Endourologic management of upper tract transitional cell carcinoma.

Abstract

Transitional cell carcinoma (TCC) occurs only rarely in the upper urinary tract and accounts for less than 5% of all cases of urothelial neoplasia. Like TCC of the bladder, however, it often represents a field change disease characterized by multiple recurrences in both time and space, though this tendency towards polychronotopism is generally confined to the ipsilateral renal unit or to the bladder. As a result, the incidence of TCC in the contralateral renal unit is only 3%. This natural history supports the use of nephroureterectomy with resection of a cuff of bladder as the gold standard for the management of upper urinary tract TCC. It in fact attempts to perform more conservative, renal sparing open operations for upper tract TCC that have universally met with high rates of local or ipsilateral recurrence. 4-6 With the advent of sophisticated techniques for the endourologic management of many benign urologic diseases of the upper tracts, there has been growing enthusiasm for the application of these same techniques to the management of upper tract TCC. Recent advances in the fields of retrograde ureteroscopy and percutaneous pyeloscopy include the development of small caliber, actively deflecting fiberoptic telescopes, improved optics, and the development of small caliber adjunctive instruments and laser fibers. These advances have opened the field of upper tract TCC to a variety of innovative approaches, particularly for those patients in whom standard nephroureterectomy may present a prohibitive operative risk or leave the patient functionally anephric. These include patients with upper tract TCC in an anatomically or functionally solitary kidney, those with bilateral disease, or patients with significant chronic renal insufficiency. Endourologic alternatives to open surgery have also been advocated for those patients with significant comorbid disease in whom an open operation would be poorly tolerated. This article will review the endourologic management of upper tract TCC to further help define its role in current urologic practice.