presentation, and/or the patient could tolerate loss of RU. Eighty-nine RU treated primarily by percutaneous resection were then analyzed. Fifty RU received adjuvant BCG therapy 2 weeks after endoscopic management for a total of 6 courses. Recurrence was defined as a positive biopsy result after the third-look nephroscopy. Progression of disease was assessed at time of recurrence and defined as an increase in grade/stage of disease. RESULTS Mean age (+/- SD) of 89 RU was 70.9 +/- 11.1 years. Overall follow-up was 61.1 + 54.8 months. Grade distribution was 56.2% (50 of 89) and 43.8% (39 of 89) for low- and high-grade disease, respectively. There was no statistical difference with regard to tumor grade or stage between treated and nontreated groups (P > .05). Recurrence, time to recurrence, and progression of disease among RU treated with BCG were subselected by grade and compared with the corresponding nontreated group. Statistical significance between any of the treated and nontreated groups was not demonstrated (P > .05). CONCLUSIONS Our data demonstrate that there is no overall oncologic benefit in the administration of adjuvant BCG with regard to disease recurrence, interval to recurrence, and progression of disease in the treatment of UTTCC.
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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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Irani J, Bernardini S, Bonnal JL, Chauvet B, Colombel M, Davin JL, Laurent G, Lebret T, Maidenberg M, Mazerolles C, Pfister C, Roupret M, Roy C, Rozet F, Saint F, Theodore C. [Urothelial tumors]. Prog Urol 2008; 17:1065-98. [PMID: 18153988 DOI: 10.1016/s1166-7087(07)74781-4] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
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Urothelial carcinoma of the upper urinary tract: surgical approach and prognostic factors. Eur Urol 2008; 53:720-31. [PMID: 18207315 DOI: 10.1016/j.eururo.2008.01.006] [Citation(s) in RCA: 135] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2007] [Accepted: 01/04/2008] [Indexed: 12/21/2022]
Abstract
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.
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Gilligan T, Dreicer R. The atypical urothelial cancer patient: management of bladder cancers of non-transitional cell histology and cancers of the ureters and renal pelvis. Semin Oncol 2007; 34:145-53. [PMID: 17382798 DOI: 10.1053/j.seminoncol.2006.12.005] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Non-transitional cell neoplasms of the bladder and upper tract transitional cell carcinomas (ureter and renal pelvis) represent only a small fraction of urothelial carcinomas. Clinicians faced with the rare case are always confronted with management dilemmas complicated by the scarcity of published experience to guide decisions. The current review brings together the best of the limited published data in an attempt to provide some reasonable context to help in the management of these difficult neoplasms.
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Affiliation(s)
- Timothy Gilligan
- Department of Solid Tumor Oncology, Taussig Cancer Center, and Glickman Urologic Institute, Cleveland Clinic, Cleveland, OH 44195, USA
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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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Lokmane E, Chabchoub K, Khodari M, El Hajj J, Danjou P. [Results of laparoscopic nephroureterectomy for transitional cell carcinoma]. Prog Urol 2007; 17:50-3. [PMID: 17373237 DOI: 10.1016/s1166-7087(07)92225-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
OBJECTIVE To report our experience of laparoscopic nephroureterectomy and to compare our results to those published in the literature. PATIENTS AND METHOD Between 1997 and 2005, 15 laparoscopic nephroureterectomies were performed by 2 surgeons, in 12 men and 3 women for upper urinary tract transitional cell carcinoma. The mean age of the patients was 66 years. Three to five trocars were used depending on intraoperative findings in order to meet oncological imperatives: primary control of the renal pedicle before any contact with the tumour dissection in the plane of the radical nephrectomy. The operative specimen was extracted in a sealed bag via an infraumbilical mini-laparotomy that allowed pelvic ureterectomy and resection of the bladder cuff. RESULTS The mean operating time was 210 min. The procedure was converted to open lumbar laparotomy in 3 patients. The mean hospital stay was 13 days. The final histological stage showed 8 invasive tumours (pT2-pT3), 4 superficial tumours (pTa-pT1), 2 CIS and a benign tumour. Two patients died from local progression of the disease. The mean follow-up was 41 months (range: 12-96 months). CONCLUSION Laparoscopic nephroureterectomy for upper urinary tract transitional cell carcinoma, still under evaluation, is indicated in selected cases. Apart from patient selection, which remains difficult preoperatively, the cancer control results depend on compliance with the principles of this surgery.
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Abstract
The histological appearance and the clinical behaviour of upper urinary tract urothelial tumours are almost identical to those of the bladder. Superficial papillary tumours rarely progress and turn to invasive disease despite a high frequency of recurrence. Technical developments in the endourology field have allowed full endoscopic access to upper tract tumours. Endoscopic resection or ablation of the tumour can be undertaken safely and effectively through ureteroscopy or percutaneous nephroscopy with low risk of extra-renal tumour seeding. For superficial (Ta, T1), low grade (I, II) tumours, a conservative approach can be selected without compromising survival and prognosis. For muscle invasive > T2 or high grade (III) tumours, nephroureterectomy remains the treatment of choice. Intracavitary BCG used after percutaneous resection reduces the risk of recurrence of upper tract urothelial tumours regardless of the grade. Finally, the world literature and our personal experience have shown that the tumour grade and stage are the two independent factors that affect survival of patients with upper urinary tract tumours.
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Affiliation(s)
- M E Jabbour
- Hôpital Saint-George, Université de Balamand, B.P 166 378, Achrafieh, Beyrouth 1100 2807, Liban
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Milner JE, Voelzke BB, Flanigan RC, Sharma SK, Perry KT, Turk TMT. Urothelial-Cell Carcinoma and Solitary Kidney: Outcomes with Renal-Sparing Management. J Endourol 2006; 20:800-7. [PMID: 17094758 DOI: 10.1089/end.2006.20.800] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
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.
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Affiliation(s)
- John E Milner
- Department of Urology, Loyola University Medical Center, Chicago, Illinois, USA
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Bradford TJ, Montie JE, Hafez KS. The Role of Imaging in the Surveillance of Urologic Malignancies. Urol Clin North Am 2006; 33:377-96. [PMID: 16829272 DOI: 10.1016/j.ucl.2006.03.001] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Urologic malignancies are common, accounting for approximately 25% of all new cancer cases in the United States. Patients with urologic malignancies require long-term surveillance to detect progression or recurrence as early as possible. The urologist is faced with the task of balancing patient safety and cost-effectiveness, while finding the most practical follow-up regimen. For each urologic malignancy, this article reviews the commonly used radiologic techniques for surveillance and offers recommended follow-up schedules.
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Affiliation(s)
- Timothy J Bradford
- Department of Urology, University of Michigan Medical Center, 1500 East Medical Center Drive, Ann Arbor, MI 48109-0330, USA
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Rouprêt M, Traxer O, Tligui M, Conort P, Chartier-Kastler E, Richard F, Cussenot O. Upper urinary tract transitional cell carcinoma: recurrence rate after percutaneous endoscopic resection. Eur Urol 2006; 51:709-13; discussion 714. [PMID: 16911852 DOI: 10.1016/j.eururo.2006.07.019] [Citation(s) in RCA: 89] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2006] [Accepted: 07/14/2006] [Indexed: 12/14/2022]
Abstract
OBJECTIVES To assess oncologic outcomes in patients undergoing percutaneous management for upper urinary tract transitional cell carcinoma (UUT-TCC) of the renal cavities. METHODS We performed a retrospective review of data for patients who underwent percutaneous conservative surgery for a UUT-TCC between 1989 and 2005: sex; age at diagnosis; mode of diagnosis; smoking; history of bladder cancer; type of surgery; complications; tumour site, size, stage and grade, and recurrence and progression. We evaluated recurrence and survival rates. RESULTS Data were analyzed for 24 patients. Median age was 70 yr. The tumour was located in the renal pelvis in 11 patients and in the caliceal system in 13 patients. Mean tumour size was 1.8 cm (range: 0.8-2.9). Four patients had a history of bladder carcinoma. Three patients experienced perioperative blood loss requiring transfusion, and one experienced colon wound. Median follow-up was 62 mo. Eight (33.3%) patients experienced local recurrence (three in the treated urinary tract, one in the contralateral tract, four in the bladder). Five patients underwent nephroureterectomy (NUT) during follow-up. Five (20.8%) patients have died, four from disease progression and one from cardiovascular causes. The 5-year disease-specific and tumour-free survival rates were 79.5% and 68%, respectively. CONCLUSIONS Percutaneous management can be recommended as an alternative to NUT or ureteroscopy for low-grade or superficial UUT-TCCs localised in the renal cavities. These patients require long-term postsurgical surveillance. For patients with high-grade or invasive tumours, open NUT remains the gold standard.
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Affiliation(s)
- Morgan Rouprêt
- Department of Urology, Groupe Hospitalo-Universitaire EST, Pitié-Tenon, Assistance Publique-Hôpitaux de Paris (AP-HP), University Paris VI, Paris, France.
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Goel MC, Matin SF, Derweesh I, Levin H, Streem S, Novick AC. Partial nephrectomy for renal urothelial tumors: clinical update. Urology 2006; 67:490-5. [PMID: 16527564 DOI: 10.1016/j.urology.2005.09.016] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2004] [Revised: 08/16/2005] [Accepted: 09/15/2005] [Indexed: 10/24/2022]
Abstract
OBJECTIVES To evaluate the contemporary indications and outcome after partial nephrectomy for renal urothelial cancer. Partial nephrectomy is an established treatment for renal cell cancer but its use for renal urothelial tumors has been studied less extensively. METHODS Records were reviewed for patients undergoing partial nephrectomy for renal urothelial tumors between January 1990 and December 2001. Partial nephrectomy was selected for those with a solitary kidney, chronic renal insufficiency, or bilateral synchronous tumors. Partial nephrectomy was performed according to the principles of partial nephrectomy. Follow-up included ultrasonography, intravenous urography, computed tomography, metastatic workup, and renal function evaluation. RESULTS This study included 12 patients (12 kidneys, 10 solitary) with a mean age of 68.5 +/- 21 years and a mean follow-up of 40.8 +/- 32 months. The pathologic T stage was Tis in 1 patient, T1 in 3, T2 in 2, and T3 in 6 patients. Of the 12 patients, 6 had negative surgical margins, and 4 of the 12 patients (30%) were tumor free after a mean follow-up of 57.7 months. Of the 6 patients with positive surgical margins (Stage T1 in 2 and T3 in 4), 1 developed recurrence and 3 developed metastasis; 4 died after a mean of 31.3 months. Overall recurrence was seen in 5 (42%) and progression (metastasis) in 6 (50%) patients. Of the 12 patients, 6 were alive, 4 of them were well (mean serum creatinine 1.83 mg/dL) at 62 months of follow-up. Two patients required dialysis. The overall long-term survival rate was 50%. CONCLUSIONS Partial nephrectomy for renal urothelial tumors is feasible and should be considered in a select population. Dialysis or renal replacement can be delayed or avoided in most of these patients, but strict surveillance remains mandatory.
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Affiliation(s)
- Mahesh C Goel
- Glickman Urological Institute, Cleveland Clinic Foundation, Cleveland, Ohio 44195, USA.
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Joudi FN, Crane CN, O'Donnell MA. Minimally invasive management of upper tract urothelial carcinoma. Curr Urol Rep 2006; 7:23-30. [PMID: 16480665 DOI: 10.1007/s11934-006-0034-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Recently published studies that evaluated minimally invasive treatments for upper tract urothelial cancer (UTUC) were reviewed, including adjuvant topical therapy. Ureteroscopic management remains the initial diagnostic and possibly therapeutic procedure of choice. Percutaneous management is used to treat bulky tumors or tumors that cannot be accessed ureteroscopically. Low-grade UTUC in appropriately selected patients can be safely and effectively treated endoscopically. High-grade disease tends to fail, regardless of treatment modality, and warrants aggressive therapy. Adjuvant therapy seems to be safe, although its efficacy is debatable. Immunotherapy appears to be most effective in patients with upper tract carcinoma in situ.
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Affiliation(s)
- Fadi N Joudi
- Department of Urology, University of Iowa, IA 52242-1089, USA
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Lee CT, Hollenbeck B, Wood DP. Ureter, Bladder, Penis, and Urethra. Oncology 2006. [DOI: 10.1007/0-387-31056-8_47] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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Palou Redorta J, Autran AM, Martínez Rodríguez RH, Huguet Pérez J, Rosales Bordes A, Villavicencio Mavrich H. [Percutaneous treatment with BCG in multiple upper tract transitional cell carcinoma]. Actas Urol Esp 2005; 29:787-90. [PMID: 16304912 DOI: 10.1016/s0210-4806(05)73342-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Upper tract transitional cell carcinoma is a low prevalent tumour and frequently associated to bladder carcinoma. The antegrade endoscopic access represents a safe, efficient and minimally invasive access. The association to immunotherapy seems effective in decreasing recurrence. We present one patient with multiple upper tract carcinoma treated with percutaneous surgery and BCG.
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Ost MC, Vanderbrink BA, Lee BR, Smith AD. Endourologic treatment of upper urinary tract transitional cell carcinoma. ACTA ACUST UNITED AC 2005; 2:376-83. [PMID: 16474734 DOI: 10.1038/ncpuro0250] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2005] [Accepted: 06/15/2005] [Indexed: 12/20/2022]
Abstract
The traditional treatment for upper tract transitional cell carcinoma (UTTCC) consists of radical nephroureterectomy. A more conservative approach, however, was required in cases of bilateral UTTCC and in patients with disease in a solitary kidney but who had underlying comorbidities that made them unsuitable candidates for open surgery. Minimally invasive treatment methods were developed for these select groups of patients. Because of technological advancements and refinement in endoscopic techniques, most patients with UTTCC, even those with normal contralateral kidneys, can now be offered minimally invasive treatment with single or multimodal approaches involving ureteroscopy or percutaneous resection. For patients with low-stage, low-grade UTTCC, five-year survival rates are comparable for those treated endourologically and those treated by nephroureterectomy. High-grade lesions have much higher recurrence and progression rates than lower-grade lesions, and nephroureterectomy is therefore recommended in patients with high-grade disease. The use of adjuvant instillation in the treatment of UTTCC, administered via antegrade and retrograde methods, has been shown to improve outcomes. For recurrences to be diagnosed and treated in a timely manner, and acceptable cancer-free survival rates maintained, long-term rigorous follow-up after endourologic treatment, with regular surveillance ureteroscopy, is crucial.
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Affiliation(s)
- Michael C Ost
- Department of Urology, Long Island Jewish Medical Center, New Hyde Park, New York 11040-1496, USA
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Caoili EM, Cohan RH, Inampudi P, Ellis JH, Shah RB, Faerber GJ, Montie JE. MDCT urography of upper tract urothelial neoplasms. AJR Am J Roentgenol 2005; 184:1873-81. [PMID: 15908545 DOI: 10.2214/ajr.184.6.01841873] [Citation(s) in RCA: 160] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
OBJECTIVE The purpose of our study was to review the MDCT urography appearance of pathologically proven transitional cell carcinomas of the renal collecting system and ureter and to correlate the MDCT urography findings with pathology findings. MATERIALS AND METHODS Of 370 MDCT urography examinations performed over an 18-month period, 18 patients were diagnosed with 27 renal collecting system or ureteral urothelial neoplasms at endoscopic biopsy (n = 8) or surgery (n = 19). Initial MDCT reports were reviewed to determine the sensitivity of original reviewers in detecting these neoplasms. Two radiologists also retrospectively reviewed these scans and characterized the CT appearance of the neoplasms on both axial CT and 3D reformatted images. Findings at retrospective review were correlated with pathology results to determine whether any CT features could be used to predict tumor grade. RESULTS Eighteen of 27 neoplasms were prospectively identified on MDCT urography, and an additional six neoplasms were detected on retrospective review. Three ureteral neoplasms could not be visualized. The 24 retrospectively detected neoplasms had three distinct MDCT appearances: circumferential urothelial wall thickening (n = 14), small masses (> 5 mm in maximal diameter) (n = 5), and large masses (> 5 mm in maximal diameter) (n = 5). All detected lesions could be seen on axial excretory phase images provided wide window settings were reviewed; however, only six were detected on 3D reconstructions. MDCT urography appearance did not correlate with tumor grade. CONCLUSION MDCT urography is a promising technique for detecting upper urinary tract neoplasms. The static 3D reconstructions used in this study are insufficient for visualization. Axial image review remains essential for tumor identification.
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Affiliation(s)
- Elaine M Caoili
- Department of Radiology, University of Michigan Health System, B1-132 Taubman Center 0302, 1500 E Medical Center Dr., Ann Arbor, MI 48109-0302, USA
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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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Razdan S, Johannes J, Cox M, Bagley DH. Current Practice Patterns in Urologic Management of Upper-Tract Transitional-Cell Carcinoma. J Endourol 2005; 19:366-71. [PMID: 15865529 DOI: 10.1089/end.2005.19.366] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
PURPOSE To determine the current practice patterns in the management of upper-tract transitional-cell carcinoma (TCC) among a large group of urologists. MATERIALS AND METHODS A survey was sent to 220 practicing members of the Society of Urologic Oncology (SUO) and the Endourological Society (ES) and members of the American Urological Association who did not belong to either society. The survey consisted of 16 focused questions pertaining to the surveillance and management of upper-tract TCC. The responses were used to create a database, which was then analyzed to determine practice trends. RESULTS Eighty-four of the urologists responded, for a response rate of 38%. Fourteen responses were excluded because of multiple answers to a given question, so 70 were included in the final analysis. Eighty percent of the respondents were in academic practice. A CT urogram was the favored initial procedure for diagnosis of upper-tract TCC and an intravenous urogram was the next commonest choice (53% and 40%, respectively). Ureterorenoscopy was the surveillance tool of choice (70%) after conservative treatment of upper- tract TCC. Laparoscopic nephroureterectomy was the preferred procedure (73%) for a high-grade, large renal-pelvic TCC. Twenty-one percent of the endourologists recommended ureteroscopic ablation for a high-grade, large distal ureteral tumor. This was in sharp contrast to 77% of the respondents who favored a distal ureterectomy for the same clinical scenario. CONCLUSIONS This study confirms that most urologists treating upper-tract TCC follow the principles reported in the published literature regarding the management of these patients. Further, most urologists, regardless of society affiliations or years in practice, favor minimally invasive techniques for the management of upper-tract TCC. This information may be useful in formulating clear guidelines for the management of this disease.
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Affiliation(s)
- Sanjay Razdan
- Department of Urology, Thomas Jefferson University, 1025 Walnut Street, Philadelphia, PA 19107, USA
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Soderdahl DW, Fabrizio MD, Rahman NU, Jarrett TW, Bagley DH. Endoscopic treatment of upper tract transitional cell carcinoma. Urol Oncol 2005; 23:114-22. [PMID: 15869996 DOI: 10.1016/j.urolonc.2004.10.010] [Citation(s) in RCA: 73] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2004] [Accepted: 10/05/2004] [Indexed: 01/14/2023]
Abstract
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.
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Affiliation(s)
- Douglas W Soderdahl
- Department of Urology, Eastern Virginia Medical School, Norfolk, VA 23510, USA
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