What is the role of ureteroscopy in the treatment of urothelial tumors of the renal pelvis and ureters?

Updated: Aug 07, 2020
  • Author: Kyle A Richards, MD, FACS; Chief Editor: Bradley Fields Schwartz, DO, FACS  more...
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Answer

Ureteroscopy offers a renal-preserving alternative to traditional nephroureterectomy and is used in patients with compromised renal function, bilateral upper tract disease, or other medical contraindications to nephroureterectomy. Ureteroscopic ablation is now the preferred choice for low-grade upper tract TCC. However, management of upper tract tumors with this approach is associated with the need for multiple additional procedures versus more definitive surgical management.

Ureteroscopy allows biopsy and treatment of tumors along the entire upper urinary tract. Cold-cup biopsy forceps or a flat-wire basket is used for tissue diagnosis and to determine tumor grade to plan for future intervention.

The use of Nd:YAG and Ho:YAG lasers, as well as small 2F-3F electrosurgical devices, enable ureteroscopic resection, coagulation, and ablation of upper tract tumors under direct vision.

A systematic review of ureteroscopic and percutaneous management by Cutress et al determined that approximately 20% of patients eventually required nephroureterectomy. Upper tract recurrence was high, at 52% for endoscopy and 37% percutaneous management. Overall survival in the pooled analysis was 72% for ureteroscopic management and 79% for percutaneous approach. The disease-specific survival rate was 91% for ureteroscopy and 89% for percutaneous resection. [26]

Cutress et al also reported their 20-year experience with endoscopic management. [53] Seventy-three patients had longer follow-up than most studies, at a mean of 63 months. Nineteen percent of patients proceeded to nephroureterectomy. The upper tract recurrence rate was 68%. The overall survival rate was 69.7% and the disease-specific survival rate was 88.9% at 5 years.

In another study of 90 patients with upper tract TCC managed endoscopically who had a history of bladder cancer, the recurrence-free survival rate at 5 years was only 29%. The authors of this study recommended a low threshold for more aggressive surgical intervention based upon stage and grade migration. [54]

Grasso et al published their 15-year experience of ureteroscopic and extirpative therapy and concluded that uteroscopic management was an acceptable option for managing low-grade disease. [55]

The following are technical considerations for ureteroscopic treatment of upper tract tumors [56] :

  • Obtain adequate tissue during initial biopsy for accurate diagnosis and grade

  • When ablating ureteral tumors, minimize the risk of stricture with the use of laser rather than the more deeply penetrating electrosurgical devices

  • Drain the bladder with a small catheter or use a ureteral access sheath to improve flow and visibility, which can be limited by bleeding

  • Facilitate resection by slowing the patient’s respiratory rate, which decreases movement and stabilizes the operative field during resection and ablation


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