Distal Ureterectomy Research Articles

MP23-12 ENDOMETRIOSIS – URINARY TRACT INVOLVEMENT AND PREDICTIVE FACTORS FOR MAJOR SURGERY

You have accessJournal of UrologyInfections/Inflammation/Cystic Disease of the Genitourinary Tract: Kidney & Bladder II1 Apr 2017MP23-12 ENDOMETRIOSIS – URINARY TRACT INVOLVEMENT AND PREDICTIVE FACTORS FOR MAJOR SURGERY Maria José Freire, Paulo Jorge Dinis, Rita Medeiros, Luís Sousa, Fernanda Águas, and Arnaldo Figueiredo Maria José FreireMaria José Freire More articles by this author , Paulo Jorge DinisPaulo Jorge Dinis More articles by this author , Rita MedeirosRita Medeiros More articles by this author , Luís SousaLuís Sousa More articles by this author , Fernanda ÁguasFernanda Águas More articles by this author , and Arnaldo FigueiredoArnaldo Figueiredo More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2017.02.740AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Endometriosis affects 5-15% of premenopausal females. Urinary tract endometriosis (UTE) is present in about 1- 2% of all women with endometriosis. Objective: To assess the severity and surgical treatment of deep infiltrating endometriosis (DIE) with involvement of the urinary tract (UT) as well as the existence of predictive factors for major surgery in patients with UTE. METHODS Retrospective analysis of 656 women undergoing surgery for endometriosis, between January 2005 and August 2016, in a large academic centre. The authors identified a group of 28 (4.3%) patients, with a mean age of 38 ± 6.9 years (27-50) at diagnosis, who underwent minor surgery (percutaneous nephrostomy [PCN] or any kind of endoscopic surgery) or major surgery (open or laparoscopic procedures) for UTE. Mode of presentation, surgeries performed, post-operative data and complication rates were analysed. RESULTS Only 4 patients (14.3%) were asymptomatic and the most frequent symptom was lumbar pain (n = 14, 50%). The mean lesions size was 2.8 ± 1.7 cm (0.5-5) and affected the ureter in 13 (46.4%), the bladder in 11 (39.3%) and both structures in 4 (14.3%) patients. The left ureter was the most involved (n=10, 35.7%). Hydronephrosis was detected in 18 (64.3%) patients and 12 (42.9%) had renal function impairment (7 [25%] had partial loss, and 5 [17.9%] total loss of renal function). Patients with ureteric involvement were more likely to lose renal function (p = 0.034). Concerning minor surgeries, 12 (42.9%) patients underwent TURB, 9 (32.1%) double-J stenting or PCN, and 4 (14.3%) ureteroscopy. The major surgeries were distal ureterectomy in 9 (32.1%), nephrectomy in 3 (10.7%) and excision of endometriomas by laparotomy/laparoscopy in 4 (14.3%) cases. Each patient had in average 1.79 ± 1.3 (1-6) surgeries, and 11 (39.3%) had more than one surgery. The total hospitalization time was 6.3 ± 7.4 days (1-32). Patients with ureteric involvement underwent major surgeries more often (p = 0.025) and had longer hospital stay (8.2 vs 3.1 days, p = 0.05). With a mean follow-up of 36.3 months, no patient with bladder involvement had recurrence, 3 (10.7%) showed ureteral re-estenosis (Clavien-Dindo grade IIIb), 1 (3.6%) remained with lumbar pain and 1 (3.6%) had double-J stent calcification. CONCLUSIONS Despite being a histologically benign pathology, DIE can have serious consequences in the UT, often leading to multiple procedures and may result in total loss of kidney function. Surgery is highly successful in most cases and patients with ureteric involvement are more likely to undergo major surgery and have longer hospitalization. © 2017FiguresReferencesRelatedDetails Volume 197Issue 4SApril 2017Page: e297-e298 Advertisement Copyright & Permissions© 2017MetricsAuthor Information Maria José Freire More articles by this author Paulo Jorge Dinis More articles by this author Rita Medeiros More articles by this author Luís Sousa More articles by this author Fernanda Águas More articles by this author Arnaldo Figueiredo More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Nephron-sparing management (distal ureterectomy with reimplantation of ureter) for carcinoma of distal ureter: A single-center experience

ObjectiveRadical nephroureterectomy with bladder-cuff excision has been the traditional treatment for upper tract urothelial carcinoma because of its high rate of recurrence. However, given the morbidity of nephrectomy and the risk of developing chronic kidney disease or dialysis-dependent renal failure, the nephron-sparing approach may be preferable in selected patients. Materials and methodsA total of 118 patients who received unilateral distal ureterectomy with reimplantation at a single center in Taiwan were included, using surgical code numbers, from March 2006 to December 2014. A total of 82 patients were excluded due to nonmalignancy and 17 due to concomitant bladder cancer. Finally, 19 patients with primary, solitary, unilateral ureter lesions and confirmed to have ureter malignancy (urothelial carcinoma, n=18; squamous cell carcinoma, n=1) were included. ResultsOf the 19 patients (13 males and 6 females) included, the mean age was 69.3±10.7 years. Tumor pathological staging was Tis (n=1), Ta (n=3), T1 (n=2), T2 (n=6), and T3 (n=5). Histopathology grading was low grade (n=3) and high grade (n=13). No local recurrence was noted; nine patients had bladder recurrence (47.4%), three had distant metastasis (15.8%), and two had progression and finally underwent radical nephroureterectomy (10.5%). The mean time to bladder recurrence was 12.4 months (3–24 months); the mean follow-up time was 28.1 months (1–90 months). The 5-year overall survival rate was 73.7% (14/19); four patients were lost to follow-up, and one patient expired. The mean 5-year progression-free survival was 67.74%. The mean preoperative creatinine level was 1.61 mg/dL, and at 12 months after operation it was 1.56 mg/dL (p=0.95). ConclusionIn selected patients, distal ureterectomy with reimplantation, in our experience, is a feasible option for distal ureter tumor. Favorable postoperative outcomes with a low local recurrence rate, a low rate of progression to nephroureterectomy, and renal function preservation may prove the value of this modality and should be taken into consideration in suitable patients.

Unusual case of upper urinary tract obstruction: a case report

Ureteric endometriosis is a very rare cause of upper urinary tract obstruction. Patients presented with left ureteric colic since 1 month, two episodes severe in intensity radiating from lt loin to groin. 2x2 cm hard growth in mid ureter with dense adhesions to peritoneum, lt fallopian tube and ovary, lt internal iliac vein and serosa of sigmoid colon, left distal ureterectomy, left salpingo-oopherectomy and psoas hitch ureteric reimplantation was performed and specimen was sent for HPE. Diagnosis of left ureteric endometriosis was made on histopathological evaluation report. This diagnosis should be considered in the D/D of ureteral obstruction in a young female especially on lt side. Carefully performed surgery in the form of ureteral excision and reimplantation preserves renal function.

Open Distal Ureterectomy and Boari Flap Reconstruction for Distal Ureteric Transitional Cell Carcinoma

Open Distal Ureterectomy and Boari Flap Reconstruction for Distal Ureteric Transitional Cell Carcinoma

KIDNEY-SPARING SEGMENTAL URETERECTOMY WITH TRANSURETHRAL BLADDER CUFF EXCISION FOR DISTAL URETERAL CARCINOMA

(Introduction and objectives) Radical nephroureterectomy with complete distal ureterectomy is the standard therapy for upper tract urothelial malignancy. Segmental ureterectomy with ueteroneocytostomy is an alternative for distal ureteral carcinoma. We describe extravesical complete distal ureterectomy combined by transurethral bladder cuff excision with frozen-section analysis. (Patient and methods) Since December 2008, 11 patients (median age 77 year old, male 10, female 1, right 10, left 1) with solitary distal ureteral carcinoma who had mild hydronephrosis of ipsilateral kidney remaining renal function on enhanced CT. Under general anesthesia, the patient was placed in lithotomy position, rigid cystoscopy was inserted into the bladder. Cold punch biopsy of 4 sites of bladder mucosa 5 mm away from ureteral orifice (12, 3, 6, 9 o'clock) was carried out and sent to frozen-section analysis. Use resectoscopy with needle-type electrode, incise the bladder mucosa along the biopsy sites circumferentially and incise submucosa tissue around the ureteral orifice deeply enough to detach intramural ureter. Then lower abdominal midline incision was made. After entering the retroperitoneal space, the ureter was dissected and ureteral margin was sent to frozen-section analysis. The distal ureter was dissected until the margin of bladder mucosa incised by transurethrally. After ascertainment of no cancer cell in the frozen-section, close the defect in the bladder. Then the ureter was re-implanted into the bladder by extravesical approach. (Results) Median estimate blood loss was 150 ml (40-350 ml) and median operative time was 258 min (170-317 min.). No patients in our series required a blood transfusion. The mean tumor size was 20+/- 4.4 mm. Pathological T stage was Ta 3, T1 3, T2 2 and T3 3. No positive surgical margin was noted. Mean serum creatinine before and 1 month after surgery was 1.05+/- 0.21 mg/dl and 089+/- 0.13 mg/dl. Mean eGFR before and 1 month after surgery was 54.1+/- 11.4 and 63.4+/- 8.4. Median followup was 35 months (range 4 to 93). Although there were two patients who died from distant metastatic disease, no patients have encountered cancer recurrence in the remained ipsilateral upper urinary tract. (Conclusions) Segmental ureterectomy combined by transurethral bladder cuff excision with frozen-section analysis could perform complete resection of distal ureteral carcinoma and preserve ipsilateral renal function. This technique is feasible for patients with distal ureteral carcinoma as an optional treatment. Better preservation of renal function can lead to increased tolerance of cisplatin-based adjuvant or salvage chemotherapy.

VE07 - Robotic right distal ureterectomy and ureteroneocystostomy with bladder psoas muscle hitch, boari flap reconstruction and right lynphadenectomy

VE07 - Robotic right distal ureterectomy and ureteroneocystostomy with bladder psoas muscle hitch, boari flap reconstruction and right lynphadenectomy

A Case for Nephron Sparing Surgery in the Management of Upper Tract Urothelial Carcinoma.

Upper tract urothelial carcinoma (UTUC) is rare and its management presents many challenges. Outside of distal ureterectomy for select cases, management has been primarily radical nephroureterectomy. Endoscopic nephron sparing management (NSM) is recognized to have some role in UTUC treatment; however, it is yet to gain firm footing in the treatment algorithm. In this review, we discuss the benefits of NSM with regards to oncologic outcomes, renal function preservation, and cost savings. Finally, we propose recognition of endoscopic NSM as a first-line treatment in selected patients with low risk disease.

Radical Nephroureterectomy Without Patient or Port Repositioning Using the Da Vinci Xi Robotic System: Initial Experience

To report our initial experience on robot-assisted radical nephroureterectomy, using the da Vinci Xi robotic system without patient or port repositioning. The patients were in a modified flank position. A Bugbee electrode was used to cauterize and mark the ureteral orifice, aiding in the final robotic excision of the distal ureter. For the first step of the procedure, the second robotic arm holds the scope, the fourth robotic arm holds Port #1 (monopolar curved scissors), the first robotic arm holds Port #2 (Fenestrated bipolar forceps), and the third robotic arm holds Port #4 (Prograsp forceps). After completion of nephrectomy, all robotic arms were released and reconfigured. In the new setting, the third robotic arm and second robotic arm were switched between the camera port and the fourth port. The first port remained working with the monopolar curved scissors whereas Prograsp forceps was moved to the second port and fenestrated bipolar forceps was moved to the third port. Two patients underwent 2 successful radical nephroureterectomies with the above-mentioned technique. The console time for the first patient was 150 minutes whereas the estimated blood loss was 200 mL. The console time and blood loss for the second patient were 140 minutes and 300 mL, respectively. The hospitalization time and catheter removal time were 3 days for both patients and no complications were observed. The use of the da Vinci Xi robotic system enabled us to perform both nephrectomy and distal ureterectomy and/or bladder cuff excision without any repositioning of the patient or trocars.

800 Oncological outcomes of radical nephroureterectomy versus kidney-sparing surgery for elective treatment of clinically organ-confined upper tract urothelial carcinoma of the distal ureter

Abstract To compare the oncological outcomes of radical nephroureterectomy (RNU), distal ureterectomy (DU), and endoscopic surgery (ENDO) for elective treatment of clinically organ-confined upper tract urothelial carcinoma (UTUC) of the distal ureter. From a multi-institutional collaborative database, we identified 304 patients with unifocal clinically organ-confined UTUC of the distal ureter and bilateral functional kidneys. Overall survival (OS), cancer-specific survival (CSS), local recurrence-free survival (LRFS), and intravesical recurrence-free survival (IVRFS), according to the surgery type, were compared using Kaplan-Meier statistics. Univariable and multivariable Cox regression analyses were performed to assess the adjusted outcomes of RNU, DU, and ENDO. Overall, 128 (42.1%), 134 (44.1%), and 42 (13.8%) patients were treated with RNU, DU, and ENDO, respectively. Although OS, CSS, and IVRFS were equivalent between the three surgical procedures, the 5-year LRFS rate was lower in the ENDO group (35.7%) when compared to RNU (95.0%; p

Oncologic Outcomes of Kidney Sparing Surgery versus Radical Nephroureterectomy for the Elective Treatment of Clinically Organ Confined Upper Tract Urothelial Carcinoma of the Distal Ureter

We compared the oncologic outcomes of radical nephroureterectomy, distal ureterectomy and endoscopic surgery for elective treatment of clinically organ confined upper tract urothelial carcinoma of the distal ureter. From a multi-institutional collaborative database we identified 304 patients with unifocal, clinically organ confined urothelial carcinoma of the distal ureter and bilateral functional kidneys. Rates of overall, cancer specific, local recurrence-free and intravesical recurrence-free survival according to surgery type were compared using Kaplan-Meier statistics. Univariable and multivariable Cox regression analyses were performed to assess the adjusted outcomes of radical nephroureterectomy, distal ureterectomy and endoscopic surgery. Overall 128 (42.1%), 134 (44.1%) and 42 patients (13.8%) were treated with radical nephroureterectomy, distal ureterectomy and endoscopic surgery, respectively. Although rates of overall, cancer specific and intravesical recurrence-free survival were equivalent among the 3 surgical procedures, 5-year local recurrence-free survival was lower for endoscopic surgery (35.7%) than for nephroureterectomy (95.0%, p <0.001) or ureterectomy (85.5%, p = 0.01) with no significant difference between nephroureterectomy and distal ureterectomy. On multivariable analyses only endoscopic surgery was an independent predictor of decreased local recurrence-free survival compared to nephroureterectomy (HR 1.27, p = 0.001) or distal ureterectomy (HR 1.14, p = 0.01). Distal ureterectomy and endoscopic surgery did not significantly correlate to cancer specific or intravesical recurrence-free survival. However, when adjustment was made for ASA(®) (American Society of Anesthesiologists(®)) score, distal ureterectomy (HR 0.80, p = 0.01) and endoscopic surgery (HR 0.84, p = 0.02) were independent predictors of increased overall survival, although no significant difference was found between them. Because of better oncologic outcomes, distal ureterectomy could be considered the elective first line treatment of clinically organ confined urothelial carcinoma of the distal ureter.

Nephron-sparing management (distal ureterectomy with reimplantation of ureter) for carcinoma of distal ureter: A single center experience

Nephron-sparing management (distal ureterectomy with reimplantation of ureter) for carcinoma of distal ureter: A single center experience

Distal ureterectomy techniques in Laparoscopic Nephroureterectomy (LNU) and Robotic-assisted Laparoscopic Nephroureterectomy (RALNU) - A Review of the Literature.

Laparoscopic Nephroureterectomy and Robotic-Assisted Laparoscopic Nephroureterectomy are reported as alternative procedures to the open approach in the management of Upper Tract Transitional Cell Carcinoma (UTTCC). Although, they are considered to be equivalently effective to Open Nephroureterectomy (ONU), controversy still exists regarding the best method for managing the distal ureter and bladder cuff during the laparoscopic and robotic-assisted laparoscopic approach. This review describes the surgical steps, the advantages and disadvantages of several techniques used for ureter and bladder cuff resection including open excision, transurethral resection of ureteral orifice (‘Pluck’ Technique), ureteric intussusception and total laparoscopy or robotic-assisted laparoscopy. Although, the existing data does not confirm the superiority of one technique over another, total laparoscopic and robotic-assisted laparoscopic nephroureterectomy with complete laparoscopic dissection and suture reconstruction of ureter and bladder cuff seem to be better tolerated than open nephroureterectomy providing equal efficacy and without deteriorating the oncological outcome. Transurethral resection of the ureteric orifice and the bladder cuff after occlusion of the ureter with a balloon catheter seems to be an attractive alternative option for low stage, low grade tumors of the renal pelvis and the proximal ureter, in case we would like to avoid a low abdominal incision. Η Λαπαροσκοπική Νeφροουρητηρeκτομή και η Ρομποτικά Υποβοηθούμeνη Λαπαροσκοπική Νeφροουρητηρeκτομή αναφέρονται ως eναλλακτικές eπιλογές της Ανοικτής Νeφροουρητηρeκτομής στη διαχeίριση ασθeνών μe Καρκίνο Αποχeτeυτικής μοίρας του Ουροποιητικού Συστήματος. Παρόλο που όμως θeωρούνται ισοδύναμeς eπeμβάσeις μe την Ανοικτή Νeφροουρητηρeκτομή, παραμένeι αμφιλeγόμeνο ποιος τρόπος eίναι ο καλύτeρος όσον αφορά την αντιμeτώπιση του άπω τμήματος του ουρητήρα και την eκτομή της eνδοκυστικής μοίρας αυτού. Η παρούσα ανασκόπηση πeριγράφeι τα χeιρουργικά βήματα και τα πλeονeκτήματακαι Μeιονeκτήματα των διάφορωντeχνικών πουχρησιμοποιούνται για την eκτομή του τeλικού τμήματος του ουρητήρα, όπως eίναι η ανοικτή ουρητηρeκτομή, η διουρηθρική eκτομή του ουρητηρικού στομίου (‘pluck’ τeχνική), η τeχνική eγκολeασμού του ουρητήρα και η ολική Λαπαροσκοπική ή ολική Ρομποτικά-Υποβοηθούμeνη Λαπαροσκοπική eκτομή του ουρητήρα. Αν και οι υπάρχουσeς μeλέτeς δeν eπιβeβαιώνουν την ανωτeρότητα κάποιας τeχνικής συγκριτικά μe κάποια άλλη, η ολική Λαπαροσκοπική και η ολική Ρομποτικά-Υποβοηθούμeνη Λαπαροσκοπική Νeφροουρητηρeκτομή μe καθολική eκτομή της eνδοκυστικής μοίρας του ουρητήρα και του κυστικού τοιχώματος που τον πeριβάλλeι φαίνeται να eίναι καλύτeρα Ανeκτές σe σχέση μe την ανοικτήν eφροουρητηρeκτομή, παρέχοντας ισοδύναμη αποτeλeσματικότητα, χωρίς να eπηρeάζουν το Ογκολογικό αποτέλeσμα. Eναλλακτικά, σe πeρίπτωση που θέλουμe να αποφύγουμe τη Χαμηλή κοιλιακή τομή, η διουρηθρική eκτομή του ουρητηρικού στομίου, μeτά από τοποθέτηση ουρητηρικού καθeτήρα μe μπαλόνι απόφραξης, φαίνeται να αποτeλeί μια καλή eπιλογή για νόσους χαμηλού σταδίου της νeφρικής πυέλου και του eγγύς μουρητήρα.

Multi-institutional analysis of renal function outcomes following radical nephroureterectomy and partial ureterectomy for upper tract urothelial carcinoma

PurposeTo compare renal function outcomes in patients undergoing radical nephroureterectomy (RNU) or partial (distal) ureterectomy (PU) for upper tract urothelial carcinoma (UTUC). MethodsClinicopathologic data of patients undergoing RNU or PU for UTUC from 1998 to 2012 were compiled. Glomerular filtration rate was calculated preoperatively and postoperatively using the Modification of Diet in Renal Disease equation. We defined “event” as new-onset stage III chronic kidney disease (CKD) or worsening of CKD stage with preexisting CKD. Event-free survival was assessed with Kaplan-Meier methods. Cox regression analyses were performed to identify predictors of events. ResultsIn total, 193 patients underwent RNU (n = 143) or PU (n = 50) over a median follow-up of 25.9 months. Overall, 15% of patients died of UTUC. High tumor grade (85.9% vs. 66.0%, P = 0.003) and locally advanced stage (>pT2, 37.8% vs. 18.0%, P = 0.014) were significantly more frequent in the RNU cohort. Stage III or higher CKD was present in 61% of RNU patients vs. 48% of PU patients (P = 0.135) at baseline. Although total event rate was higher in the PU cohort (66% vs. 43.4%, P = 0.008), event rates within the first 3 months of surgery were similar between the groups (P = 0.572). Adjuvant chemotherapy was the only predictor of events on Cox regression. ConclusionsRates of new-onset CKD or worsening of CKD stage were similar in patients treated with RNU and PU. Adjuvant chemotherapy may have a more significant effect on renal outcomes than surgical approach, warranting further investigation. Consideration should be given to preoperative chemotherapy, as adjuvant chemotherapy is limited by decreased renal function following surgery.

WITHDRAWN: Robotic distal ureterectomy with psoas hitch and ureteroneocystotomy: Surgical technique and outcomes

WITHDRAWN: Robotic distal ureterectomy with psoas hitch and ureteroneocystotomy: Surgical technique and outcomes

Multiple visceral resections for pelvic recurrence from surgically treated clear cell ovarian tumor - a case report

Ovarian clear cell carcinoma is a distinct histopathological subtype of epithelail ovarian cancer with a more aggressive biological behaviour and a higher capacity to recur. We present the case of a 47 year old patient diagnosed with a clear cell ovarian tumor invading an ileal loop submitted to radical surgery followed by adjuvant chemotherapy. At one year follow up she was diagnosed with a pelvic recurrence invading the right ureter and the right ileocolon so the patient was re-submitted to surgery. The recurrence was resected en bloc with the right ileocolon and distal ureterectomy. The continuity of the digestive tract was re-established bya ileo-transverse anastomosis while the right ureter was re-inserted in the urinary bladder. The postoperative course was uneventful.

Primary Squamous Cell Carcinoma of the Ureter in a Patient with No Risk Factors

Upper urinary tract squamous cell carcinomas are uncommon tumors. Several risk factors have been identified with this entity. We present a case primary squamous cell carcinoma of the distal ureter in an individual with no identifiable risk factors. The patient is a 70 year-old man who presented with bilateral flank pain. Laboratory investigations showed high serum creatinine. There was left hydronephrosis on ultrasonography. Computed Tomography (CT) showed an ill-defined soft tissue mass in the left ureter. A left retrograde pyelogram revealed a mass 4 cm from the ureterovesical junction, with ureter dilation proximal to it. The patient underwent distal ureterectomy and stented ureteroneocystostomy. Pathological study of the tumor revealed a moderately differentiated stage 3 invasive squamous cell carcinoma. On serial follow up, the patient showed significant improvement of the left hydronephrosis and improvement of the renal function. Two-year follow-up was negative for recurrence.

Distal ureterectomy techniques in laparoscopic and robot-assisted nephroureterectomy: Updated review.

Controversies exist about the best method for managing the distal ureter during the laparoscopic (LNU) and robot-assisted nephroureterectomy (RANU). Therefore, PubMed, Scopus and Web of Science databases were searched in order to identify articles describing the management of distal ureter during LNU or RANU in patients suffering from upper urinary tract urothelial cell carcinoma. Forty seven articles were selected for their relevance to the subject of this review. The approaches that are usually performed regarding the distal ureter management are open excision, transurethral resection of ureteral orifice (Pluck Technique), ureteric intussusception and pure LNU or pure RANU. Pure LNU and RANU with complete laparoscopic dissection and suture reconstruction of ureter and bladder cuff seems to be better tolerated than open nephroureterectomy providing equal efficacy, without deteriorating the oncological outcome, however evidence is poor. Transurethral resection of the ureteric orifice and the bladder cuff after occlusion of the ureter with a balloon catheter seems to be an attractive alternative option for low stage, low grade tumors of the renal pelvis and the proximal ureter, while stapling technique is correlated with the increased risk of positive surgical margins. The open resection of the distal ureter in continuity with the bladder cuff is considered the most reliable approach, preferred in our practice as well, however the existing data are based on retrospective and non-randomized studies.

Laparoscopic Distal Ureterectomy with Ureteroneocystostomy and Psoas Hitch

Abstract Introduction: In upper urinary tract carcinoma (UUTC), kidney-sparing surgery could represent a valid alternative1,2 to radical nephroureterectomy, even if long-term results remain a matte...

Effect of Treatment Modality on Post-Operative Renal Function in Patients with Upper Tract Urothelial Cancer

Background: While endoscopic management (EM) and distal ureterectomy (DU) provide renal-sparing alternatives to radical nephroureterectomy (NU), the effects on renal function have never directly been compared. Objectives: While NU is the gold standard for treating upper tract urothelial carcinoma (UTUC), EM and DU have become popular for certain lesions. However, the true effect of these procedures on renal function has been under-studied. We analyzed the impact of EM, DU, and NU on post-operative renal function in both the short- and long-term intervals. Methods: Patients undergoing EM, DU, or NU for UTUC were included. Clinicopathologic information was collected. eGFR values were calculated via MDRD formula. Absolute change in eGFR was compared amongst groups. Linear mixed model regression analysis was used to determine the impact of procedure type on post-operative eGFR. Results: 273 patients underwent 325 procedures from 1991 to 2012. In both short- and long-term intervals, post-operative eGFR was significantly worse following NU compared to EM. For the long-term interval, this difference remained while controlling for age, race, gender, pathologic stage, pre-operative hydronephrosis, and having a solitary kidney (all p<0.05). Post-operative eGFR change was not significantly impacted by DU compared to EM. Conclusion: EM is superior to NU and equivalent to DU in preserving post-operative eGFR for UTUC patients. The non-inferiority of DU in this outcome validates its use as a kidney-sparing alternative alongside EM. The effects of these treatment modalities on renal function should be considered with oncologic outcomes when deciding management for these patients.

Routine diagnostic ureteroscopy for suspected upper tract transitional-cell carcinoma.

Upper tract transitional-cell carcinoma (utTCC) is uncommon. Standard evaluation includes imaging, cytology, and cystoscopy and gold standard treatment is nephroureterectomy (NU) with solid oncologic outcomes and elevated morbidity. In this study, we report on the value of including routine ureteroscopy (URS) for evaluating suspected utTCC in shifting the treatment toward less morbid options and increasing preoperative diagnostic accuracy. Records of patients presenting between 2002 and 2013 with suspected utTCC were reviewed. Since 2010, URS has been included routinely in the evaluation protocol. Demographic, clinical, and pathologic characteristics were recorded and compared between earlier experience (group 1) and with routine URS (group 2). In addition, the number needed to treat (NNT) was calculated with respect to shifting the procedure choice from NU to other options as well as in reducing the rates of misdiagnoses. A total of 118 patients were included: 63 in group 1 and 55 in group 2. The pathology-confirmed TCC rates were comparable between the two groups (78 vs 85%). The rates of NU decreased with routine URS use from 89% to 69% (P=0.011, NNT=5.05) whereby patients were treated endoscopically or with distal ureterectomy. Misdiagnoses decreased from 15.5% to 2.1% with routine URS (P=0.021, NNT=7.44). Sepsis occurred in two patients after URS. In this initial study, routine URS evaluation for suspected utTCC appears to enable an increased use of other treatment choices rather then NU, with an estimated five URS avoiding one NU. Moreover, routine URS reduced the rates of misdiagnosis of TCC. Complications associated with URS may add an additional morbidity burden, however.