Rigid Uretero-Resectoscopic Management of Ureteral Tumors
Abstract
Ureteroscopic resection of upper tract is indicated by patient preference, medical comorbidities, and location/size of tumor. The literature on ureteral recurrence reports a recurrence rate of 48% for low grade and 60% for high grade, but the real recurrence rate is likely to be higher. Risk factors for recurrence include size >2 cm, grade, prior history of urothelial cell carcinoma and stage. The most important factor appears to be grade. Patients who failed conservative therapy and had a delayed radical nephroureterectomy had similar disease-specific survival and pathological stage to those who choose immediate radical nephroureterectomy. In our experience, ureteral tumors are best treated with ureteraoresectoscope. One must be careful with resecting near vessels such as the iliacs in the mid-ureter. In many cases, the resection will need to be staged secondary to the bulky nature of the tumor. If the lesion appears to be extensive or high grade, we instill Mitomycin C at the end of the procedure.
Keywords
Ureteroscopic resection Upper tract recurrence Risk factors for recurrence Uretero-resectoscope Mitomycin C Upper tract urothelial carcinomaNotes
Acknowledgements
Author acknowledges the contribution of Sean Fullerton, MD, Westchester Medical Health Network, New York Medical College, Valhalla, NY and thanks him for his helpful comments and feedback.
Supplementary material
Ureteroscopic resection using the Wolf rigid uretero-resectoscope (MP4 487420 kb)
Uretroscopic resection using the Storz rigid ureteroresectoscope (MP4 33409 kb)
Second session for resection of residual tumor and margins that are now better visualized (MP4 132258 kb)
Follow-up digital video-ureteroscopy now shows no residual tumor. The previously resected orifice allows for reflux into distal ureter for topical treatment (MP4 183005 kb)
References
- 1.Cutress ML, Stewart GD, Zakikhani P, et al. Ureteroscopic and percutaneous management of upper tract urothelial carcinoma (UTUC): systematic review. BJU Int. 2012;110:614.CrossRefPubMedGoogle Scholar
- 2.Schmeller NT, Hofstetter AG. Laser treatment of ureteral tumors. J Urol. 1989;141:840.CrossRefPubMedGoogle Scholar
- 3.Martinez-Pineiro JA, Garcia Matres MJ, Martinez-Pineiro L. Endourological treatment of upper tract urothelial carcinomas: analysis of a series of 59 tumors. J Urol. 1996;156:377.CrossRefPubMedGoogle Scholar
- 4.Cutress ML, Stewart GD, Tudor EC, et al. Endoscopic versus laparoscopic management of noninvasive upper tract urothelial carcinoma: 20-year single center experience. J Urol. 2013;189:2054.CrossRefPubMedGoogle Scholar
- 5.Deligne E, Colombel M, Badet L, et al. Conservative management of upper urinary tract tumors. Eur Urol. 2002;42:43.CrossRefPubMedGoogle Scholar
- 6.Roupret M, Hupertan V, Traxer O, et al. Comparison of open nephroureterectomy and ureteroscopic and percutaneous management of upper urinary tract transitional cell carcinoma. Urology. 2006;67:1181.CrossRefPubMedGoogle Scholar
- 7.Iborra I, Solsona E, Casanova J, et al. Conservative elective treatment of upper urinary tract tumors: a multivariate analysis of prognostic factors for recurrence and progression. J Urol. 2003;169:82.CrossRefPubMedGoogle Scholar
- 8.Suh RS, Faerber GJ, Wolf JS Jr. Predictive factors for applicability and success with endoscopic treatment of upper tract urothelial carcinoma. J Urol. 2003;170:2209.CrossRefPubMedGoogle Scholar
- 9.Chromecki TF, Bensalah K, Remzi M, et al. Prognostic factors for upper urinary tract urothelial carcinoma. Nat Rev Urol. 2011;8:440.CrossRefPubMedGoogle Scholar
- 10.Krambeck AE, Thompson RH, Lohse CM, et al. Endoscopic management of upper tract urothelial carcinoma in patients with a history of bladder urothelial carcinoma. J Urol. 2007;177:1721.CrossRefPubMedGoogle Scholar
- 11.Thompson RH, Krambeck AE, Lohse CM, et al. Endoscopic management of upper tract transitional cell carcinoma in patients with normal contralateral kidneys. Urology. 2008;71:713.CrossRefPubMedGoogle Scholar
- 12.Lee BR, Jabbour ME, Marshall FF, et al. 13-year survival comparison of percutaneous and open nephroureterectomy approaches for management of transitional cell carcinoma of renal collecting system: equivalent outcomes. J Endourol. 1999;13:289.CrossRefPubMedGoogle Scholar
- 13.Fuglsig S, Krarup T. Percutaneous nephroscopic resection of renal pelvic tumors. Scand J Urol Nephrol Suppl. 1995;172:15.PubMedPubMedCentralGoogle Scholar
- 14.Lucas SM, Svatek RS, Olgin G, et al. Conservative management in selected patients with upper tract urothelial carcinoma compares favourably with early radical surgery. BJU Int. 2008;102:172.CrossRefPubMedGoogle Scholar
- 15.Gadzinski AJ, Roberts WW, Faerber GJ, et al. Long-term outcomes of immediate versus delayed nephroureterectomy for upper tract urothelial carcinoma. J Endourol. 2012;26:566.CrossRefPubMedGoogle Scholar
- 16.Hendin BN, Streem SB, Levin HS, et al. Impact of diagnostic ureteroscopy on long-term survival in patients with upper tract transitional cell carcinoma. J Urol. 1999;161:783.CrossRefPubMedGoogle Scholar
- 17.Boorjian S, Ng C, Munver R, et al. Impact of delay to nephroureterectomy for patients undergoing ureteroscopic biopsy and laser tumor ablation of upper tract transitional cell carcinoma. Urology. 2005;66:283.CrossRefPubMedGoogle Scholar
- 18.Haddad M, Cloutier J, Cornu JN, et al. Immediate nephroureterectomy or after attempting conservative treatment, on elective indications, for upper urinary tract urothelial carcinoma: comparison of the pathology reports on a retrospective monocentric study. J Endourol. 2015;29:969.CrossRefPubMedGoogle Scholar
- 19.Gaboardi F, Bozzola A, Dotti E, et al. Conservative treatment of upper urinary tract tumors with Nd:YAG laser. J Endourol. 1994;8:37.CrossRefPubMedGoogle Scholar
- 20.Engelmyer EI, Belis JA. Long-term ureteroscopic management of low-grade transitional cell carcinoma of the upper urinary tract. Tech Urol. 1996;2:113.PubMedPubMedCentralGoogle Scholar
- 21.Daneshmand S, Quek ML, Huffman JL. Endoscopic management of upper urinary tract transitional cell carcinoma: long-term experience. Cancer. 2003;98:55.CrossRefPubMedGoogle Scholar
- 22.Johnson GB, Fraiman M, Grasso M, Broadening experience with the retrograde endoscopic management of upper urinary tract urothelial malignancies. BJU Int. 95 Suppl 2; 2005:110.CrossRefPubMedGoogle Scholar
- 23.Pak RW, Moskowitz EJ, Bagley DH. What is the cost of maintaining a kidney in upper-tract transitional-cell carcinoma? An objective analysis of cost and survival. J Endourol. 2009;23:341.CrossRefPubMedGoogle Scholar
- 24.Cornu JN, Rouprêt M, Carpentier X, et al. Oncologic control obtained after exclusive flexible ureteroscopic management of upper urinary tract urothelial cell carcinoma. World J Urol. 2010;28:151.CrossRefPubMedGoogle Scholar
- 25.Gadzinski AJ, Roberts WW, Faerber GJ, et al. Long-term outcomes of nephroureterectomy versus endoscopic management for upper tract urothelial carcinoma. J Urol. 2010;183:2148.CrossRefPubMedGoogle Scholar
- 26.Raymundo EM, Lipkin ME, Bañez LB, et al. Third prize: the role of endoscopic nephron-sparing surgery in the management of upper tract urothelial carcinoma. J Endourol. 2011;25:377.CrossRefPubMedGoogle Scholar
- 27.Grasso M, Fishman AI, Cohen J, et al. Ureteroscopic and extirpative treatment of upper urinary tract urothelial carcinoma: a 15-year comprehensive review of 160 consecutive patients. BJU Int. 2012;110:1618.CrossRefPubMedGoogle Scholar
- 28.Yokogi H, Wada Y, Mizutani M, et al. Bacillus Calmette-Guérin perfusion therapy for carcinoma in situ of the upper urinary tract. Br J Urol. 1996;77:676.CrossRefPubMedGoogle Scholar