Endourologic management of upper tract transitional cell carcinoma.

Abstract

Transitional cell carcinoma (TCC) involves the upper tracts in approximately 2-5% of cases. These tumors are usually associated with field changes of the entire urothelium of an affected pyeloureteral unit or bladder [8]. As such, ipsilateral recurrence is high, approximately 25-40% [22], following conservative surgical resection of tumor. Consequently, the gold standard for therapy remains radical nephroureterectomy. With technological advances in instrumentation and imaging, minimally invasive techniques are now being utilized for the management of upper tract transitional cell carcinoma. In an attempt to decrease the morbidity of open nephroureterectomy, the laparoscopic approach has been applied to upper tract tumor management. Laparoscopic nephroureterectomy was first reported by Clayman et al. in 1991 [4]. The advantages of the laparoscopic approach include decreased surgical pain, shortened hospital stay, and rapid post-operative recovery [14, 21, 27, 29]. There are several instances in which nephroureterectomy may not be the best treatment option. Conservative therapy is recommended in patients with a functionally or anatomically solitary kidney, bilateral tumors, diminished overall renal function, and patients with medical comorbidity which precludes surgery. In some patients, the risk of chronic dialysis-dependent renal failure may outweigh the risk of death or disease progression from TCC (Table 1). Endourologic techniques have been developed to both diagnose and treat upper tract transitional cell carcinoma (Table 2). Retrograde diagnostic endoscopy of the upper tracts was first performed by Hugh Hampton Young in 1912 [33]. Since then, technological advances in instrumentation, permit access to most upper tract tumors with ureteroscopy. Percutaneous tumor resection has been utilized since the 1980s for conservative management of renal pelvic tumors. Percutaneous access permits passage of larger instruments for tumor resection. With both percutaneous nephroscopic access and the retrograde ureteroscopic approach, there is no upper tract tumor that is endoscopically unapproachable. In this review, we will describe the various endourologic techniques used to treat upper tract transitional cell carcinoma. The advantages and disadvantages of each technique will be discussed, the clinical indications for each technique will be outlined, and clinical outcomes will be examined.