Management of Patients With Upper Urinary Tract Transitional Cell Carcinoma

Jay D Raman; Douglas S Scherr*

Disclosures

Nat Clin Pract Urol. 2007;4(8):432-443. 

In This Article

Diagnosis and Staging

Gross or microscopic hematuria is the most common presentation of upper-tract TCC, with flank pain or palpable masses occurring much less frequently. Some patients are asymptomatic; 10–15% have incidental lesions detected on radiographic evaluation. Intravenous urography has historically been used to evaluate the upper urinary tract. More recently, however, CT with a delayed 'urographic' phase is performed, allowing for characterization of the lesion and evaluation of the contralateral renal unit, as well as providing staging information. A filling defect is the most common abnormality noted on imaging studies, although nonvisualization is reported in 20% of renal pelvis and 40% of ureteral tumors.[6,7]

Diagnostic evaluation of suspected upper-tract TCC involves cystourethroscopy, selective upper-tract urinary cytology, retrograde ureteropyelography, and biopsy of suspected lesions. The sensitivity of urinary cytology correlates closely with pathologic tumor grade. Selective upper-tract cytology of high-grade lesions, including carcinoma in situ, has a reported accuracy of detection of almost 80%, whereas for well-differentiated tumors the accuracy rate is only 10% to 40%.[8,9] Ureteropyeloscopy allows for direct visualization of suspected lesions and offers the opportunity to biopsy such abnormalities to obtain a tissue diagnosis. Biopsies typically note an 80–90% concordance of pathologic grade between the endoscopic and the final pathologic specimen; however, almost 50% of the ureteroscopic biopsies fail to correlate with pathologic stage.[10,11]

Following a diagnosis of upper-tract TCC, several management options are available. The particular choice of treatment is dependent on the clinical staging ( Box1 ) of the upper-tract lesion as well as patient and surgeon-specific variables. The indications, techniques, and outcomes for different forms of therapy are discussed later in this Review. An algorithm for the management of upper-tract TCC is included for referral (Figure 1).

Algorithm for the management of upper-tract TCC. After a tissue diagnosis is obtained by ureteroscopy and biopsy, lesions that are amenable to endoscopic ablation will be managed either by a retrograde ureteroscopic or an antegrade percutaneous technique. Larger, bulkier lesions will require a more substantive procedure such as a segmental ureterectomy or a radical nephroureterectomy.

After a tissue diagnosis is obtained by ureteroscopy and biopsy, lesions that are amenable to endoscopic ablation will be managed either by a retrograde ureteroscopic or an antegrade percutaneous technique. Larger, bulkier lesions will require a more substantive procedure such as a segmental ureterectomy or a radical nephroureterectomy.

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