I. Introduction
Transitional cell carcinoma of the upper urinary tract (ureter and/or renal pelvis) accounts for approximately 2-5% of all urothelial carcinomas. Traditionally, management of these lesions has consisted of open or laparoscopic nephroureterectomy with a bladder cuff or, if the lesion is distal, a distal ureterectomy with a bladder cuff and ureteral reimplantation. This surgical approach to UTUC yielded a 45-90% cancer-specific survival at 5 years; 10-30% of these patients developed metastatic disease. With the introduction of ureteroscopes and percutaneous techniques in the early 1980s and their continued technological improvements, direct visualization and treatment of an upper urinary tract urothelial tumor is now possible and efficient. Historically, endoscopic management of UTUC was reserved for patients with bilateral disease, a solitary kidney, chronic kidney disease (CKD), or significant co-morbidities that would preclude a major abdominal operation (Note: These indications are almost identical for the widespread adoption of partial nephrectomy for renal tumors). Rendering a patient functionally or anatomically anephric is fraught with significant health risks, thus endoscopic management was employed. One study cites the 5-year overall survival range for patients aged 55-84 with end-stage renal disease as 10-32%.
As endoscopic management for UTUCs have became technically feasible for patients with absolute indications, data began to mature that showed equivalent 5-year cancer-specific and overall survival between patients treated with endoscopic, nephron-sparing approaches versus traditional extirpative management. Table 1 is a synopsis of the most recent studies comparing open versus endoscopic management of UTUC. In sum, these studies show that endoscopic management of UTUC has equivalent overall, cancer-specific, and metastatic-free survivals to traditional management for low-grade and low-stage UTUC tumors. Patients who undergo endoscopic management do have a higher local recurrence rate (20-85%) and are subject to more procedures for long-term surveillance. Most practioners are unwilling to subject patients with high-grade UTUC to endoscopic management unless absolute indications exist; as of yet, there is no data to support the use of endoscopic management for high-grade disease.
|
Series (year) |
# of renal units |
Median/mean follow-up (months) |
Treatment (Ntx-u v. Endoscopic) |
5-year survival (Low-grade v. high grade) |
5-year survival (Ntx-u v. Endoscopic) |
|
|
|
|
|
|
|
|
Wolf et al. (2010) |
96 |
76.9 |
62 v. 34 |
OS: 73.0% v. 43.0% CSS: 94.0% v. 75.0% MFS: 91.0% v.67.0%
|
OS*: 47.8-71.8% v. 25.0-74.8% CSS: 72.4-89.2% v. 85.7-100.0% MFS: 63.5-87.8% v. 85.7-94.4%
|
|
Lucas et al. (2008) |
120 |
45.8 |
79 v. 41 |
OS**: 66.4-75.4% v. 45.0-71.5% CSS: 86.2-87.4% v. 68.6-75.0% RFS: NR |
OS: 72.1% v. 61.7% CSS: 83.0% v. 81.6% RFS: NR |
|
Roupret et al. (2006) |
97 |
51.5-60.0 |
54 v. 43 |
OS: NR CSS: 81.9% v. 47.3% MFS: NR |
OS: NR CSS: 84.0% v. 80.7% RFS: 75.3% v.71.5% |
|
Sowter et al.^ (2007) |
41 |
41.6 |
Endoscopic management only |
n/a |
OS: 80% CSS: 100.0% Recurrence rate: 74.3% |
|
Krambeck et al. (2007) |
37 |
2.9 yrs |
Endoscopic management only |
n/a |
OS: NR CSS: 49.3% RFS: 27.1% |
|
Elliott et al. (2001) |
21 |
6.1 yrs |
Endoscopic management only |
OS^^: 66.0% CS: 100.0% Recurrence rate: 25-46% |
n/a |
|
* Ranges indicate difference between low-grade and high-grade disease ** Treatment modality grouped together when examining survival of low-grade tumors versus high-grade tumors ^ Endoscopic management only ^^ Low-grade tumors only |
|||||
Table 1. Comparison of series employing endoscopic treatment of UTTCC as primary management strategy
II. Technique
Diagnostic ureteroscopy is employed as the first-line treatment for evaluation of a filling defect seen on CT urography, intravenous urography, or retrograde ureteropyelography. A distal lesion can be accessed with a semi-rigid ureteroscope while a lesion in the proximal ureter or renal collecting system is best approached with a flexible ureteroscope. The method for ureteral access is similar to the technique employed for ureteroscopy for stone disease (see Surgical Procedures Atlas VIII).
A brief step-wise approach to ureteroscopic evaluation and management of upper urinary tract urothelial carcinomas is presented below:
1. A wire is placed into the desired kidney under fluoroscopic and cystoscopic guidance (Fig1). The choice of wire is at the discretion of the operating urologist; we use a 0.038 Guidewire. (See review of wires under ureteroscopy Atlas.) During this portion of the procedure, take care to perform a thorough cystoscopic examination of the bladder as a bladder lesion will develop in 23-75% of patients with an UTUC.
Figure 1: Placement of initial wire
2. We then insert a dual-lumen access catheter over the existing wire (Fig 2) into the ureter for two reasons: the dual-lumen catheter passively dilates the distal ureter and we can obtain a selective cytology from the interested side and then place a second wire (0.038 Guidewire) without losing access to the kidney (Fig 3).
Figure 2: Placement of 2nd wire
Figure 3: Insertion of dual-lumen access catheter
3. Once we have cytology, we then perform another retrograde pyelogram to outline the collecting system (Fig 4).
Figure 4: Retrograde Pyelogram (make sure cytology has been obtained prior to injection of dye)
4. For renal pelvic and/or calyceal lesions, we then advance the flexible ureteroscope under fluoroscopic guidance up into the renal pelvis over one of the Guidewires (Fig 5). Once the ureteroscope is in good position, the Guidewire is removed and the second wire is used as a safety wire.
Figure 5: Advancement of ureteroscope under fluoroscopic guidance.
4a. Sometimes you may have trouble traversing the distal ureter with the flexible ureteroscope. Rather than using a balloon dilator to dilate the distal ureter, we have found that leaving the cystoscopic sheath in the bladder and using it to provide backing as you try to navigate the distal ureter is a helpful means to circumnavigate this potential impediment. If you are ever in doubt or cannot bypass the distal ureter, simply leave a JJ stent and return for your diagnostic ureteroscopy in 1-2 weeks.
5. Once you have the ureteroscope in the renal pelvis (Fig 6), you can perform a thorough upper tract endoscopic examination, using fluoroscopy as an aid in accessing difficult calyces.
Figure 6: Assessment of calyx with ureteroscope. Fuoroscopy is used to help direct the ureteroscope into appropriate anatomic location.
6. If you find a papillary lesion, obtain a repeat cytology with the ureteroscope directed at the lesion. Then obtain multiple biopsies of the lesion with either a flat-wire basket or a 3 Fr. ureteroscopic biopsy forceps.
7. Remember, grade correlates with stage. In multiple series, low-grade tumors correlated with Ta or T1 disease in 86.6-100.0% of cases. Similarly, high-grade tumors correlated with invasive TCC in 66.7-96.0% of cases. Thus, a low-grade lesion is going to be superficial and should be treated endoscopically. This may require multiple endoscopic treatments, however this is preferable in light of renal preservation.
8. Once you have sufficient biopsies, the tumor then can be treated with either the Nd:YAG and/or Ho:YAG laser or a ureteroscopic Bugbee. See Surgical Atlas VIII for a brief review of lasers. In brief, Nd:YAG laser has a greater depth of penetration (4-6 mm) and can be used to coagulate the tumor. The Nd:YAG laser does not need to touch the tumor for effect. The Ho:YAG laser has a shallower depth of penetration (less than 0.5 mm) and can be used to ablate the tumor deeper.
9. These are the recommended fibers and settings for each laser:
a. 200 um or 365 um fiber
b. Nd:YAG: 30W
c. Ho:YAG: 1J and 10Hz
10. In general, it is best to use the Nd:YAG laser first to coagulate the superficial portion of the tumor. This laser’s depth of penetration is not as precise as the Ho:YAG, so care must be taken when treating the deeper portions of the tumor. The Nd:YAG laser can perforate the ureter or the renal pelvis. When ablating large lesions, it is helpful to begin ablation at the more proximal portion of the tissue and then work distally. This hopefully helps to avoid advancing the fiber into the mucosa or wall of the ureter or renal pelvis.
11. The Ho:YAG laser can then be used to ablate the deeper aspects of the tumor and detach the tumor from the underlying parenchyma/urothelium. The Ho:YAG laser must be in direct or close contact of the tumor in order to treat the lesion.
12. For difficult to access calyceal tumors, a 2 Fr. Bugbee electrocautery probe can be used to fulgurate a lesion. The smaller probe allows for more ureteroscopic deflection in order to treat the difficult to access lesion. When using the Bugbee electrocautery, fulgurate on the cutting mode. This theoretically reduces the chance of an ureteral stricture or infundibular stenosis.
13. Once tumor treatment is complete, the decision to leave a temporary ureteral stent is left to the treating urologist. Nevertheless, there are few disadvantages to inserting a JJ stent in this setting.
14. Percutaneous resection of UTUC is generally reserved for tumors larger than 1.5 cm or bulky proximal ureteral tumors. The technique for this approach is very similar to a percutaneous approach for stone management (PCNL). Once intrarenal access has been obtained, a cystoscopic resectoscope can be used to remove the tumor followed by deep laser ablation.
III. Complications
The most common technical complications associated with endoscopic management of UTUC are similar to those seen with any upper tract endoscopic intervention: ureteral perforation and ureteral stricture. Reported rates of ureteral perforation and ureteral stricture are 1-4% and 9-12%. Not all ureteral strictures are due to technical considerations and biopsy of the stricture must be performed to rule out recurrent disease.
IV. Recommended Readings
1. Bagley DH and Grasso M. Ureteroscopic laser treatment of upper urinary tract neoplasms. World Journal of Urology. 28: 143-9, 2010.
2. Soderdahl DW et al. Endoscopic treatment of upper tract transitional cell carcinoma. Urologic Oncology. 23: 114-22, 2010.
This page was written for UrologyMatch.com by Daniel J. Canter, MD
Dr. Canter is a graduate of the University of Pennsylvania Urology Residency Program. He is currently a Society of Urologic Oncology Fellow at Fox Chase Cancer Center.
- ‹ previous
- 9 of 18
- next ›
