The outcome of patients on dialysis with upper urinary tract transitional cell carcinoma

PURPOSE: Transitional cell carcinoma is the most common upper urinary tract cancer in Taiwanese patients on dialysis. It is a unique finding compared with Western countries. Unfortunately, the long-term outcomes of patients with upper urinary tract transitional cell carcinoma on dialysis are largely unknown. This study presents clinical outcome of patients on dialysis with upper urinary tract transitional cell carcinoma. MATERIALS AND METHODS: We retrospectively reviewed the medical records of all patients with upper urinary tract transitional cell carcinoma who had end stage renal disease and underwent dialysis. Traditional prognostic factors including age, sex, tumor grade, stage and tumor location were analyzed with respect to disease recurrence and survival. RESULTS: A total of 73 patients were included in this study. The major complaints were painless gross hematuria and urethral bloody discharge. Disease relapsed in 40 (54.8%) patients at average time of 15 months (2 to 92). Univariate analysis failed to identify significant prognostic factors for recurrence. The average duration between primary and contralateral metachronous upper urinary tract transitional cell carcinoma recurrence was 36 months (range 5 to 96). Patients on dialysis with upper urinary tract transitional cell carcinoma who had previous or concurrent bladder tumor, or who had a history of recurrent bladder tumor, had high contralateral upper urinary tract transitional cell carcinoma recurrence. (p = 0.038) The statistically significant prognostic factor for disease-free survival was pT stage (p = 0.041). CONCLUSIONS: Patients on dialysis with painless gross hematuria or bloody urethral discharge must undergo detail urinary system evaluation. Since patients with upper urinary tract transitional cell carcinoma on dialysis have a high recurrence rate and metachronous or even multiple, early synchronous tumor characteristics that may be missed by imaging, total urinary tract exenteration is a recommended therapeutic option.     

The impact factors on prognosis of patients with pT3 upper urinary tract transitional cell carcinoma

PURPOSE: Stage 3 upper urinary tract transitional cell carcinoma is a heterogeneous disease including different tumor locations (pelvis vs ureter) and invasion patterns (renal parenchyma, peripelvic fat and periureteral fat). Unfortunately the outcomes of patients with pT3 disease with different invasion pattern are largely unknown. This study presents the clinical outcome of patients with pT3 disease with upper urinary tract transitional cell carcinoma. MATERIALS AND METHODS: We retrospectively reviewed the medical records of all patients with pT3 disease with upper urinary tract transitional cell carcinoma. Four patient groups were classified according to tumor location and tumor invasion pattern. Prognostic factors including age, gender, tumor grade, tumor size, tumor number, tumor location and microscopic finding of vascular invasion were analyzed with respect to disease recurrence and survival. RESULTS: A total of 72 patients were included in this study. The most common complaint and tumor relapse pattern were painless gross hematuria and distant metastasis, respectively. Patients with pT3 disease with superficial parenchymal invasion had better disease-free and recurrence-free survival than the other 3 groups. Initial tumor location (p = 0.02) and vascular invasion (p = 0.02) were independent factors for disease-free survival, and vascular invasion (p = 0.001) was the only predictive factor for recurrence-free survival. CONCLUSIONS: The present study demonstrated that patients with pT3 disease with superficial parenchymal invasion should be considered to have lower stage disease, and that vascular involvement is the only independent prognostic factor for patients with pT3 disease for disease-free and recurrence-free survival. Systemic adjuvant therapy should be recommended for patients with pT3 disease with vascular involvement.     

The role of volume weighted mean nuclear volume in predicting the prognosis of patients with primary transitional cell carcinoma of the upper urinary tract: a report of 102 new cases

PURPOSE: We compare estimates of volume weighted mean nuclear volume (MNV) with histological grading to determine the prognosis of primary transitional cell carcinoma of the upper urinary tract using a Cox proportional hazards model. MATERIALS AND METHODS: We retrospectively reviewed 102 patients who underwent nephroureterectomy for primary transitional cell carcinoma of the upper urinary tract at our hospital between April 1981 and March 1997. Traditional prognostic factors, such as patient age, sex, stage and grade, multiplicity and unbiased estimates of MNV were analyzed with respect to disease recurrence and survival. RESULTS: Estimates of mean nuclear volume were significantly larger for patients with than without lymph node metastasis (p = 0.0031). No prognostic factor significantly correlated with recurrence of transitional cell carcinoma of the bladder. For pTxN0M0 cases univariate analysis revealed that histological grade (p = 0.0018), pathological T stage (p = 0.0030) and estimates of MNV (p = 0.0001) correlated significantly with disease specific survival, and multivariate stepwise regression analysis revealed that estimate of MNV was the only powerful predictor of prognosis (p = 0.0007). CONCLUSIONS: Our results indicate that estimate of MNV is an important predictor of prognosis for transitional cell carcinoma of the upper urinary tract. We recommend MNV estimate as a supportive method for subjective histological grading.     

Laparoscopic radical nephroureterectomy for upper tract transitional cell carcinoma: the Cleveland Clinic experience

PURPOSE: We report our single institutional experience with retroperitoneal laparoscopic radical nephroureterectomy in patients with upper tract transitional cell carcinoma and compare results to those achieved by the open technique. MATERIALS AND METHODS: A total of 77 patients underwent radical nephroureterectomy for pathologically confirmed upper tract transitional cell carcinoma. Of these patients 42 underwent laparoscopic nephroureterectomy from September 1997 through January 2000 and 35 underwent open surgery. All specimens were extracted intact. Of the laparoscopic group the juxtavesical ureter and bladder cuff were excised by our novel transvesical needlescopic technique in 27 and radical nephrectomy was performed retroperitoneoscopically in all 42. Data were compared retrospectively with 35 patients undergoing open radical nephroureterectomy from February 1991 through December 1999. RESULTS: Laparoscopy was superior in regard to surgical time (3.7 versus 4.7 hours, p = 0.003), blood loss (242 versus 696 cc, p <0. 0001), specimen weight (559 versus 388 gm., p = 0.04), resumption of oral intake (1.6 versus 3.2 days, p = 0.0004), narcotic analgesia requirements (26 versus 228 mg., p <0.0001), hospital stay (2.3 versus 6.6 days, p <0.0001), normal activities (4.7 versus 8.2 weeks, p = 0.002) and convalescence (8 versus 14.1 weeks, p = 0.007). Complications occurred in 5 patients (12%) in the laparoscopic group, including open conversions in 2, and in 10 (29%) in the open group (p = 0.07). Followup was shorter in the laparoscopic group (11.1 versus 34.4 months, p <0.0001). The 2 groups were similar in regard to bladder recurrence (23% versus 37%, p = 0.42), local retroperitoneal or port site recurrence (0% versus 0%) and metastatic disease (8.6% versus 13%, p = 1.00). Mortality occurred in 2 patients (6%) in the laparoscopic group and 9 (30%) in the open group. Cancer specific survival (97% versus 87%) and crude survival (97% versus 94%) were similar between both groups (p = 0.59). CONCLUSIONS: In patients with upper tract transitional cell carcinoma who are candidates for radical nephroureterectomy the retroperitoneal laparoscopic approach satisfactorily duplicates established technical principles of traditional open oncological surgery, while significantly decreasing morbidity from this major procedure. Short-term oncological and survival data of the laparoscopic technique are comparable to open surgery. Although long-term followup data are not yet available, it appears that laparoscopic radical nephroureterectomy may supplant open surgery as the standard of care in patients with muscle invasive or high grade upper tract transitional cell carcinoma.     

Upper tract urothelial recurrence following radical cystectomy for transitional cell carcinoma of the bladder: an analysis of 1,069 patients with 10-year followup

PURPOSE: Risk factors for upper tract recurrence following radical cystectomy for transitional cell carcinoma of the bladder are not yet well-defined. We reviewed our population of patients who underwent radical cystectomy to identify prognostic factors and clinical outcomes associated with upper tract recurrence. MATERIALS AND METHODS: From our prospective database of 1,359 patients who underwent radical cystectomy we identified 1,069 patients treated for transitional cell carcinoma of the bladder between January 1985 and December 2001. Univariate analysis was completed to determine factors predictive of upper tract recurrence. RESULTS: A total of 853 men and 216 women were followed for a median of 10.3 years (maximum 18.5). There were 27 (2.5%) upper tract recurrences diagnosed at a median of 3.3 years (range 0.4 to 9.3). Only urethral tumor involvement was predictive of upper tract recurrence. In men superficial transitional cell carcinoma of the prostatic urethra was associated with an increased risk of upper tract recurrence compared with prostatic stromal invasion or absence of prostatic transitional cell carcinoma (p <0.01). In women urethral transitional cell carcinoma was associated with an increased risk of upper tract recurrence (p = 0.01). Despite routine surveillance 78% of upper tract recurrence was detected after development of symptoms. Median survival following upper tract recurrence was 1.7 years (range 0.2 to 8.8). Detection of asymptomatic upper tract recurrence via surveillance did not predict lower nephroureterectomy tumor stage, absence of lymph node metastases or improved survival. CONCLUSIONS: Patients with bladder cancer are at lifelong risk for late oncological recurrence in the upper tract urothelium. Patients with evidence of tumor involvement within the urethra are at highest risk. Surveillance regimens frequently fail to detect tumors before symptoms develop. However, radical nephroureterectomy can provide prolonged survival.     

上尿路移行细胞癌患者预后因素的Cox模型分析

目的：通过Cox比例风险模型。分析上尿路移行细胞癌患者的预后因素。指导临床治疗。方法：45例肾盂、输尿管移行细胞癌患者接受分析。年龄、性别、就诊时问、术前血色素、术中输血量、手术方式、病理分级、临床分期、肿瘤数目、肿瘤大小、术后有无复发、PCNA指数等12个变量进入Cox模型。结果：临床分期、PCNA指数、肿瘤数目、就诊时问四项参数与预后有关,其中临床分期、PCNA指数关系非常密切。病理分级、手术方式两项参数也有一定关系。根据临床分期和PCNA指数将患者分为A、B、C三组,术后5年生存率分别为92．65、38．4％与3％。差异非常显著。结论：Cox模型表明临床分期、PCNA指数与预后关系最密切。肿瘤数目、病理分级、就诊时问、手术方式对预后也有重要影响。根据临床分期和PCNA指数将患者分为不同的组,对判断预后。指导临床治疗有一定意义。     

Retroperitoneal lymph node dissection (RPLD) in conjunction with nephroureterectomy in the treatment of infiltrative transitional cell carcinoma (TCC) of the upper urinary tract: impact on survival

OBJECTIVES: To evaluate the prognostic impact of retroperitoneal lymph node dissection (RPLD) performed during nephroureterectomy on time to recurrence and survival in patients with infiltrative transitional cell carcinoma (TCC) of the upper urinary tract. METHODS: The charts of 82 patients with T2-T4 TCC of the upper tract were retrospectively reviewed. The median patient age was 67.7 yr. Seventy-nine patients underwent nephroureterectomy and three had partial nephrectomy. Forty patients (48.8%) had RPLD with removal of more than five nodes after nephroureterectomy (group 1), whereas 42 (51.2%) had nephroureterectomy only (group 2). Median follow-up was 64.7 mo. The prognostic role of RPLD, T (2 vs. 3-4), G (2 vs. 3), N (0 vs. 1-2 vs. x), age (<65 vs. >65 yr) and sex on time to recurrence and survival were evaluated. RESULTS: Median time to recurrence and overall survival were 51.2 and 52.5 mo, respectively, in group 1 and 18.5 and 21.2 mo in group 2. Univariate analysis demonstrated that RPLD and T and N status were significantly related both to time to recurrence (p=0.009, 0.008, and 0.009, respectively) and survival (p=0.000006, 0.003, and 0.003). When analyzed using the Cox proportional hazard model, RPLD and T category were the only two factors demonstrating independent significance on overall survival (p=0.004 and 0.008). CONCLUSIONS: The results indicate a possible curative role of RPLD in the treatment of patients with infiltrative TCC of the upper urinary tract. Further randomized trials are needed to confirm these results.     

Ureteroscopic management of upper tract transitional cell carcinoma in patients with normal contralateral kidneys

PURPOSE: The standard treatment for upper tract transitional cell carcinoma in patients with a normal contralateral kidney is nephroureterectomy with a bladder cuff or segmental ureterectomy. We evaluate whether ureteroscopic tumor resection with vigilant surveillance is a safe alternative in select patients. MATERIALS AND METHODS: Patients with isolated upper tract filling defects on an excretory urogram and a normal contralateral kidney were diagnosed ureteroscopically with papillary low intermediate grade appearing transitional cell carcinoma. Biopsies of the lesions were obtained, and the tumors were treated with laser ablation or electrofulguration in the same sitting. Patients with cytopathological results of high grade transitional cell carcinoma underwent nephroureterectomy. Surveillance consisted of ureteroscopy every 3 months until tumor-free and ureteroscopy every 6 months thereafter. RESULTS: Between 1989 and 1998, 23 patients with normal creatinine (mean 1.0, range 0.7 to 1.6) underwent ureteroscopic resection of unilateral upper tract transitional cell carcinoma. On initial biopsy 22 tumors were grade 1 or 2 and 1 was grade 2 to 3. After the primary tumor was treated 8 (35%) patients remained tumor-free and 15 (65%) had multiple recurrences, which were treated ureteroscopically. Mean followup was 35 months (range 8 to 103 months). All 23 patients are alive without evidence of disease progression. At last followup 4 patients (17%) had persistent disease, 4 (17%) elected to undergo nephroureterectomy and 15 (65%) are free of ipsilateral disease for a mean duration of 17 months (range 6 to 77). CONCLUSIONS: Ureteroscopic treatment of focal low intermediate grade superficial upper tract transitional cell carcinoma is a safe alternative to nephroureterectomy in select patients when vigilant ureteroscopic followup is used.     

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.     

Conservative management of upper urinary tract tumors

PURPOSE: We determined the immediate and long-term results of endoscopic management of upper tract transitional cell in regard to rates of tumor recurrence and preservation of renal function. MATERIALS AND METHODS: From January 1990 to July 1999, 61 patients (mean age 66.2 years) underwent endoscopic management of upper tract cell carcinoma. Of the patients 20 (32%) had a solitary kidney. Tumors were resected in a one time procedure by ureteroscopy only in 31.5%, by percutaneous nephroscopy in 29% or both in 8%; multiple treatment was necessary in 31.5% of cases using percutaneous nephroscopy only. RESULTS: Immediate nephrectomy was done in six cases for high grade (three patients), insufficient local control (two cases) or patient's choices (one case). There were six cases of benign tumors excluded from survival Kaplan Meier analysis. With a mean follow-up of 39.9 months, the rate of kidney preservation, recurrence free rate, global survival and specific survival rates were, respectively, 81%, 68%, 77%, and 84%. CONCLUSIONS: Nephron sparing percutaneous management of upper tract cell carcinoma is applicable in a significant number of patients with a filling defect of upper urinary tract TCC. In carefully selected patients the results are at least comparable to other forms of management of tumor control and preservation of renal function.     

Adjuvant chemotherapy in the management of pT3N0M0 transitional cell carcinoma of the upper urinary tract

INTRODUCTION: We investigate the efficacy of postoperative adjuvant chemotherapy for locally advanced, but lymph node negative, pathologic stage T3 transitional cell carcinoma (TCC) of the upper urinary tract. PATIENTS AND METHODS: A retrospective study on 27 patients who had undergone radical nephroureterectomy with regional lymphadenectomy for pT3N0M0 primary upper urinary tract TCC at our institution from 1996 to 2001 was performed. Among the 27 patients, 16 also received adjuvant chemotherapy following surgery (adjuvant group), whereas the other 11 patients did not (nonadjuvant group). RESULTS: Adjuvant and nonadjuvant therapy groups were not significantly different with respect to age, sex, performance status, tumor grade, and tumor location. Overall, 5 of the 16 patients (31%) in the adjuvant group and 4 of the 11 patients (36%) in the nonadjuvant group had recurrence of cancer at 40 months of follow-up. The two groups demonstrated no significant differences in recurrence-free survival (p = 0.794) and disease-specific survival (p = 0.783). CONCLUSIONS: Although it would be difficult to draw any definite conclusions from the results of our investigations, our data suggest that adjuvant therapy with traditional conventional chemotherapeutic regimens alone may not be effective as previously anticipated in significantly improving survival rates for locally advanced, but lymph node negative, TCC of the upper urinary tract.     

Adjuvant methotrexate,vinblastine, adriamycin,and cisplatin chemotherapy has potential to prevent recurrence of bladder tumors after surgical removal of upper urinary tract transitional cell carcinoma

Objectives: To evaluate the efficacy of adjuvant platinum based chemotherapy in upper urinary tract urothelial cancer following surgical resection in terms of survival benefit and inhibition of bladder cancer recurrence. Methods: Between April 1986 and August 2005, a total of 132 patients with a diagnosis of upper urinary tract urothelial cancer underwent radical nephroureterectomy with cuff of bladder at our department. A total of 46 patients (13 with pT2pN0M0 and 33 with pT3 pN0M0 transitional cell carcinoma without prior bladder cancer) were enrolled. Patients with locally advanced disease were divided into two groups: the adjuvant chemotherapy group (24 patients) who received adjuvant methotrexate, vinblastine, adriamycin, and cisplatin (M‐VAC) and the non‐adjuvant chemotherapy group who did not receive adjuvant M‐VAC (22 patients). Results: There were no statistically significant differences in patient characteristics or 10‐year survival between the two groups. The recurrence rate in the non‐adjuvant chemotherapy group was significantly higher than in the adjuvant chemotherapy group (log‐rank test, P < 0.0001). Only non‐adjuvant chemotherapy was a significant and independent risk factor (hazard ratio 6.97) for the development of intravesical recurrence (P < 0.01). Conclusion: Adjuvant M‐VAC is an important optional adjuvant therapy and can prevent recurrent bladder tumors following surgery for upper urinary tract transitional cell carcinoma. To determine whether adjuvant chemotherapy has further benefit, a randomized study would be needed.     

腹腔镜与开放手术治疗上尿路移行上皮肿瘤的远期疗效比较

目的：比较后腹腔镜下与开放性肾、输尿管及膀胱袖状切除术治疗上尿路移行上皮肿瘤的远期临床疗效。方法：回顾性分析48例行后腹腔镜下肾、输尿管及膀胱袖状切除术及55例行开放性肾、输尿管及膀胱袖状切除术患者的临床资料,比较两种术式术中、术后各种参数的差异。结果：后腹腔镜组与开放手术组患者在性别、年龄、肿瘤位置、及肿瘤分期上的差异无统计学意义。后腹腔镜组在术中估计出血量、术后住院时间等方面明显优于开放组（P〈0．05）。术后平均随访26．4个月,后腹腔镜组与开放组总生存率分别为79．17％、85．19％,疾病特异生存率分别为91．67％、94．44％,组间差异均无统计学意义（P〉0．05）。两组无瘤复发生存率分别为79．17％、72．22％,两组膀胱无复发生存率分别为79．17％、79．63％,组间差异均无统计学意义（P〉0．05）。结论：与传统开放手术相比,后腹腔镜下手术具有出血少、创伤小、患者痛苦少、恢复快、住院时间短等特点,并且二种手术方式具有相同的远期疗效。     

后腹腔镜联合下腹部Glison切口治疗上尿路移行细胞癌的临床价值——与同类开放性手术的对比研究

目的：回顾性比较后腹腔镜上尿路移行细胞癌根治术（LNU）与开放性上尿路移行细胞癌根治术（ONU）患者的临床资料,探讨后腹腔镜联合下腹部Glison切口治疗上尿路移行细胞癌手术的临床价值。方法：回顾性分析88例经病理检查证实的上尿路移行细胞癌患者临床资料,其中42例行LNU,46例行0Nu,采用t检验比较患者术中出血、术后恢复时间等资料,采用Kaplan—Meier法比较生存率,采用log—rank检验法比较组间生存率。结果：两组间平均手术时间差异无统计学意义,LNU组术中失血量、术后肠道恢复时间及住院时间明显少于ONU组,LNU组和ONU组5年总生存率分别为81．0％和73．7％（P=0．689）,两者之间差异无统计学意义。结论：后腹腔镜联合下腹部Glison切口治疗上尿路上皮肿瘤创伤小,安全有效,可达到与开放手术相同的肿瘤控制效果,可部分替代开放性上尿路上皮肿瘤根治术。     

Recurrence and survival following laparoscopic radical nephroureterectomy with various forms of bladder cuff control

PURPOSE: We document recurrence and survival following laparoscopic radical nephroureterectomy (LNUX) for upper tract transitional cell carcinoma (TCC) using primarily 2 methods of managing the bladder cuff. MATERIALS AND METHODS: The records of 60 patients undergoing LNUX at our institution for upper tract TCC were reviewed retrospectively. En bloc excision of the bladder cuff was primarily performed transvesically by our described cystoscopic secured detachment and ligation method (CDL) or extravesically using a laparoscopic stapling device (LS). RESULTS: Median followup was 23 months (range 1 to 45). Recurrence developed in 27%, 7% and 12% of cases in the bladder at a median of 5 months, retroperitoneum at 8 months and distant sites at 8 months, respectively. Compared to the novel CDL technique LS resulted in a higher positive margin rate (p = 0.046). Overall survival correlated with bladder recurrence (p = 0.003), upper tract TCC stage (p = 0.01) and method of bladder cuff control when comparing CDL vs LS (p = 0.04). Freedom from recurrent upper tract disease was related to pathological stage (p = 0.015) and bladder cuff excision method (p = 0.02). CONCLUSIONS: These data underscore the aggressive nature of high stage, high grade upper tract TCC and validate the importance of complete excision of the distal ureter and bladder cuff during LNUX. In patients without coexisting bladder tumor the CDL method, which allows formal bladder cuff excision in a secured manner akin to that of established open surgical principles, appears oncologically valid.     

Prognostic variables in patients with transitional cell carcinoma of the renal pelvis and proximal ureter

Recent technological advances in urological endoscopic surgery of the renal pelvis and proximal ureter via ureteroscopy or percutaneous nephroscopy have made it possible to consider parenchymal-sparing procedures in patients with transitional cell carcinoma. To define the role of these procedures in the management of renal pelvic or proximal ureteral transitional cell carcinoma we analyzed retrospectively 31 patients who underwent nephroureterectomy for transitional cell carcinoma of the renal pelvis and/or proximal ureter. High grade upper urinary tract transitional cell carcinoma and a history of metachronous or synchronous bladder transitional cell carcinoma were independent adverse prognostic factors. However, patients with low grade upper urinary tract transitional cell carcinoma and no evidence of a urothelial field change had a 100 per cent 5-year survival rate. It would appear that parenchymal-sparing endoscopic techniques should be regarded with caution in patients with either high grade transitional cell carcinoma of the renal pelvis and proximal ureter or a history of bladder cancer.     

Retrograde endoscopic laser therapy and ureteroscopic surveillance for transitional cell carcinoma of the upper urinary tract

OBJECTIVE: To investigate the efficacy of endoscopic laser therapy and ureteroscopic surveillance for transitional cell carcinoma (TCC) of the upper urinary tract. Methods: Tumors of the upper urinary tract were detected at ureteroscopy. After TCC was diagnosed by biopsy, retrograde endoscopic laser therapy was performed. Recurrent tumors were treated endoscopically and the patients were followed by ureteroscopic surveillance at 3- to 6-month intervals. RESULTS: Seven patients underwent ureteroscopic treatment. The tumor was grade 1 in five patients and grade 2 in two patients. The average tumor size was 1.3 cm. One patient with large, multifocal tumors died of metastatic disease, and one died of an unrelated cause. One patient requested nephroureterectomy after endoscopic treatment. The remaining four patients were followed up for a mean of 32 months after initial treatment. Each patient received an average of 5.3 ureteroscopic surveillance procedures while 3.3 recurrences on average were detected. Recurrence occurred in all the patients who showed normal radiographic findings. Urine cytology was also of little value in predicting tumor recurrence, except in one patient with carcinoma in situ. The recurrent tumors detected by ureteroscopy were successfully treated by repeated endoscopic procedures. After the follow up, three patients remained alive with no signs indicative of disease, but one patient with an initial grade 2 tumor died of recurrence after 30 months. CONCLUSIONS: Given that ureteroscopic evaluation is essential for surveillance after endoscopic treatment of upper urinary tract TCC because of residual concern about recurrence, patients treated endoscopically should be recommended to undergo long-term endoscopic follow up.     

Oncological outcome of retroperitoneoscopic nephroureterectomy for upper urinary tract transitional cell carcinoma

OBJECTIVE: To report the oncological outcome of retroperitoneoscopic nephroureterectomy (RNU) with bladder cuff excision for upper urinary tract transitional cell carcinoma (TCC), and to compare the outcome with that of the traditional open nephroureterectomy (ONU). PATIENTS AND METHODS: From January 2001, 48 patients with upper urinary tract TCC were enrolled in the study; 25 had RNU and 23 had ONU. Oncological parameters (disease-free survival and disease-specific survival) were calculated from the time of surgery to the date of last follow up and were analysed by the Kaplan-Meier method. RESULTS: Mean follow up was 24.3 months in the RNU group, significantly shorter than in the ONU group. Bladder recurrence was identified in two patients with grade 3 pathological stage pT3, one patient with grade 3 stage pT2 disease and two patients with grade 2 stage pT2 disease. Multiple organ metastases in the lung, liver and lymph nodes were associated with bladder recurrence in two cases (grade 2 stage pT3, and grade 3 stage pT3). The recurrence rate was 20% (5 of 25 cases) and mean time to recurrence was 9.5 months. In the ONU group, bladder recurrence and metastases developed in four and three patients, respectively. The recurrence rate was 17% (4 of 23 cases) and mean time to recurrence was 23.4 months. No significant difference was detected in the disease-free survival rate and cancer-specific survival rate between the two groups (P=0.759 and P=0.866, respectively). CONCLUSION: The oncological outcome of RNU appears to be equivalent to that of ONU. Moreover, long-term follow up is necessary to evaluate the oncological outcome in comparison to ONU.     

Significance of cancer involvement at the ureteral margin detected on routine frozen section analysis during radical cystectomy

INTRODUCTION: We investigated the clinical significance of preoperatively-unsuspected ureteral involvement of cancer detected on intraoperative frozen section analysis of ureteral margins during radical cystectomy. PATIENTS AND METHODS: We performed a retrospective study of 115 patients who received radical cystectomy for locally-advanced but node-negative transitional cell carcinoma of the bladder between 1995 and 2002 by reviewing their records. RESULTS: Of 115 total patients, 5 (4.3%) demonstrated carcinoma in situ at the ureteral margin with 2 of 5 having a positive margin on final pathologic analysis. Meanwhile, only 3 of 115 total patients (2.6%) later showed upper urinary tract recurrence at a median interval of 30 months after cystectomy. And all 3 patients had intramural or juxtavesical ureter involvement of disease (p = 0.006), while not demonstrating carcinoma in situ in ureteral margins resected during cystectomy. On multivariate analysis, only the stage and grade of bladder cancer along with pathologic feature of vascular invasion were observed to be independent prognostic predictors of disease-specific survival. CONCLUSIONS: Cancer involvement of the distal ureteral margin detected through intraoperative frozen section analysis may not be a significant factor regarding upper tract recurrence and survival of patients with locally-advanced bladder cancer after radical cystectomy. Upper tract recurrence may be more prone to occur in patients with cancer involvement at the intramural or juxtavesical ureter.     

Blood groups and transitional cell carcinoma of the upper urinary tract

A retrospective analysis of the blood groups of 74 patients with transitional cell carcinoma of the upper urinary tract is presented. The blood group distribution of the patients reflected that of the general population. No relationship was found between blood groups and stage and grade of the tumour or patient survival. Nor were blood groups predictive of bladder tumour recurrence and stump recurrence in patients who had undergone simple nephrectomy.