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

Radical Nephroureterectomy

Radical nephroureterectomy with excision of an ipsilateral bladder cuff is the gold-standard therapy for patients with a normal contralateral kidney.[7,25,62,63,64] This is particularly true in cases of high-grade, invasive tumors of the renal pelvis and proximal ureter or low–moderate-grade lesions that are large, bulky, or multifocal. Complete removal of the whole ipsilateral urothelium (kidney and ureter) is essential given the recurrent nature of TCC, with high rates of urothelial recurrence (7–70%) in the ureteral stump when only a nephrectomy is performed.[7,54,62] Nephroureterectomy can be performed by an open, laparoscopic, or hand-assisted laparoscopic technique. Ipsilateral adrenalectomy is generally unnecessary unless the tumor is a superior lesion with suspected direct adrenal invasion.[27]

Open nephroureterectomy can be performed through a variety of approaches depending upon the surgeon's preference, patient body habitus, and medical comorbidities. Generally, a flank incision for the nephrectomy followed by a Gibson, Pfannensteil, or lower-midine incision for the distal ureter is used. Alternatively, the operation can be performed through a single midline incision, although exposure to the kidney is limited (particularly for left-sided masses). The indications for laparoscopic surgery are identical to that for the open approach. Laparoscopic nephroureterectomy can be performed by a pure laparoscopic or a hand-assisted laparoscopic technique via either a transperitoneal or retroperitoneal approach. With the hand-assisted technique, the hand incision is conveniently placed to facilitate the distal ureterectomy (Figure 2).

Trocar configuration and hand-assist device placement for (A) right and (B) left hand-assisted laparoscopic nephroureterectomy (HALN). (A) For right-sided HALN, four ports were used: a 12 mm trocar at the mid-clavicular line 2 cm below the umbilicus (working instrument), a 5 mm periumbilical trocar (working instrument), a 5 mm trocar at the midline 5 cm above the umbilicus (camera), and a second 5 mm trocar just under the costal margin for the liver retractor. A 7 cm right lower quadrant incision was used for the hand-assist device. (B) Left-sided HALN used a 12 mm trocar at the mid-clavicular line 2 cm inferior to the umbilicus (working instrument), a 5 mm trocar adjacent to the umbilicus (working instrument), a 5 mm trocar at the midline two finger breadths below the xyphoid process (camera), and a 7 cm vertical lower midline incision for the hand device.

Regardless of the surgical modality for extirpation of the kidney and upper ureter, the entire distal ureter including the intramural portion and ipsilateral ureteral orifice must be removed. Several surgical options are available for the management of the distal ureter, irrespective of whether the technique is open or laparoscopic.[65]

Open technique. The open technique for distal ureterectomy with an ipsilateral bladder cuff can be performed via a Gibson, Pfannensteil, or lower midline incision, and by an intravesical (transvesical) or an extravesical technique. The intravesical method involves creating an anterior cystotomy in the bladder and circumscribing the full thickness of the bladder surrounding the ipsilateral ureter. The nephroureterectomy specimen with a 1 cm cuff of bladder mucosa is removed en bloc, and the residual defect and anterior cystotomy are closed with two layers of absorbable sutures. The intravesical technique is the most reliable means to confirm complete ureteral excision, which is particularly important for distal ureteral or ureteral orifice tumors to ensure a negative surgical margin. It is the opinion of the authors that this technique is the optimal method for management of the distal ureter.

The extravesical technique involves dissection of the ureter through the detrusor hiatus to ensure a complete dissection of the intramural portion of the ureter. With gentle traction on the ureter, a right angle clamp or an endoscopic gastrointestinal anastomosis (GIA) stapler can be used to transect the ureter with a cuff of bladder. The advantage of the extravesical technique is the avoidance of a second cystotomy site requiring closure. However, care must be taken to ensure complete dissection of the intramural ureter while avoiding contralateral ureteral injury from excessive traction.

Transurethral resection of the ureteral orifice: 'pluck' technique. The patient is placed in the lithotomy position and endoscopic resection is performed of the ureteral orifice and the intramural ureter until perivesical fat is seen. The goal of this technique is the complete detachment of the ureter from the bladder, allowing for it to be 'plucked' during the antegrade dissection. Potential complications associated with this technique include fluid and electrolyte disturbances caused by third-space resorption, pelvic or peritoneal seeding of tumor cells from bladder extravasation, and failure to adequately address tumors of the intramural ureter.[66,67] Of particular concern is the potential for leakage of cancer cells into the retroperitoneum because the ureter has not been occluded.[66,68,69]

A novel modification to the pluck technique has been described by Wong and Leveillee.[70] Rather than resecting the ureter transurethrally before nephroureterectomy, this group advocates early ureteral ligation to prevent distal tumor migration followed by circumferential excision of the cuff of bladder without midprocedural repositioning. Kurzer et al. performed this technique on 49 patients without evidence of pelvic or abdominal recurrences, allowing the bladder defect created by the transurethral resection to close spontaneously with catheter drainage.[71]

Intussusception (stripping) technique. A ureteral catheter is inserted at the start of the procedure, and the ureter is dissected as distally as possible during the nephrectomy portion of the operation. The ureter is ligated and transected with the ureteral catheter secured to the proximal portion of the distal ureter. The patient is repositioned in the lithotomy position, and the distal ureter is intussuscepted into the bladder by traction on the ureteral catheter. A resectoscope is then used to excise the bladder cuff, thus releasing the distal ureter. Potential problems with this approach are highlighted in a series from Giovansili and colleagues in which stripping failed in 6 of 32 patients (18.7%), requiring an additional iliac incision to complete the distal ureterectomy.[72]

Transvesical laparoscopic approach. This approach was initially described by Gill et al., who used two transvesical 2 mm suprapubic trocars and a ureteral stent in the ipsilateral ureter.[73] The ureter is tented upwards, a loop ligature is placed around the ureteral stent creating a closed system, and a Collins knife is then used to excise the ureteral orifice. Several other variations on this technique with similar outcomes have been described.[70,74,75]

Most series suggest that nephroureterectomy provides an improved recurrence-free and overall survival benefit compared with simple nephrectomy.[7,25,59] Clinical outcomes are most highly dependent upon pathologic stage and grade. Hall and colleagues reviewed data from over 250 patients and noted that 5-year actuarial survival rates were >90% for pathologic stage pTa, pTis, and pT1 lesions, but dropped below 50% for pT3 lesions, and under 5% for pT4 tumors.[76] Pathologic grade also closely correlated with 5-year survival in this study.

Multiple series have been published on laparoscopic nephroureterectomy with variations regarding the use of hand-assistance, approach (transperitoneal versus retroperitoneal), and management of the distal ureter. Compared with open surgery, the collective experience of laparoscopic surgery indicates a benefit with respect to postoperative analgesia requirements, hospitalization duration, cosmesis, and convalescence. With intermediate follow-up, cancer-related outcomes seem similar between the open and laparoscopic surgical modalities ( Table 1 ).[77,78,79,80,81,82,83,84,85,86]

Owing to the rarity of upper-tract TCC, there are no definitive data supporting the use of lymph node dissection. Lymphadenectomy can improve clinical staging, a finding that might support inclusion in adjuvant chemotherapy trials. Most conclusions about the therapeutic benefit of lymphadenectomy are extrapolated from bladder TCC data, which suggest that the number of lymph nodes removed and the lymph node density are important prognostic variables in patients undergoing cystectomy with pathologic evidence of lymph node metastases.[87]

Tumors of the renal pelvis and upper ureter spread to the para-aortic and paracaval lymph nodes, while distal ureteral tumors metastasize to pelvic nodes. A regional lymphadenectomy should be performed with a perihilar and paracaval/para-aortic dissection for renal pelvis and upper ureteral tumors, and an ipsilateral pelvic lymphadenectomy should be conducted for distal ureteral tumors.[25,88]

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