Treatment of transitional cell carcinoma of the ureter: is the controversy justified?

Oncologic outcomes of radical nephroureterectomy (RNU)

Radical nephroureterectomy is the mainstay of surgical treatment for upper tract urothelial carcinoma (UTUC), a disease which comprises approximately 5% of urothelial malignancies. Minimally-invasive and nephron-sparing interventions have been explored, although thus far have not shown comparable oncologic outcomes except in a relatively narrow set of patients. Due to the relative rarity of the disease, it has taken decades and multi-disciplinary efforts to sufficiently identify prognostic factors of oncologic outcomes. Despite these efforts, however, oncologic outcomes of nephroureterectomy have remained remarkably stable over the past 30 years. New techniques, such as laparoscopic and robotic surgery, have been applied to this procedure. High level evidence regarding equivalent oncologic outcomes is lacking and open surgery remains the standard of care for high-stage disease, although there is a role for laparoscopic and robotic nephroureterectomy. The importance of bladder cuff removal in improving oncologic outcomes has been broadly accepted, although there is no consensus as to the most oncologically appropriate technique. There does appear to be evidence that endoscopic techniques confer worse oncologic control. The role of lymphadenectomy remains controversial, although there is evidence that increased nodal yield could have oncologic benefit. Given disease heterogeneity and varied technical approaches to the procedure, no consensus standardized template has been identified. There is level 1 evidence for the use of intravesical chemotherapy peri-operatively and that this intervention can improve the risk of intravesical recurrence. Advances in systemic neoadjuvant and adjuvant chemotherapy have yielded promising results and are likely to become standard of care for patients without contraindications. Immunotherapy and targeted biologic agents are also likely to improve the surgical efficacy of radical nephroureterectomy as well. Ultimately, more high level evidence is needed to identify successful surgical and medical approaches to UTUC and multi-institutional collaboration is critical to this progress.

Oncological and renal outcomes of segmental ureterectomy vs. radical nephroureterectomy for upper tract urothelial carcinoma

Segmental ureterectomy (SU) represents a promising alternative for the treatment of upper tract urothelial carcinomas (UTUCs) as it is a less invasive procedure and guarantees the preservation of renal units. The present study evaluated oncological outcomes and renal functions following SU when compared with radical nephroureterectomy (RNU). A total of 26 patients with UTUCs who underwent SU (n=12) or RNU (n=14) were retrospectively evaluated. SU was performed in patients with clinically unifocal disease. In the SU group, the following surgeries were carried out: 7 direct ureterocystoneostomy, 1 reimplantation on psoas hitch bladder, 1 reimplantation on Boari flap bladder, 2 ureteral end-to-end anastomosis and 1 subtotal ureterectomy. In the SU group, tumors were low grade urothelial carcinoma (UC) in 6 patients, high grade UC in 5 patients and high grade UC with squamous cell differentiation in 1 patient, as well as ≤pT1 in 5, ≥pT2 in 6 and pTis in 1 patient; 'p' refers to the pathological state. The 5-year overall, cancer-specific, recurrence free and metastasis free survival in the SU group were 77.8, 87.5, 34.4 and 80.8%, respectively, which all exhibited no significant differences when compared with those of the RNU group. With regard to renal function, postoperative estimated glomerular filtration rates were preserved in the SU group. The present study demonstrated that SU does not result in poorer cancer control when compared with RNU. Thus, SU is an acceptable alternative to RNU in selected cases, as it is less invasive and preserves renal functions.

The effect of tumor location on prognosis in patients with primary ureteral urothelial carcinoma

OBJECTIVES

To investigate the association of tumor location on oncological outcomes in patients treated with radical nephroureterectomy (RNU) for primary ureteral urothelial carcinoma (UC).

MATERIALS AND METHODS

From January 1990 to December 2007, 127 patients with primary solitary ureteral UC who underwent RNU at our institution were included. The patients were divided into 3 groups based on tumor location-proximal, middle, or distal ureter. Patients' medical records were reviewed retrospectively. The clinicopathologic data and oncologic outcomes were compared among the groups.

RESULTS

Of the 127 patients, 40 (31.5%) had tumors in the proximal ureter, 40 (31.5%) in the middle ureter, and 47 (37.0%) in the distal ureter. Patients with distal ureteral UC were more likely to undergo open procedures to manage the bladder cuff (P = 0.005). Other clinical and histopathologic variables were not different among the 3 groups. Comparing the proximal, middle, or distal ureteral UC, bladder recurrence developed in, respectively, 25.0%, 25.0%, and 21.3% cases (P = 0.892); local retroperitoneal recurrence in 2.5%, 12.5%, and 4.3% (P = 0.141); contralateral recurrence in 0%, 0%, and 4.3%(P = 0.177); and distant metastasis in 17.5%, 10.0%, and 4.3% (P = 0.147). Recurrence-free and cancer-specific survival among the 3 groups were not different (P = 0.781 and 0.192, respectively).

CONCLUSIONS

Tumor location cannot be used to predict oncologic outcomes in patients treated with RNU for primary ureteral UC. Therefore, clinical decisions or follow-up protocol should not differ among patients with primary proximal, middle, or distal ureteral UC.

[European guidelines for the diagnosis and management of upper urinary tract urothelial cell carcinomas: 2011 update. European Association of Urology Guideline Group for urothelial cell carcinoma of the upper urinary tract]

CONTEXT

The European Association of Urology (EAU) Guideline Group for urothelial cell carcinoma of the upper urinary tract (UUT-UCC) has prepared new guidelines to aid clinicians in assessing the current evidence-based management of UUT-UCC and to incorporate present recommendations into daily clinical practice.

OBJECTIVE

This paper provides a brief overview of the EAU guidelines on UUT-UCC as an aid to clinicians in their daily practice.

EVIDENCE ACQUISITION

The recommendations provided in the current guidelines are based on a thorough review of available UUT-UCC guidelines and papers identified using a systematic search of Medline. Data on urothelial malignancies and UUT-UCCs in the literature were searched using Medline with the following keywords: urinary tract cancer, urothelial carcinomas, upper urinary tract, carcinoma, transitional cell, renal pelvis, ureter, bladder cancer, chemotherapy, nephroureterectomy, adjuvant treatment, neoadjuvant treatment, recurrence, risk factors, and survival. A panel of experts weighted the references.

EVIDENCE SYNTHESIS

There is a lack of data in the current literature to provide strong recommendations due to the rarity of the disease. A number of recent multicentre studies are now available, whereas earlier publications were based only on limited populations. However, most of these studies have been retrospective analyses. The TNM classification 2009 is recommended. Recommendations are given for diagnosis as well as for radical and conservative treatment; prognostic factors are also discussed. Recommendations are provided for patient follow-up after different therapeutic options.

CONCLUSIONS

These guidelines contain information for the diagnosis and treatment of individual patients according to a current standardised approach. When determining the optimal treatment regimen, physicians must take into account each individual patient's specific clinical characteristics with regard to renal function including medical comorbidities; tumour location, grade and stage; and molecular marker status.

European guidelines for the diagnosis and management of upper urinary tract urothelial cell carcinomas: 2011 update

CONTEXT

The European Association of Urology (EAU) Guideline Group for urothelial cell carcinoma of the upper urinary tract (UUT-UCC) has prepared new guidelines to aid clinicians in assessing the current evidence-based management of UUT-UCC and to incorporate present recommendations into daily clinical practice.

OBJECTIVE

This paper provides a brief overview of the EAU guidelines on UUT-UCC as an aid to clinicians in their daily practice.

EVIDENCE ACQUISITION

The recommendations provided in the current guidelines are based on a thorough review of available UUT-UCC guidelines and papers identified using a systematic search of Medline. Data on urothelial malignancies and UUT-UCCs in the literature were searched using Medline with the following keywords: urinary tract cancer, urothelial carcinomas, upper urinary tract, carcinoma, transitional cell, renal pelvis, ureter, bladder cancer, chemotherapy, nephroureterectomy, adjuvant treatment, neoadjuvant treatment, recurrence, risk factors, and survival. A panel of experts weighted the references.

EVIDENCE SYNTHESIS

There is a lack of data in the current literature to provide strong recommendations due to the rarity of the disease. A number of recent multicentre studies are now available, whereas earlier publications were based only on limited populations. However, most of these studies have been retrospective analyses. The TNM classification 2009 is recommended. Recommendations are given for diagnosis as well as for radical and conservative treatment; prognostic factors are also discussed. Recommendations are provided for patient follow-up after different therapeutic options.

CONCLUSIONS

These guidelines contain information for the diagnosis and treatment of individual patients according to a current standardised approach. When determining the optimal treatment regimen, physicians must take into account each individual patient's specific clinical characteristics with regard to renal function including medical comorbidities; tumour location, grade and stage; and molecular marker status.

Robotic nephroureterectomy with partial duodenectomy for invasive ureteral tumor

Robotic surgery is gaining acceptance in the management of diverse urological disorders. Any minimally invasive procedure carries a risk of open conversion either for complications or unexpected intraoperative findings, but the additional dexterity of robotic instrumentation may allow even complex situations to be managed laparoscopically. We report the case of an upper tract transitional cell carcinoma discovered at the time of robotic nephroureterectomy to be invading the duodenum that was successfully excised robotically.

Temporal stage and grade migration in surgically treated patients with upper tract urothelial carcinoma

STUDY TYPE

Therapy (individual cohort).

LEVEL OF EVIDENCE

2b.

OBJECTIVE

To examine the temporal trends in stage and grade at presentation, as well as cancer-specific mortality (CSM) rates, in surgically treated patients with upper tract urothelial carcinoma (UTUC), as few population-based studies addressed contemporary cancer-control outcomes in patients with UTUC.

PATIENTS AND METHODS

Within the Surveillance, Epidemiology and End Results (SEER) database, we identified 4915 patients diagnosed with UTUC between 1983 and 2004, who had either a nephroureterectomy (NU) or a segmental ureterectomy (SU). Patients were divided into four groups according to the year-of-surgery quartiles. The chi-square test and the chi-square trend test were used for comparison of proportions and trends over time. Kaplan-Meier plots were used to graphically depict CSM rates. Multivariable Cox regression models were used to test the effect of the year-of-surgery quartiles on CSM. Covariates consisted of SEER stage, tumour grade, age, race, primary tumour site, type of surgery, and SEER registries.

RESULTS

Of 4915 assessable patients, 1316, 1328, 1146 and 1125 were, respectively, treated in 1983-1988, 1989-94, 1995-99 and 2000-2004. Of those, 4430 had a NU and 485 had a SU. The rates of non-localized stage and of grade III-IV disease at surgery increased, respectively, from 49.8% to 69.5% (P < 0.001) and 45.7 to 70.2% (P < 0.001) during the study period. CSM rates at 4 years after surgery reflected the temporal stage and grade differences, and increased from 18.2 to 23.9% (P = 0.03) between 1983-1988 and 2000-2004. In multivariable analyses, when stage and grade were taken into account, most contemporary patients showed more favourable CSM rates than their historic counterparts (hazard ratio 0.7, P = 0.02).

CONCLUSIONS

We report a stage and grade migration at NU or SU towards more aggressive disease among surgically treated patients between 1983 and 2004. Despite this observation, the CSM rates of contemporary patients have not worsened, which validates the role of NU and SU as effective treatments for UTUC.

Management of patients with upper urinary tract transitional cell carcinoma

Multiple therapeutic options are available for the management of patients with upper urinary tract transitional cell carcinoma (TCC). Radical nephroureterectomy with an ipsilateral bladder cuff is the gold-standard therapy for upper-tract cancers. However, less invasive alternatives have a role in the treatment of this disease. Endoscopic management of upper-tract TCC is a reasonable strategy for patients with anatomic or functional solitary kidneys, bilateral upper-tract TCC, baseline renal insufficiency, and significant comorbid diseases. Select patients with a normal contralateral kidney who have small, low-grade lesions might also be candidates for endoscopic ablation. Distal ureterectomy is an option for patients with high-grade, invasive, or bulky tumors of the distal ureter not amenable to endoscopic management. In appropriately selected patients, outcomes following distal ureterectomy are similar to that of radical nephroureterectomy. Bladder cancer is a common occurrence following the management of upper-tract TCC. Currently, there are no variables that consistently predict which patients will develop intravesical recurrences. As such, surveillance with cystoscopy and cytology following surgical management of upper-tract TCC is essential. Extrapolating from data on bladder TCC, both regional lymphadenectomy and neoadjuvant chemotherapy regimens are likely to be beneficial for patients with upper-tract TCC, particularly in the setting of bulky disease.

Elective management of transitional cell carcinoma of the distal ureter: can kidney-sparing surgery be advised?

OBJECTIVE

To determine the long-term oncological outcome of patients with primary transitional cell carcinoma (TCC) of the distal ureter electively treated with either kidney-sparing surgery (KSS) or radical nephroureterectomy (RNU) in a retrospective, non-randomized, single-centre study.

PATIENTS AND METHODS

Of 43 consecutive patients with a primary solitary distal ureter TCC, 19 had KSS, consisting of distal ureter resection with bladder cuff excision and ureter reimplantation, and 24 had RNU with bladder cuff excision.

RESULTS

The median (range) age at surgery was 69 (31-86) years for the KSS group and 73 (59-87) years for the RNU group, patients in the latter having worse hydronephrotic kidneys. The median (range) follow-up was 58 (3-260) months. A recurrent bladder tumour was diagnosed after a median of 15 months in five of the 19 patients treated by KSS and after a median of 5.5 months in eight of the 24 treated by RNU. Five of the 19 patients treated by KSS and six of the 24 treated by RNU died from metastatic disease despite chemotherapy. Recurrence-free, cancer-specific and overall survival were comparable in the two groups. In two patients (11%) treated by KSS an ipsilateral upper urinary tract TCC recurred after 42 and 105 months, respectively.

CONCLUSION

Treatment by distal ureteric resection is feasible in patients with primary TCC of the distal ureter. The long-term oncological outcome seems to be comparable with that of patients treated by RNU. Furthermore, kidney preservation is advantageous if adjuvant or salvage chemotherapy is required.

[Conservative treatment of upper urinary tract tumors]

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.

Transitional cell carcinoma of the ureter: prognostic factors influencing progression and survival

OBJECTIVES

We retrospectively evaluated prognostic factors for progression-free and disease-specific survival in a large cohort of patients with transitional cell carcinoma (TCC) of the ureter.

METHODS

A single-centre series of 145 consecutive patients treated with partial resection of the ureter or nephroureterectomy between 1975 and 2004 was evaluated. Median follow-up was 96 mo. Routine preoperative laboratory parameters as well as clinical and tumour-specific data were assessed. Univariate and multivariate statistical analyses were performed.

RESULTS

Five-year disease-specific survival ranged from 96.1% for stages pTa to 28.6% for pT4. Grade1 tumours were associated with 5-yr disease-specific survival rates of 100% compared with 84% for G2, and 51.9% for G3 tumours, respectively. Univariate analyses identified pT stage and grade, tumour diameter, cM and pN categories, weight loss, the presence of synchronous tumour in the renal pelvis as well as elevated levels for humoral factors such as serum alkaline phosphatase (AP), white blood cell (WBC) count, platelet count, gamma-glutamyl transferase, creatinin, and blood urea nitrogen as prognostic factors. In multivariate analyses, tumour grade and WBC counts were predictive for low progression-free survival rates, whilst simultaneous tumour in the renal pelvis, high AP levels, and WBC counts were correlated with worse disease-specific survival.

CONCLUSIONS

Our retrospective analysis provides clinical factors to identify patients with TCC of the ureter at high risk for progression and death of disease. Interestingly, humoral factors such as elevated serum AP levels and high WBC counts were demonstrated to be of paramount prognostic significance besides tumour stage, grade and multifocality.

Current Practice Patterns in Urologic Management of Upper-Tract Transitional-Cell Carcinoma

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.

Comparative study of ureteral stripping versus open ureterectomy for nephroureterectomy in patients with transitional carcinoma of the renal pelvis

OBJECTIVES

To evaluate the clinical outcome of nephroureterectomy with endoscopically assisted transurethral ureteral stripping for transitional cell carcinoma of the renal pelvis in a comparative study.

METHODS

Sixty patients with localized renal pelvic cancer were enrolled in a prospective comparative nonrandomized study. Of these, 28 patients underwent nephroureterectomy with endoscopically assisted transurethral ureteral stripping and 32 underwent conventional nephroureterectomy with a bladder cuff. Both short-term and long-term results were analyzed in this series.

RESULTS

The operating time for patients with ureteral stripping was significantly shorter than for those with a standard two-incision nephroureterectomy (median 183 versus 250 minutes, P = 0.0231), and the amount of blood loss was significantly less (median 150 versus 390 mL, P = 0.0002). Intravesical recurrence was detected in 10 (35.7%) of the 28 patients with ureteral stripping, and the 1-year and 3-year recurrence-free rate was 68.0% and 57.7%, respectively. Seven patients treated by the standard two-incision nephroureterectomy (21.9%) experienced intravesical recurrence, with a 1-year and 3-year recurrence-free rate of 96.8% and 75.0%, respectively. The recurrence rate was significantly greater in the group with ureteral stripping (P = 0.0287).

CONCLUSIONS

Compared with conventional nephroureterectomy with a bladder cuff, nephroureterectomy with transurethral stripping is a minimally invasive procedure with a shorter operating time and less blood loss, but a statistically significantly greater intravesical recurrence rate. Greater consideration should be taken before selecting this procedure.

Laparoscopic and renal sparing approaches to tumours of the ureter and kidney

Until recently, malignancies of the kidney and ureter were managed with open radical surgery. Over the last decade the urologic community has adopted the skill of laparoscopic surgery for the treatment of these tumours. Parenchymal sparing procedures have become the standard of care in the treatment of selected patients with renal and ureteral tumours and many of these surgical procedures can be performed laparoscopically or ureteroscopically. Due partly to necessity and partly to the advancement of technology, renal and ureteral sparing procedures have become commonplace for definitive treatment and palliation of these tumours. The morbidity of such procedures is significantly less than for open surgery and the future of urologic minimally invasive surgery appears secure. This review article is aimed at updating the reader in the most recent advances in these techniques.

When is partial ureterectomy acceptable for transitional-cell carcinoma of the ureter?

Because the disease is so often multifocal and has a high likelihood of recurrence, transitional-cell carcinoma of the ureter traditionally has been treated by nephroureterectomy. As reviewed in this article, partial ureterectomy may be a feasible option for some patients, particularly those with a solitary kidney, bilateral tumors, or renal insufficiency. This conservative procedure also may be appropriate for patients with grade 1 and possibly grade 2 tumors in stage Ta/T1.

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.

Laparoscopic nephroureterectomy. A new standard for the surgical management of upper tract transitional cell cancer

Laparoscopic nephroureterectomy for upper tract TCC still remains somewhat controversial. Unlike laparoscopic radical nephrectomy, which has become widely accepted, LNU is still in its earliest stages. Although there are obvious benefits for the patient who has LNU--less pulmonary complications, less postoperative discomfort, a shorter hospital stay, a better cosmetic result, and a brief convalescence--there are significant concerns. The longer operative time creates a negative financial and professional inducement to learn this technique. Operative times need to fall into the 4-hour range or less to make the procedure cost-effective. Analysis of the efficacy of laparoscopic nephroureterectomy as a curative treatment modality is important. In the short-run, LNU seems to provide similar results to open nephroureterectomy for upper TCC. Although concerns over port site seeding, bladder recurrence, and intraperitoneal seeding have been voiced, these problems have not occurred. The higher incidence of local recurrence noted in the authors' series, however, is of concern and remains an unsettled issue. Despite these local recurrences, the overall cancer survival for a given grade and stage of upper tract TCC seem to be similar to survivals recorded after open nephroureterectomy. Still, the number of LNU cases remains small, and follow-up is brief. These patients need to be monitored closely, with follow-up CT scans over the next decade. The authors believe that there are still several significant hurdles standing in the path of LNU before it can become a widely accepted procedure. Issues of cost, training, and long-term efficacy must be answered definitively. To obtain these types of data, it will be necessary to create a multi-institutional, cooperative study to obtain sufficient numbers of patients with a more than 5-year follow-up on which to base future recommendations.

[Treatment of pyelocaliceal transitional cell carcinoma with partial nephrectomy]

Nephroureterectomy is the choice treatment for tumours of the upper urinary tract. Conservative surgical management is sometimes warranted due to the risk of renal failure or just as palliative treatment. Contribution of two cases of transitional tumours in the pyelocalyceal zone treated with partial nephrectomy, and discussion of the usefulness and indication of conservative surgery for these tumours.

Risk factors for the development of bladder cancer after upper tract urothelial cancer

OBJECTIVES

To determine the clinical and pathologic risk factors for initial intravesical recurrence in patients with primary renal pelvic and/or ureteral cancer and to examine the progression in the bladder in patients having high risk factors for intravesical recurrence.

METHODS

This study included 69 patients with renal pelvic and/or ureteral cancer. We excluded patients with distant metastases, those with a short period of follow-up, and those having a previous history or concomitance of bladder cancer. The exclusion criteria were chosen to avoid contamination by patients with a poor prognosis who might die of the primary cancer before bladder cancer development. Multivariate analysis by Cox's proportional hazards model was used to determine what clinical and pathologic variables significantly affected the initial intravesical recurrence of cancer. We also studied the stage progression of cancer that recurred in the bladder.

RESULTS

Initial intravesical recurrence of the cancer was found in 22 patients during a median follow-up period of 53 months (range 12 to 225). The intravesical disease-free rate after upper tract urothelial cancer was 65% (rate of disease recurrence in bladder 35%) at 5 years by the Kaplan-Meier method. The extent (multifocality) of the upper urinary cancer (P = 0.0038) and pathologic stage (P = 0.0409) independently influenced intravesical recurrence. Age, sex, adjuvant chemotherapy, configuration of the primary tumor, primary cancer size, and pathologic grade did not affect recurrence. The rate of stage progression also was not influenced by the extent of the disease in the upper urinary tract.

CONCLUSIONS

The extent and pathologic stage of cancer in the upper urinary tract were significant and independent factors for initial intravesical recurrence of cancer. However, no difference was found in clinical outcome in terms of stage progression between patients having high risk factors for intravesical recurrence and those without them.

Results of conservative treatment of upper urinary tract transitional cell carcinoma

BACKGROUND

The treatment preserving the kidney for upper urinary tract tumor is still controversial. The indications and results of conservative treatment remain to be elucidated. Experiences of this type of treatment are reported.

METHODS

Between April 1981 and March 1998, 14 patients with upper urinary tract transitional cell carcinoma were treated with renal preserving methods. Five were elective and nine were imperative cases. Treatments performed were partial nephrectomy, partial ureterctomy with or without adjuvant chemotherapy, endoscopic tumor resection and topical bacillus Calmette-Guerin instillation in one, 10, two and one patient, respectively.

RESULTS

Crude and cause-specific 5 year-survival rates were 91.7 and 100%, respectively. Of 14 patients, five had bladder recurrences, but ipsilateral local recurrence developed in only one patient. Two patients died from metastasis of transitional cell carcinoma 61 and 89 months after initial treatment. The lesions of carcinoma in situ were well controlled with topical bacillus Calmette-Guerin therapy.

CONCLUSION

The results of conservative treatment for upper urinary tract tumor were satisfactory and local excision can be indicated for low grade, solitary tumors located in the distal ureter.

Conservative surgery for ureteral tumor associated with horseshoe kidney

PURPOSE

We demonstrate the successful conservative management of a ureteral tumor in a horseshoe kidney.

MATERIALS AND METHODS

A patient with low grade transitional cell carcinoma of the left lower ureter had asymptomatic horseshoe kidney. Biopsy specimen revealed low grade tumor in the lower urinary tract that was associated with a congenital abnormality. The patient underwent total ureterectomy with bladder cuff excision and ileal ureteral interposition.

RESULTS

With this technique renal function was preserved without resection through the isthmus of the kidney. The patient has no evidence of recurrent disease after 20-month followup by cytology, computerized tomography, excretory urogram and cystoscopy.

CONCLUSIONS

Organ preserving surgery is an alternative to total nephroureterectomy in lower ureteral tumors in select patients.

Upper-tract transitional cell carcinoma

Advances in ureteroscopic techniques have made it possible to treat many upper-tract tumors conservatively. Such treatment has demonstrated acceptable survival and renal preservation in high-risk patients, particularly those with a solitary kidney, bilateral tumors, poor renal function, or prohibitive operative risk. It is also preferred in patients with grade I TCC, particularly when located in the distal ureter. For patients with regionally extensive upper-tract urothelial neoplasms, use of endourologic techniques should be considered to control hemorrhage, relieve obstruction, and preserve as much functioning renal tissue as possible. Success with small, solitary, low-grade tumors allows the application of this technique to patients with a normal contralateral kidney on an elective basis. Adjuvant BCG or mitomycin C therapy appears to be safe, but confirmation of any benefits awaits the results of larger trials. Benign neoplasms can occur in the upper urinary tract and should be distinguished from TCC, thus avoiding more radical treatment for a benign lesion. Endoscopic surveillance should be maintained because recurrences can develop without radiographic evidence.

Endourological management of upper tract urothelial tumors

Advances in ureteroscopic and percutaneous techniques have made it possible to treat many upper tract malignancies by conservative, parenchyma sparing surgery. Percutaneous techniques generally allow for easier and better access to the renal pelvis and improved tumor resection. However, concerns for tumor spillage and nephrostomy tract seeding make the ureteroscopic approach best for initial management of accessible renal pelvic lesions, particularly when the diagnosis is unclear. Ureteral tumors, especially those arising in the lower third of the ureter, are technically easier to treat endoscopically than are renal pelvic tumors. Fulguration or laser photocoagulation may be used to ablate the tumor following cold-cup biopsy for histological diagnosis. Supplemental therapy using laser treatment of the tumor base, and postoperative instillation of BCG and mitomycin C offer great potential benefit in terms of improved tumor control. Confirmation of such benefit awaits the results of larger trials. Presently, standard nephroureterectomy remains the procedure of choice for most transitional cell carcinomas of the upper urinary tract in patients with a normal contralateral kidney. For those with a solitary kidney, renal insufficiency, bilateral tumors or severe intercurrent disease preventing a major open operation conservative management using endoscopic techniques is a viable alternative. Overall, it appears that grade and stage are far more important determinants of long-term out-come than the type of operation in those with transitional cell carcinoma of the upper urinary tract. For this reason, some physicians have recommended conservative management of low grade, noninvasive lesions even in the face of a normal opposite kidney. However, the majority of patients with upper tract urothelial tumors are best treated by nephroureterectomy, which leads to a low risk of local recurrence and obviates the need for rigorous postoperative upper tract surveillance.

Endourological treatment of large neoplasm in the lower tract of the ureter

Conservative endourological treatment of transitional cell carcinoma of renal pelvis and ureter is controversial. The treatment should be reserved for selected cases and for low grade, low stage, monofocal tumors. Personal experience with endourological treatment of a transitional cell carcinoma of the lower tract of the ureter is presented.