Treatment Of Upper Tract Transitional Cell Carcinoma Research Articles

Minimally invasive approach in the management of upper- urinary-tract tumours

Nephroureterectomy with bladder cuff excision has been the gold standard treatment for upper tract transitional cell carcinoma (UTTCC) for more than 60 years. However, endoscopic treatment of urothelial tumours of renal pelvis and ureter is gaining acceptance as a conservative treatment modality. A review in the English language of the Medline and Pub Med databases was performed using the keywords upper urinary tract transitional cell carcinoma and endoscopic management. There was a particular emphasis on treatment outcomes from published series. Endoscopic treatment of UTTCC alone for high-grade tumours is not advised owing to high rates of both local recurrence and disease progression, while many authors do not recommend primary endoscopic management of UTTCC in elective situations if pathological analysis and tumour grade cannot be obtained. Endourological management of UTTCC has become an accepted treatment option in highly selected patients, provided long-term close surveillance to detect and treat recurrences is ensured.

A 20-Year Experience With Percutaneous Resection of Upper Tract Transitional Carcinoma: Is There an Oncologic Benefit With Adjuvant Bacillus Calmette Guérin Therapy?

To determine whether there is an oncologic benefit of adjuvant bacillus Calmette Guérin (BCG) after resection of upper tract transitional cell carcinoma (UTTCC). A total of 133 renal units (RU) treated by percutaneous resection for UTTCC between 1985 and 2005 were retrospectively analyzed. Forty-four RU were excluded because of carcinoma in situ, high grade/stage, metastatic disease present at initial presentation, and/or the patient could tolerate loss of RU. Eighty-nine RU treated primarily by percutaneous resection were then analyzed. Fifty RU received adjuvant BCG therapy 2 weeks after endoscopic management for a total of 6 courses. Recurrence was defined as a positive biopsy result after the third-look nephroscopy. Progression of disease was assessed at time of recurrence and defined as an increase in grade/stage of disease. Mean age (+/- SD) of 89 RU was 70.9 +/- 11.1 years. Overall follow-up was 61.1 + 54.8 months. Grade distribution was 56.2% (50 of 89) and 43.8% (39 of 89) for low- and high-grade disease, respectively. There was no statistical difference with regard to tumor grade or stage between treated and nontreated groups (P > .05). Recurrence, time to recurrence, and progression of disease among RU treated with BCG were subselected by grade and compared with the corresponding nontreated group. Statistical significance between any of the treated and nontreated groups was not demonstrated (P > .05). Our data demonstrate that there is no overall oncologic benefit in the administration of adjuvant BCG with regard to disease recurrence, interval to recurrence, and progression of disease in the treatment of UTTCC.

Transitional-Cell Carcinoma Recurrence Rate after Nephroureterectomy in Patients Who Undergo Open Excision of Bladder Cuff v Transurethral Incision of the Ureteral Orifice

The gold standard treatment for upper-tract transitional-cell carcinoma is radical nephroureterectomy, but management of the distal ureter is not standardized. Two treatment options to detach the distal ureter are open cystotomy (OC) and excision of a bladder cuff or transurethral incision of the ureteral orifice (TUIUO). We compared the clinico-pathologic outcomes of these two techniques. Hospital records were reviewed on all 51 patients who had undergone open or laparoscopic nephroureterectomy at our institution between 1 January 1990 and 30 June 2005. Patient demographics, intraoperative parameters, and pathology data were collected. The mean follow-up was 23.2 months (range 4.5-75 months) and 22.1 months (range 1-50 months) for the OC and TUIUO groups, respectively. There were no significant differences in sex, age at operation, American Society Anesthesiologists risk score, previous transitional-cell tumors, pathologic tumor grade and stage, or metastatic disease status in the two groups. Five patients had an unplanned incomplete ureterectomy. The bladder recurrence rates were similar in the OC group (22.2%; 6/27) and the TUIUO group (26.3%; 5/19). There were no pelvic recurrences in either group. Four of the five patients who had an incomplete ureterectomy had tumor recurrences, three in the form of metastatic disease. Management of the distal ureter by TUIUO in appropriate patients offers the same rate of bladder recurrence as OC. Incomplete ureterectomy results in a significantly higher rate of recurrence, often associated with the development of metastatic disease.

Ureteroscopic Resection of Upper-Tract Transitional-Cell Carcinoma

Technological advances have increased the applicability of endoscopic treatment for upper-tract transitional-cell carcinoma (TCC). Percutaneous and ureteroscopic tumor resection have become reasonable treatment options for patients with anatomically or functionally solitary kidneys, bilateral upper-tract tumors, significant renal insufficiency, or comorbid disease that would preclude standard open surgery. This approach also is being used increasingly on those with a normal contralateral kidney in whom nephroureterectomy and en bloc removal of the ipsilateral ureteral orifice and surrounding bladder cuff is considered the standard therapy. This paper reviews the current role of ureteroscopic management of upper-tract TCC.

Endourologic treatment of upper urinary tract transitional cell carcinoma

The traditional treatment for upper tract transitional cell carcinoma (UTTCC) consists of radical nephroureterectomy. A more conservative approach, however, was required in cases of bilateral UTTCC and in patients with disease in a solitary kidney but who had underlying comorbidities that made them unsuitable candidates for open surgery. Minimally invasive treatment methods were developed for these select groups of patients. Because of technological advancements and refinement in endoscopic techniques, most patients with UTTCC, even those with normal contralateral kidneys, can now be offered minimally invasive treatment with single or multimodal approaches involving ureteroscopy or percutaneous resection. For patients with low-stage, low-grade UTTCC, five-year survival rates are comparable for those treated endourologically and those treated by nephroureterectomy. High-grade lesions have much higher recurrence and progression rates than lower-grade lesions, and nephroureterectomy is therefore recommended in patients with high-grade disease. The use of adjuvant instillation in the treatment of UTTCC, administered via antegrade and retrograde methods, has been shown to improve outcomes. For recurrences to be diagnosed and treated in a timely manner, and acceptable cancer-free survival rates maintained, long-term rigorous follow-up after endourologic treatment, with regular surveillance ureteroscopy, is crucial.

Editorial Comment: Retroperitoneal Laparoscopic Nephroureterectomy and Management Options for the Distal Ureter

Journal of EndourologyVol. 15, No. 4 Transitional-cell Carcinoma of the Renal PelvisEditorial Comment: Retroperitoneal Laparoscopic Nephroureterectomy and Management Options for the Distal UreterFray F. MarshallFray F. MarshallSearch for more papers by this authorPublished Online:6 Jul 2004https://doi.org/10.1089/089277901300189411AboutSectionsPDF/EPUB ToolsPermissionsDownload CitationsTrack CitationsAdd to favorites Back To Publication ShareShare onFacebookTwitterLinked InRedditEmail "Editorial Comment: Retroperitoneal Laparoscopic Nephroureterectomy and Management Options for the Distal Ureter." , 15(4), p. 397FiguresReferencesRelatedDetailsCited ByLaparoscopic Approaches to Renal MalignanciesCurrent Problems in Cancer, Vol. 30, No. 4 Volume 15Issue 4May 2001 To cite this article:Fray F. Marshall.Editorial Comment: Retroperitoneal Laparoscopic Nephroureterectomy and Management Options for the Distal Ureter.Journal of Endourology.May 2001.397-397.http://doi.org/10.1089/089277901300189411Published in Volume: 15 Issue 4: July 6, 2004PDF download

Laparoscopic nephroureterectomy: making management of upper-tract transitional-cell carcinoma entirely minimally invasive.

Endoscopic treatment of upper-tract transitional-cell carcinoma (TCC) is well established. Nevertheless, many patients still required major ablative surgery. We have applied our experience with laparoscopic nephrectomy to the performance of laparoscopic nephroureterectomy in order to make the management of upper-tract TCC entirely minimally invasive. Since 1993, we have performed 22 laparoscopic nephroureterectomies for upper-tract TCC. Initially, we excluded patients with tumors below the pelvic brim, but we now offer a trial of laparoscopy to all patients. We describe the evolution of our technique, which involves resecting the ureteral orifice prior to laparoscopic dissection of the kidney and ureter. We have had to convert three cases to open surgery, one each for bleeding, failure to progress, and unappreciated tumor extent. Operative times averaged 156 minutes, which compares well with contemporary times for open nephroureterectomy. Complication rates, transfusion requirements, and length of stay, although higher than those of laparoscopic nephrectomy, were all reduced in comparison with open nephroureterectomy.

Model of Human Transitional Cell Carcinoma: Tumor Xenografts in Upper Urinary Tract of Nude Rat

An in vivo model for the study of human transitional cell carcinoma (TCC) in the urinary tract is desirable. Orthotopic xenografts are useful in order to approximate better the behavior of human tumor cells in situ. Prior models have been described in the urinary bladder of the nude mouse and rat. We have developed the first model of implantation of human TCC in the upper urinary tract of an experimental animal. The kidneys of homozygous nude rats 4 weeks of age were inoculated with 1-5 x 10(6) cells of the RT4 well-differentiated papillary human TCC line through bilateral flank incisions, with transparenchymal injection of tumor cells into either the collecting system (renal pelvis) or the parenchyma. The overall implantation rate was 92% (54/59 kidneys). However, implantation into the collecting system occurred in only 45% (18/45) of the group. Ligation of the ureter prior to inoculation to produce urine stasis improved the mucosal implantation rate. Despite suspect urine cytology findings in the renal pelvis injection group, no distal seeding of the urinary tract was seen. Intraparenchymal tumor growth was less differentiated and had a higher fraction of mitotic cells than mucosal tumors. Vascular and lymphatic invasion were commonly seen; however, distant metastasis was not observed. This model will prove useful in determining the role of seeding in recurrent disease and in developing less invasive modalities for the treatment of upper tract TCC.