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

Segmental Resection

Historically, open nephron-sparing surgery for upper-tract TCC was used in patients with a large renal pelvis tumor in a solitary kidney or synchronous bilateral tumors. Advances in endourologic techniques, particularly percutaneous antegrade renal surgery, have largely supplanted this open approach for the conservative management of renal pelvis tumors. A flank incision is used for kidney exposure, followed by a pyelotomy and resection of the renal pelvis tumor. The base of the lesion is cauterized, the pyelotomy defect is repaired, and postoperative drainage is accomplished by ureteral stenting or via a percutaneous nephrostomy tube.

The cumulative risk of tumor recurrence within the ipsilateral renal pelvis following pyelotomy or partial nephrectomy ranges from 7% to 70%.[7,53,54,55] The high recurrence rates are secondary to the inherent field change defect observed with upper-tract TCC.

Distal ureterectomy with reimplantation is a reasonable alternative for patients with high-grade, invasive, or bulky tumors of the distal ureter that are not amenable to endoscopic ablation. Preservation of the ipsilateral renal moiety is particularly advantageous for patients with borderline renal function who might require adjuvant cisplatin-based chemotherapy regimens. It is essential to exclude the presence of concurrent proximal ureteral or renal pelvis disease, which would necessitate a complete nephroureterectomy. If the upper ureter is not accessible preoperatively because of obstruction, intraoperative flexible ureteroscopy can be performed to visualize the upper urinary tract. In addition to bladder reimplantation, the surgical procedure might require a Psoas hitch or Boari bladder flap, depending upon the length of resected ureter. Although the open approach has traditionally been described for distal ureteral resection, early reports of success with both the laparoscopic and robotic techniques indicate that these may be feasible options in the future.[56,57] Finally, bladder reimplantation should be at a site that is amenable for future upper-tract access as recurrence rates are not insignificant.

Segmental ureterectomy of the proximal or mid-ureter with primary ureterostomy is rarely indicated. Exceptions to this would be proximal tumors not amenable to endoscopic ablation in a functional solitary kidney.

In appropriately selected patients with solitary ureteral lesions, outcomes following subtotal ureterectomy are similar to that of radical nephroureterectomy. Mazeman reported that the incidence of regional failure was similar for 246 patients treated by nephroureterectomy compared with 44 patients treated by distal ureterectomy.[53] Recurrence rates in the ipsilateral ureter range from 10% to 25% and vary with pathologic stage and grade of the original tumor.[58,59,60,61] Low-grade, low-stage lesions have excellent 5-year outcomes with ipsilateral ureteral recurrence rates of less than 5%.[58] In contrast, the prognosis for higher stage lesions is worse, with 5-year survival rates of 65% for T1 lesions and 50% for T2 tumors.[7]

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