Upper Tract Tumor En Bloc Enucleation: A Novel Approach to the Diagnosis and Management of Upper Tract Urothelial Carcinoma

Abstract

ObjectivesTo describe and demonstrate our novel en bloc enucleation technique for the endoscopic diagnosis and treatment of upper tract tumors. MethodsWe detail the instruments required for this procedure, as well as the surgical technique to perform an en bloc enucleation and specimen removal. Endoscopic video of a 2 cm renal pelvis tumor demonstrates all aspects of the technique, and histopathologic slides illustrate the diagnostic information obtained. ResultsA ureteral access sheath is inserted distal to the upper tract tumor, and a flexible ureteroscope is used to visualize the extent of upper tract disease and tumor characteristics. A 200 μm thulium fiber laser partially ablates the tumor surface to create an edge for tissue biopsy and post-ablation urine cytology. The tumor base is identified and the sub epithelial connective tissue is carefully entered with low ablation laser settings. The correct tissue plane is extended by maintaining the ureteroscope in the subepithelial connective tissue and continuing the dissection along the entire width of the tumor base. Once the tumor is enucleated, a Nitinol stone retrieval basket is used to remove the specimen(s) and a ureteral stent is placed. ConclusionsEn bloc enucleation may provide extensive histopathologic information in upper tract urothelial carcinoma. In cases where complete enucleation is not feasible, this procedure may afford a mechanism for large caliber biopsies.