Technologic improvements in imaging and direct endoscopic visualization of all levels of the urinary tract allow earlier and more accurate initial diagnosis and treatment and improved follow-up.
Treatment may be based primarily on the risk the tumor poses and on the efficacy of a specific treatment rather than on other considerations.
- The least invasive and least ablative treatment necessary for safe control of the tumor is preferred.
- Most upper tract urothelial tumors are not large or bulky.
- Laparoscopic surgery is ideal, at least for the renal portion of radical nephroureterectomy when the tumor warrants removal of the entire renal unit.
- A variety of approaches with various combinations of laparoscopic and open techniques are employed for distal ureterectomy.
- Low-grade noninvasive upper tract tumors are managed initially by ablative renal-sparing surgery.
- Retrograde ureteroscopy and ureteropyeloscopy are preferred when tumor size, number, and access allow complete tumor ablation.
- Percutaneous antegrade tumor ablation is chosen when the anatomy and the tumor do not allow complete ablation through a retrograde approach.
Open Nephron-Sparing Surgery for Renal Pelvis Tumors
- Open conservative surgery may be applied in selected cases when nephron sparing for preservation of renal function is required.
- Tumor in a solitary kidney, synchronous bilateral tumors, and predisposition to form multiple recurrences, as in endemic Balkan nephropathy, are all reasons to consider nephron sparing.
Open Radical Nephroureterectomy
- Radical nephroureterectomy with excision of a bladder cuff is recommended for large, high-grade, invasive tumors of the renal pelvis and proximal ureter.
- Radical surgery also retains a role in treatment of medium-grade, noninvasive tumors of the renal pelvis and upper ureter when they are large, multifocal, or rapidly recurring despite maximal efforts at conservative surgery.
- Regional lymphadenectomy is included with radical nephroureterectomy.
Laparoscopic Radical Nephroureterectomy
- The indications for laparoscopic nephroureterectomy are the same as those for open nephroureterectomy.
- Laparoscopic nephroureterectomy can be performed by transperitoneal, retroperitoneal and hand-assisted approaches.
- All show a significant decrease in morbidity compared with an open surgical approach for appropriately selected patients.
- All laparoscopic techniques involve two distinct portions of the procedure: nephrectomy and excision of the distal ureter with intact specimen extraction for accurate staging.
In summary there does not appear to be a significant difference between laparoscopic and open nephroureterectomy when the principles of surgical oncology are followed. Management of the bladder cuff still has shown variability and a tendency toward higher recurrences with minimally invasive approaches. Lymphadenectomy can be performed laparoscopically and should be utilized based on the clinical situation.
Ureteroscopy
- The ureteroscopic approach to tumors is generally favored for ureteral and smaller renal tumors.
- With the advent of small-diameter rigid and flexible ureteroscopes, tumor location is less of a limiting factor than in the past.
- The advantage of a ureteroscopic approach is lower morbidity than that of the percutaneous and open surgical counterparts, with the maintenance of a closed system.
- With a closed system, nonurothelial surfaces are not exposed to the possibility of tumor seeding.
- The major disadvantages of a retrograde approach are related to the smaller instruments required.
- Smaller endoscopes have a smaller field of view and working channel.
- This limits the size of tumor that can be approached.
- In addition, some portions of the upper urinary tract, such as the lower pole calyces, cannot be reliably reached with working instruments.
- Smaller instruments limit the ability to remove large tumors and to obtain deep specimens for reliable staging.
- Retrograde ureteroscopy is difficult in patients with prior urinary diversion.
- The lesion is sampled first for cytology and for histopathologic staging, if possible; then it is ablated.
- The holmium : YAG laser is well suited for use in the ureter. The tissue penetration is less than 0.5 mm, which allows tumor ablation with excellent hemostasis and minimal risk of full-thickness injury to the ureter.
- Settings most commonly used for the holmium : YAG laser are energy of 0.6 to 1 J with frequency of 10 Hz.
- The Nd : YAG laser has a tissue penetration of up to 5 to 6 mm, depending on laser settings and duration of treatment.
- In contrast to the holmium : YAG laser, which ablates tumor, the Nd : YAG laser works by coagulative necrosis with subsequent sloughing of the necrotic tumor.
- The safety margin is significantly lower and can limit its use in the ureter, where the ureteral wall is thin.
- Settings most commonly used for the Nd : YAG laser are 15 W for 2 seconds for ablation of tumor and 5 to 10 W for 2 seconds for coagulation.
- A ureteral stent is placed for a variable duration to aid with the healing process. Large tumors usually require multiple treatment sessions during several months.
Results
- The overall recurrence rates for ureteral and renal pelvic lesions were 33% and 31.2%, respectively, and the risk of bladder recurrence was 43%.
- The most important prognostic indicator for tumor recurrence was grade.
Adjuvant Therapy After Organ-Sparing Therapy
Instillation Therapy
- The same agents used to treat urothelial carcinoma of the bladder are used to treat tumors of the upper urinary tract.
- The most common complication of instillation therapy is bacterial sepsis.
- To minimize this problem, patients must be evaluated for active infection before each treatment and only a low-pressure delivery system should be used.
- Agent-specific complications of the various therapies include ramification of systemic absorption of the agent.
Brachytherapy
- Brachytherapy to the nephrostomy tract through iridium wire or delivery system has been deomonstrated.
- The only major complication attributed to the brachytherapy was cutaneous fistula formation requiring nephroureterectomy.
Distant relapse with metastatic disease is the main limitation in survival of patients, not local recurrence.
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