Nephroureterectomy In Patients Research Articles

Single-session laparoscopic cystectomy and nephroureterectomy.

Patients with high grade and/or muscle invasive bladder cancer and with concomitant diseases of the upper urinary tract, e.g. urothelial tumors (transitional cell carcinoma – TCC) or afunctional hydronephrotic kidneys, may be candidates for simultaneous cystectomy and nephroureterectomy. Although the progress in laparoscopic techniques made these procedures feasible and safe, they are still technically demanding so only experienced surgeons can perform them. The aim of the study is to report our experience with laparoscopic simultaneous en bloc resection of the urinary bladder together with unilateral or bilateral nephroureterectomy in patients with TCC. Our material consists of three cases operated on in three centers between 2002 and 2011. After having completed bilateral (1 case) or unilateral (2 cases) nephroureterectomy, we performed radical cystectomy with pelvic lymph node dissection. All the specimens, including the kidneys, ureters, bladder, and reproductive organs in the female, were collected in endobags and were retrieved en bloc using hypogastric incision in the male patient and the vaginal route in the female patients. The demographic and perioperative information was collected and analyzed. All procedures were completed laparoscopically without the need of conversion to open surgery. No major intra- or postoperative complications were observed. Only 1 patient suffered from prolonged lymphatic leakage. From our experience we can conclude that single-session laparoscopic cystectomy and nephroureterectomy are technically feasible and safe, and may be offered for the treatment of selected cases of TCC of the urinary tract.

Prediction of Cancer Specific Survival After Radical Nephroureterectomy for Upper Tract Urothelial Carcinoma: Development of an Optimized Postoperative Nomogram Using Decision Curve Analysis

We conceived and proposed a unique and optimized nomogram to predict cancer specific survival after radical nephroureterectomy in patients with upper tract urothelial carcinoma by merging the 2 largest multicenter data sets reported in this population. The international and the French national collaborative groups on upper tract urothelial carcinoma pooled data on 3,387 patients treated with radical nephroureterectomy for whom full data for nomogram development were available. The merged study population was randomly split into the development cohort (2,371) and the external validation cohort (1,016). Cox regressions were used for univariable and multivariable analyses, and to build different models. The ultimate reduced nomogram was assessed using Harrell's concordance index (c-index) and decision curve analysis. Of the 2,371 patients in the nomogram development cohort 510 (21.5%) died of upper tract urothelial carcinoma during followup. The actuarial cancer specific survival probability at 5 years was 73.7% (95% CI 71.9-75.6). Decision curve analysis revealed that the use of the best model was associated with benefit gains relative to the prediction of cancer specific survival. The optimized nomogram included only 5 variables associated with cancer specific survival on multivariable analysis, those of age (p = 0.001), T stage (p <0.001), N stage (p = 0.001), architecture (p = 0.02) and lymphovascular invasion (p = 0.001). The discriminative accuracy of the nomogram was 0.8 (95% CI 0.77-0.86). Using standard pathological features obtained from the largest data set of upper tract urothelial carcinomas worldwide, we devised and validated an accurate and ultimate nomogram, superior to any single clinical variable, for predicting cancer specific survival after radical nephroureterectomy.

768 Concomitant CIS is a risk factor for the occurrence of progressive bladder cancer after nephroureterectomy in patients with upper urinary tract urothelial cancer

768 Concomitant CIS is a risk factor for the occurrence of progressive bladder cancer after nephroureterectomy in patients with upper urinary tract urothelial cancer

Prognonstic impact of renin-angiotensin system blockade in localised upper-tract urothelial carcinoma

Background:The potential role of the renin-angiotensin system (RAS) in the promotion of tumour growth has been investigated, and the administration of RAS inhibitors, such as angiotensin-converting enzyme inhibitors (ACEIs) or angiotensin II receptor blockers (ARBs), may improve disease control in malignancy. We investigated the prognostic impact of RAS inhibitors by analysing data from patients with upper-tract urothelial carcinoma (UTUC).Methods:A total of 279 patients who underwent nephroureterectomy for localised UTUC (pTa-3N0M0) were identified at our three institutions. We retrospectively investigated the prognostic outcomes following nephroureterectomy in patients administered or not administered ACEIs or ARBs.Results:The median follow-up period was 3.4 years. RAS inhibitors were administered to 48 patients (17.2%). Multivariate analysis showed that the appearance of pathological T3, positive lymphovascular invasion, and no RAS inhibitor administration (P=0.027 HR=3.14) were independent risk factors for a decrease in subsequent metastasis-free survival. The 5-year metastasis-free survival rate was 93.0% in patients who administered RAS inhibitors, and 72.8% in their counterparts who did not (P=0.008).Conclusion:The absence of RAS inhibitor administration was an independent risk factor for subsequent tumour metastasis in patients with localised UTUC. We propose RAS inhibitors may be a potent choice as an effective treatment following nephroureterectomy.

UP-03.140 Endoscopic Laser Therapy as Alternative for Nephroureterectomy in Patients with Upper Urinary Tract Transitional Cell Carcinoma

UP-03.140 Endoscopic Laser Therapy as Alternative for Nephroureterectomy in Patients with Upper Urinary Tract Transitional Cell Carcinoma

Long-term Outcomes of Immediate Versus Delayed Nephroureterectomy for Upper Tract Urothelial Carcinoma

To compare immediate nephroureterectomy with delayed nephroureterectomy after a trial of nephron-sparing endoscopic surgery in patients who were treated initially at our institution from 1996 to 2004 for upper tract urothelial carcinoma. Patients were monitored for upper tract recurrences, metastases, cancer-specific and overall survival. Survival outcomes and perioperative measurements were compared between treatment groups. Of 73 patients, 62 underwent immediate nephroureterectomy and 11 proceeded to nephroureterectomy after failed endoscopic management. Mean follow-up for all patients was 58 months and 75 months for patients who were alive at last follow-up. Patients treated initially with endoscopy averaged a surveillance procedure every 3.7 months and had a median delay to nephroureterectomy of 10 months. Perioperative measurements at time of nephroureterectomy did not differ between groups. Overall survival 5 years from initial resection in the delayed group and from nephroureterectomy in the immediate group was 64% and 59%, respectively; the corresponding 5-year cancer-specific and metastasis-free survival estimates were 91% vs 80% and 77% vs 73%, respectively (P>0.05). Pathologic progression from low to high-grade occurred in three of seven patients from the delayed group. Failure of endoscopic management necessitating nephroureterectomy does not appear to affect survival outcomes compared with immediate nephroureterectomy in patients with upper tract urothelial carcinoma. A trial of endoscopic management can be considered in patients with low-grade disease and a normal contralateral kidney. Endoscopy is a viable option when there are imperative indications for nephron sparing in the setting of high-grade disease.

Preoperative positive urine cytology is a risk factor for subsequent development of bladder cancer after nephroureterectomy in patients with upper urinary tract urothelial carcinoma

To determine the independent risk factors of bladder recurrence in patients with upper urinary tract urothelial carcinoma (UUT-UC). A total of 364 patients underwent nephroureterectomy (NUx) for UUT-UC between January 2005 and April 2009 in Okayama University and 17 affiliated hospitals. Patients with concomitant bladder cancer were excluded from the analysis. The clinicopathologic data for the remaining 288 patients with UUT-UC were retrospectively reviewed. Median follow-up after NUx was 20.2 months. The following variables were evaluated for any association with bladder recurrence: sex, age, tumor stage, tumor grade, venous invasion, lymphatic invasion, tumor location, multifocality, surgical modalities, time of ligation of the ureter, and preoperative urine cytology. The significance of each variable was tested univariately using the log-rank test. The simultaneous effects of multiple risk factors were estimated by multiple regression analysis using the Cox proportional hazards model. Bladder recurrence occurred in 103 patients (35.8%). Median time to first bladder recurrence was 6.9 months. Significant risk factors for bladder recurrences on univariate analysis were tumor location (P = 0.046) and preoperative positive urine cytology (P < 0.001). Multivariate analysis revealed that preoperative urine cytology positive was significant for bladder recurrence (HR: 1.977; 95% CI: 1.310-2.983, P = 0.001). Risk factor for subsequent development of bladder cancer after NUx was preoperative positive urine cytology.

Should bladder cuff excision remain the standard of care at nephroureterectomy in patients with urothelial carcinoma of the renal pelvis? A population-based study

Should bladder cuff excision remain the standard of care at nephroureterectomy in patients with urothelial carcinoma of the renal pelvis? A population-based study

Long-Term Outcomes of Nephroureterectomy Versus Endoscopic Management for Upper Tract Urothelial Carcinoma

We compared outcomes in patients treated with nephroureterectomy vs nephron sparing endoscopic surgery for upper tract urothelial carcinoma. Patients treated at our institution for upper tract urothelial carcinoma from 1996 to 2004 were monitored for upper tract and bladder recurrence, metastasis, and cancer specific and overall survival. Outcomes were compared between treatment groups by univariate and multivariate analyses based on pertinent pathological and demographic variables. Of 96 renal units 62 underwent immediate nephroureterectomy and 34 were managed endoscopically. Median followup in all survivors was 77 months. Overall nephroureterectomy and endoscopy complication rates were 29% and 9.3%, respectively. In patients with low grade tumors the 5-year metastasis-free survival rate after nephroureterectomy and endoscopy was 88% and 94%. The corresponding 5-year cancer specific and overall survival rates were 89% vs 100% and 72% vs 75%, respectively. Of endoscopic cases 84% had at least 1 ipsilateral recurrence. Multivariate analysis revealed that only tumor grade was significantly associated with metastasis-free survival while grade and body mass index correlated with cancer specific survival, and Charlson Comorbidity index and grade impacted overall survival. Treatment group was not associated with survival outcome. When technically feasible and in select patients, endoscopic management provides cancer related and overall survival equivalent to that of nephroureterectomy in patients with low grade upper tract urothelial carcinoma at the cost of frequent re-treatments in many patients. Nephroureterectomy is standard treatment for high grade cancer when there is a normal contralateral kidney but endoscopy should be considered when there are imperative indications for nephron sparing.

Radical nephrectomy and nephroureterectomy in patients over 80 years old

The aim of this study was to discover if elderly patients exhibit comparable outcomes and survival benefits to those achieved in younger patients. We assessed 35 patients over 80 years old treated by radical nephrectomy or nephroureterectomy for malignant and inflammatory conditions within the previous 4 years. A multivariate analysis regarding survival and recovery was conducted and included various preoperative parameters. The subjective opinion of patients or patient's relatives (in cases where the patient had past away) was estimated by answering the following questions: (a) are you satisfied with your decision to undergo the operation? (b) would you undergo it once more if needed? (c) would you advise it to a patient your age? The median age was 83.5 years. Radical nephrectomy with a flank approach was performed in 65.7% of cases and nephroureterectomy with a transabdominal approach in 34.3% of cases. The median recovery was 13 weeks. During a median follow-up of 31 months (range 12 to 53), 80% of patients were disease free. The remaining 20% passed away demonstrating a median survival of 25 months (range 13-38). Eighty-eight percent of patients were satisfied with their decision to undergo the operation, 91.4% would undergo it once more if needed and 91.4% would advise it to a patient their age. Radical nephrectomy and nephroureterectomy are safe and effective in well-selected patients over 80 years old. Elderly patients exhibit comparable preoperative outcomes and survival benefits to those achieved in younger patients. Various preoperative clinical variables that effect the survival of patients but not their recovery could be identified.

Should Bladder Cuff Excision Remain the Standard of Care at Nephroureterectomy in Patients with Urothelial Carcinoma of the Renal Pelvis? A Population-based Study

Should Bladder Cuff Excision Remain the Standard of Care at Nephroureterectomy in Patients with Urothelial Carcinoma of the Renal Pelvis? A Population-based Study

Should Bladder Cuff Excision Remain the Standard of Care at Nephroureterectomy in Patients with Urothelial Carcinoma of the Renal Pelvis? A Population-based Study

BackgroundA large, multi-institutional, tertiary care center study suggested no benefit from bladder cuff excision (BCE) at nephroureterectomy in patients with upper tract urothelial carcinoma (UC). ObjectiveWe tested and quantified the prognostic impact of BCE at nephroureterectomy on cancer-specific mortality (CSM) in a large population-based cohort of patients with UC of the renal pelvis. Design, setting, and participantsA cohort of 4210 patients with UC of the renal pelvis were treated with nephroureterectomy with (NUC) or without (NU) a BCE between 1988 and 2006 within 17 Surveillance, Epidemiology, and End Results registries. MeasurementsCumulative incidence plots and competing risks regression models compared CSM after either NUC or NU. Covariates consisted of pathologic T and N stages, grade, age, year of surgery, gender, and race. Results and limitationsRespectively, 2492 (59.2%) and 1718 (40.8%) patients underwent a nephroureterectomy with or without BCE. In univariable and multivariable analyses, BCE omission increased CSM rates in patients with pT3N0/x, pT4N0/x, and pT(any)N1-3 UC of the renal pelvis. For example, in patients with pT3N0/x disease, holding all other variables constant, BCE omission increased CSM in a 1.25-fold fashion (p=0.04). Similarly, in patients with pT4N0/x disease, BCE omission resulted in a 1.45-fold increase (p=0.02). The main limitation of our study is the lack of data on disease recurrence. ConclusionsNephroureterectomy with BCE remains the standard of care in the treatment of UC of the renal pelvis and should invariably be performed in patients with locally advanced disease. Conversely, patients with pT1 and pT2 disease could be considered for NU without compromising CSM. However, recurrence data are needed to fully confirm the validity of this option.

Gender-related Differences in Patients With Stage I to III Upper Tract Urothelial Carcinoma: Results From the Surveillance, Epidemiology, and End Results Database

To examine the effect of gender in upper tract urothelial carcinoma (UTUC) stage at nephroureterectomy (NU), as well as on cancer-specific mortality (CSM) after NU in patients with American Joint Committee on Cancer stages I-III UTUC. Our analyses relied on 2903 (59.9%) males and 1947 (40.1%) females who underwent an NU for pT(1-3)N(0/x)M(0) UTUC between 1988 and 2006, within 17 Surveillance, Epidemiology, and End Results registries. Univariable and multivariable logistic regression models examined the effect of gender on stage and grade distribution at NU. Subsequently, cumulative incidence plots explored the impact of gender on CSM rates, after accounting for other-cause mortality (OCM). Finally, competing-risks regression models tested the independent predictor status of gender in CSM analyses. Covariates consisted of pT stage, pN stage, tumor grade, primary tumor location, type and year of surgery, age, and race. Relative to males, females had a higher proportion of pT(3) UTUC (43.1% vs 39%; P = .02) and a higher proportion of grade III/IV UTUC (63.8% vs 59.8%; P = .04) at NU. The female gender represented an independent predictor of pT(3) UTUC at NU (hazard ratio [HR]: 1.15; P = .03). After accounting for OCM, CSM rates in females were higher than those in males (HR: 1.18; P = .03). However, in multivariable competing-risks regression models, no statistically significant differences in survival were recorded between males and females (HR: 1.07; P = .4). Females are more likely to have more advanced pathologic T stage and higher tumor grade at NU than males. After accounting for OCM, stage, grade, and noncancer characteristics, gender no longer affects CSM.

Editorial Comment

Patients with invasive upper tract transitional cell carcinoma (UTTCC) pose a difficult management problem with prognosis dependent on the degree of invasion, the relationship, if any, to previous superficial or invasive bladder cancer, and the presence of metastatic nodes. Similar to invasive bladder cancer, preoperative staging can often be inaccurate and distinguishing superficial invasion from deep invasion may not always be possible. Unlike invasive bladder cancer, strategies to improve survival rates using neoadjuvant systemic chemotherapy before nephroureterectomy have not been subjected to clinical trials. However, many urological and medical oncologists advocate systemic platinum-based chemotherapy before nephroureterectomy with the expectations of improving survival rates of 40%-70% for T2-T3 tumors. 1 Hall C.M. Womack S. Sagalowsky A.I. et al. Prognostic factors, recurrence, and survival in transitional cell carcinoma of the upper urinary tract: a 30 year experience in 252 patients. Cancer. 1998; 52: 594-601 Google Scholar , 2 Balaji K.C. McGuire M. Grotas J. et al. Upper tract recurrences following radical cystectomy: an analysis of prognostic factors, recurrence pattern, and stage of presentation. J Urol. 1999; 162: 1603-1606 Abstract Full Text Full Text PDF Scopus (87) Google Scholar , 3 Mullerad M. Russo P. Golijanin D. et al. Bladder cancer as a prognostic factor for upper tract transitional cell carcinoma. J Urol. 2004; 172: 2177-2181 Abstract Full Text Full Text PDF Scopus (83) Google Scholar , 4 Novara G. De Marco V. Gottardp F. et al. Independent predictors of cancer specific survival in transitional cell carcinoma of the upper urinary tract. Cancer. 2007; 110: 1715-1722 Crossref Scopus (165) Google Scholar The need for a complete, meticulous, full, bilateral pelvic lymphadenectomy has been established for invasive bladder cancer with a therapeutic advantage achieved for micrometastatic disease as well as critical information for decision-making regarding adjuvant systemic therapies. 5 Herr H.W. Bochner B.H. Dalbagni G. et al. Impact of the number of lymph nodes retrieved on outcome in patients with muscle invasive bladder cancer. J Urol. 2002; 167: 1295-1298 Abstract Full Text Full Text PDF Scopus (508) Google Scholar Still, for reasons not clear, the concept of meticulous retroperitoneal node dissection for invasive UTTCC has not been adopted by urologists worldwide despite reports for a similar therapeutic and staging advantage as reported in invasive bladder cancer. 6 Brausi M.A. Gavioli M. De Luca G. et al. Retroperitoneal lymph node dissection in conjunction with nephroureterectomy in the treatment of infiltrative transitional cell carcinoma of the upper urinary tract: impact on survival. Eur Urol. 2007; 52: 1414-1420 Abstract Full Text Full Text PDF Scopus (106) Google Scholar , 7 Roscigno M. Cozzarini C. Bertini R. et al. Prognostic value of lymph node dissection in patients with muscle-invasive transitional cell carcinoma of the upper urinary tract. Eur Urol. 2008; 53: 794-802 Abstract Full Text Full Text PDF Scopus (135) Google Scholar Assessment of the Minimum Number of Lymph Nodes Needed to Detect Lymph Node Invasion at Radical Nephroureterectomy in Patients With Upper Tract Urothelial CancerUrologyVol. 74Issue 5PreviewTo determine whether a minimum number of lymph nodes (LNs) exist to detect lymph node invasion (LNI) in patients undergoing radical nephroureterectomy (RNU) for upper tract urothelial carcinoma. Full-Text PDF Editorial CommentUrologyVol. 74Issue 5PreviewThis is a well-conducted retrospective review of a large cohort of patients with upper tract urothelial carcinoma. I commend the authors on their efforts in establishing the minimum extent of nodal dissection in this patient population. To date, there is increasing evidence on both the prognostic and therapeutic effects of lymphadenectomy in patients with urothelial carcinoma of the bladder undergoing cystectomy. Furthermore, numerous studies have examined the limits and extent of lymph node dissection in patients with bladder cancer. Full-Text PDF ReplyUrologyVol. 74Issue 5PreviewDespite the prognostic and predictive effect of lymph node (LN) metastases, the benefit of lymphadenectomy (LND) in patients treated with radical nephroureterectomy (RNU) for urinary tract urothelial cancer (UTUC) remains debatable, and the procedure is still not widely performed.1,2 Even in our retrospective study, the low median number of nodes removed reflects a significant problem of quality of care when performing LND in patients with upper tract disease. Full-Text PDF ReplyUrologyVol. 74Issue 5PreviewA maximum of 30% of patients with muscle-invasive UTUC show nodal metastases at the time of surgery, which represents a well established poor prognostic factor.1 Despite the prognostic and predictive effect of LN metastases, the benefit of lymphadenectomy (LND) in patients treated with radical nephroureterectomy (RNU) for UTUC remains debatable, and the procedure is not widely performed.2,3 Full-Text PDF

Assessment of the Minimum Number of Lymph Nodes Needed to Detect Lymph Node Invasion at Radical Nephroureterectomy in Patients With Upper Tract Urothelial Cancer

To determine whether a minimum number of lymph nodes (LNs) exist to detect lymph node invasion (LNI) in patients undergoing radical nephroureterectomy (RNU) for upper tract urothelial carcinoma. The study included 551 consecutive patients, from 13 centers worldwide, who underwent RNU and lymphadenectomy (LND) between 1992 and 2006. LND was performed at the discretion of the surgeon. All pathological slides were re-reviewed by uropathologists according to strict criteria. Receiver-operating characteristic curve coordinates were used to determine the probability of diagnosing LNI according to the total number of nodes removed. Additionally, the relationship between the number of nodes removed and the rate of positive LNs was tested in univariate and multivariate logistic regression models. Median patient age was 68 years (range: 27-97). Of 551 patients, 140 (25.4%) had positive lymph nodes. Median number of lymph nodes removed was 5 (mean 6.7, range 1-41). The Receiver-operating characteristic coordinates plot indicated that the removal of 13 nodes yielded a 90% probability to detect >or=1 positive LNs. The removal of 8 nodes resulted in a 75% probability of finding >or=1 positive nodes. Removal of >8 LNs (P = .03; odds ratio 1.49) was independently associated with LNI after adjusting for pathological stage and grade. Our data indicate that 8 LNs need to be removed at radical nephroureterectomy to achieve a 75% probability of finding >or=1 positive nodes. Further improvement of the specificity of LND will require the removal of more lymph nodes.

Adjuvant Chemotherapy for High Risk Upper Tract Urothelial Carcinoma: Results From the Upper Tract Urothelial Carcinoma Collaboration

There is relatively little literature on adjuvant chemotherapy after radical nephroureterectomy in patients with upper tract urothelial carcinoma. We determined the incidence of adjuvant chemotherapy in high risk patients and the ensuing effect on overall and cancer specific survival. Using an international collaborative database we identified 1,390 patients who underwent nephroureterectomy for nonmetastatic upper tract urothelial carcinoma between 1992 and 2006. Of these cases 542 (39%) were classified as high risk (pT3N0, pT4N0 and/or lymph node positive). These patients were divided into 2 groups, including those who did and did not receive adjuvant chemotherapy, and stratified by gender, age group, performance status, and tumor grade and stage. Cox proportional hazard modeling and Kaplan-Meier analysis were used to determine overall and cancer specific survival in the cohorts. Of high risk patients 121 (22%) received adjuvant chemotherapy. Adjuvant chemotherapy was more commonly administered in the context of increased tumor grade and stage (p <0.001). Median survival in the entire cohort was 24 months (range 0 to 231). There was no significant difference in overall or cancer specific survival between patients who did and did not receive adjuvant chemotherapy. However, age, performance status, and tumor grade and stage were significant predictors of overall and cancer specific survival. Adjuvant chemotherapy is infrequently used to treat high risk upper tract urothelial carcinoma after nephroureterectomy. Despite this finding it appears that adjuvant chemotherapy confers minimal impact on overall or cancer specific survival in this group.

Bladder cancer after nephroureterectomy in patients with urothelial carcinoma of the upper urinary tract

Objectives To determine the independent risk factors of bladder recurrence in patients with upper urinary tract (UUT) urothelial carcinoma (UC). Materials and methods A total of 181 patients with UUT-UC were enrolled in this study. Their median age was 63 years (range 36–90), and median follow-up after total nephroureterectomy was 37.5 months (range 1.0–174.0). The end-point of this study was defined as the initial intravesical recurrence of UC. Results Of the 181 patients, 64 (35.4%) developed subsequent bladder tumors at a median interval of 6.3 months (range 1.7–50.1) after initial treatment. By univariate analysis, a previous bladder tumor history ( P = 0.046) and tumor necrosis ( P < 0.001) were found to have a significant prognostic impact on bladder tumor-free survival in patients with superficial UUT-UC, whereas surgical margin status ( P = 0.045) and the use of adjuvant chemotherapy ( P = 0.003) were found to be prognostic factors for bladder tumor-free survival in those with invasive UUT-UC. However, by multivariate analysis, only tumor necrosis ( P = 0.012, relative risk = 6.512) was found to have a significant impact on intravesical recurrence in patients with superficial UUT-UC. However, surgical margin status ( P = 0.007, relative risk = 5.846) and the use of adjuvant chemotherapy ( P = 0.001, relative risk = 0.223) were retained as independent predictors of bladder tumor survival in those with invasive UUT-UC. Conclusions Our findings may be useful in patients with UUT-UC who may require more stringent follow-up by cystoscopy to detect bladder tumors.

Conservative management in selected patients with upper tract urothelial carcinoma compares favourably with early radical surgery

To compare the outcomes of patients treated for upper tract urothelial carcinoma with either immediate nephroureterectomy (NU) or initial endoscopic management. The treatments of 108 patients (120 renal units) at the authors' institution were retrospectively reviewed and divided into two groups, i.e. those who received immediate NU and those who had conservative initial therapy, which included renal units solely treated with endoscopy with or without delayed NU. Overall and disease-specific survival (DSS) were compared between the treatment groups. There were 48 low-grade tumours, of which 27 (56%) were managed conservatively and 21 (44%) by immediate NU. Seven patients treated conservatively had stage or grade progression and had delayed NU. The mean (sd) DSS at 5 years in patients with low-grade disease was equally good for conservative treatment and immediate NU, at 86.2 (9.1)% vs 87.4 (8.4)% (P = 0.909). There were 68 high-grade tumours, of which 12 (18%) patients had conservative management and 56 (82%) had immediate NU. Among the former, seven of 12 had a solitary kidney and three had bilateral disease. In patients managed endoscopically, four of 30 (13%) required delayed NU. The DSS for the conservative and immediate NU groups were 68.6 (18.6)% vs 75.0 (8.1)% (P = 0.528). Management with a conservative approach in selected patients provides comparable outcomes to immediate NU in patients with low-grade disease.

Laparoscopic Nephroureterectomy in Patient with an Upper Urinary Tract Transitional Cell Carcinoma: Safety and Efficacy

Purpose: To evaluate the safety and efficacy of a laparoscopic nephroureterectomy in patients with a transitional cell carcinoma of the renal pelvis and ureter. Materials and Methods: All patients underwent a nephroureterectomy for an upper tract transitional cell carcinoma. Of these, 23 and 22 underwent a laparoscopic nephroureterectomy (LNU) and open nephroureterectomy (ONU), respectively, between January 2002 and June 2006. After the nephrectomy had been performed, a 5-6cm modified Gibson incision was created to allow dissection of the lower ureter and bladder cuff, and extraction of the intact specimen. A retrospective analysis was performed on the operating time, blood loss, analgesic requirement, ambulation time, interval to resume oral intake, hospital stay, complications and follow-up results for both groups. Results: The LNU was superior to the ONU with regard to the mean operation time; 275 (190-390) versus 258 (180-400) (p=0.259), blood loss; 188 (130-250) versus 488ml (350-750) (p<0.05), ambulation time; 2.5 versus 3.3 days (p<0.05), interval to resume oral intake 2.1 versus 2.8 days (p<0.05), and hospital stay; 8.3 versus 11.1 days (p<0.05). Complications developed in 4 and 5 of the LNU and ONU patients, respectively, but all were resolved with conservative management. The mean follow-up duration of the LNU and ONU groups were 29 versus 14 months, respectively. Conclusions: Based on our experience, a laparoscopic nephroureterectomy is better tolerated with respect to pain, has less blood loss, shorter hospital stays, ambulation time and time to oral intake. LNU is safe for an upper tract transitional cell carcinoma, and is also an efficacious alternative to open surgery. However, a long-term follow-up will be warranted to ascertain accurate oncologic data. (Korean J Urol 2007;48:252-258)

腎盂尿管癌の病理学的予後因子に関する検討

To determine the pathologic risk factors after nephroureterectomy in patients with urothelial carcinoma of the renal pelvis and ureter. We investigated the clinicopathological features of 131 patients (94 males and 37 females) with urothelial carcinoma of the renal pelvis and ureter who underwent nephroureterectomy at our department and related facilities from August, 1994 to August, 1997. The mean age of the patients was 68 years, ranging from 24 to 86 years. The 1-, 3- and 5-year cause-specific survival rates (Kaplan-Meier's method) for all of the patients were 91.8%, 76.7%, and 67.8%, respectively. The significant prognostic factors for survival rates by univariate analysis using the log rank test were tumor stage, infiltration pattern, lymphatic invasion, vessel invasion and lymph node metastasis. On the other hand, multivariate analysis using Cox proportional hazards regression model showed the most influential prognostic factors to be vessel invasion and tumor stage. From these results, in urothelial carcinoma of the renal pelvis and ureter underwent nephroureterectomy, we suggested that vessel invasion and tumor stage were the independent prognostic factors.