Percutaneous management of upper-tract transitional cell carcinoma

The gold standard treatment for supravesical urothelial carcinoma has been open radical nephroureterectomy based on the premise that this cancer is a field defect. However, nephroureterectomy is an extensive procedure that may not be tolerated by all patients. Percutaneous and ureteroscopic approaches have been utilized in an attempt to avoid the potential morbidity associated with traditional open surgery. This review provides an update on percutaneous management of upper-tract urothelial transitional-cell cancer based on a review of the pertinent literature.     

Robot-assisted laparoscopic nephroureterectomy

BACKGROUND: Laparoscopic nephroureterectomy for upper-tract urothelial tumors is a minimally invasive approach that parallels the open technique in oncologic efficacy. Multiple approaches to manage the distal ureter have been described. We developed a new technique using the daVinci robot system to perform a transvesical excision of the distal ureter and bladder cuff. PATIENTS AND METHODS: Ten consecutive patients with upper-tract urothelial cancer underwent a laparoscopic nephroureterectomy. The daVinci robot was docked through the umbilical, ipsilateral lateral rectus, and an additional contralateral lateral rectus port. The bladder was clam-shelled in a coronal orientation at the dome and the distal ureterectomy performed. RESULTS: Our technique was successful in all ten patients. The mean operative time for the entire case was 4.4 hours. The average hospital stay was 3 days. CONCLUSIONS: Robot-assisted laparoscopic nephroureterectomy is a safe, minimally invasive approach to upper- tract urothelial cancer that reduces the technical challenge of excision of the distal ureter.     

Case report: percutaneous management of transitional-cell carcinoma of the upper urinary tract using the bipolar resectoscope

BACKGROUND: The traditional management of upper-tract urothelial tumors is radical nephroureterectomy. However, in recent years, minimally invasive nephron-sparing endoscopic approaches have been utilized. We present our initial experience using the bipolar resectoscope with saline irrigation in the management of renal transitional-cell carcinoma (TCC). CASE REPORT: A 74-year-old woman presented with a 3.5-cm filling defect in the collecting system on CT. Cystoscopy and retrograde ureterography demonstrated normal bladder mucosa and a normal contralateral ureter. Ureteroscopy revealed a papillary TCC in the renal pelvis. Ureteroscopic treatment was declined because of the lesion's size. We elected to proceed with percutaneous resection. Using the bipolar resectoscope, the lesion was removed completely. The procedure was accomplished in 90 minutes. The estimated blood loss was 50 mL. The hospital stay was 23 hours. Pathology examination revealed a low-grade TCC. Follow-up for 9 months has shown no recurrence. CONCLUSION: In our initial experience, percutaneous treatment of upper-tract urothelial tumors may be accomplished using the bipolar resectoscope with favorable results.     

Ureteroscopic management of upper urinary tract transitional cell carcinoma

PURPOSE OF REVIEW: Traditionally, nephroureterectomy has been the treatment of choice for transitional cell carcinoma of the upper urinary tract. In an effort to preserve renal function, conservative therapy has evolved from complex open surgery to minimally invasive ureteroscopic therapy. Considering the relatively recent emergence of ureteroscopic therapy, a review of technical considerations and treatment outcome is timely. RECENT FINDINGS: There is emerging evidence that ureteroscopic treatment of low grade upper tract lesions provides an acceptable oncologic result while preserving functioning renal parenchyma. In patients with low grade upper tract urothelial lesions, progression is rarely reported. Ureteroscopy has for over a decade been the premier diagnostic tool, with the actively deflectable flexible instrument being employed to map the entire intrarenal collecting system. Improvements in instrumentation and refinement in technique have broadened the application of the ureteroscope in treating upper urinary tract urothelial tumors. SUMMARY: For low grade lesions, which make up more than 50% of all presentations, ureteroscopic management has proven efficacious. As with similar grade lesions in the bladder, these patients require careful, consistent, and often lifelong follow up as many will develop recurrent lesions throughout the urothelium. Here too, ureteroscopy has a central role in surveillance.     

Conservative Nephron-Sparing Treatment of Upper-Tract Tumors

While radical nephroureterectomy represents the gold standard for managing upper-tract urothelial carcinoma, nephron-sparing approaches have increasingly been utilized in the elective setting. Such considerations are accentuated by contemporary studies highlighting sequelae related to chronic kidney disease following nephrectomy. Kidney sparing treatments including segmental ureteral resection and endoscopic ablation may therefore be appropriate in select patients with small, solitary, low-grade upper-tract tumors. Bladder and ipsilateral upper-tract recurrences are frequent after nephron-sparing treatments for UTUC, thereby underscoring the need to maintain strict radiographic and endoscopic surveillance protocols in patients amenable to this rigorous compliance program.     

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.     

Evolving management of upper-tract transitional-cell carcinoma at a tertiary-care center

BACKGROUND AND PURPOSE: Traditional management of upper-tract transitional-cell carcinoma (TCC) has been open nephroureterectomy. Minimally invasive options, including laparoscopic and endoscopic techniques, are being applied with increasing frequency, however. To assess the impact of these techniques on the current management of upper-tract TCC, we reviewed our experience managing this problem over the last 3 years. PATIENTS AND METHODS: Since January 1998, 84 patients underwent definitive management of upper-tract TCC using open, laparoscopic, or endoscopic techniques. This study group includes 57 men and 27 women with a mean age of 69.9 years. RESULTS: Fifty-three patients (63.9%) were treated by laparoscopic nephroureterectomy. Twelve patients (14.5%) were treated endoscopically, with percutaneous resection in 7 patients and ureteroscopic resection in 5 patients. The indications for nephron-sparing management in these 12 patients included solitary kidneys in 6 patients, significant comorbidities in 4 patients, and bilateral disease in 1 patient. Endoscopic management was elective in one patient. Nineteen patients (22.9%) underwent open surgical procedures consisting of nephroureterectomy in 16 patients and distal ureterectomy with reimplantation in 3 patients. CONCLUSIONS: Advances in laparoscopy and endourology are significantly impacting the definitive management of upper-tract TCC. Patients with a normal contralateral kidney are currently offered laparoscopic nephroureterectomy, while those with an absent or functionally compromised contralateral kidney are generally managed with endoscopic resection. Although minimally invasive techniques have demonstrated advantages regarding postoperative pain, hospital stay, and return to regular activities, only critical long-term follow-up regarding rates of local and distant recurrence will determine the ultimate role of these techniques.     

Management of patients with upper urinary tract transitional cell carcinoma

Multiple therapeutic options are available for the management of patients with upper urinary tract transitional cell carcinoma (TCC). Radical nephroureterectomy with an ipsilateral bladder cuff is the gold-standard therapy for upper-tract cancers. However, less invasive alternatives have a role in the treatment of this disease. Endoscopic management of upper-tract TCC is a reasonable strategy for patients with anatomic or functional solitary kidneys, bilateral upper-tract TCC, baseline renal insufficiency, and significant comorbid diseases. Select patients with a normal contralateral kidney who have small, low-grade lesions might also be candidates for endoscopic ablation. Distal ureterectomy is an option for patients with high-grade, invasive, or bulky tumors of the distal ureter not amenable to endoscopic management. In appropriately selected patients, outcomes following distal ureterectomy are similar to that of radical nephroureterectomy. Bladder cancer is a common occurrence following the management of upper-tract TCC. Currently, there are no variables that consistently predict which patients will develop intravesical recurrences. As such, surveillance with cystoscopy and cytology following surgical management of upper-tract TCC is essential. Extrapolating from data on bladder TCC, both regional lymphadenectomy and neoadjuvant chemotherapy regimens are likely to be beneficial for patients with upper-tract TCC, particularly in the setting of bulky disease.     

Correlation of upper-tract cytology, retrograde pyelography, ureteroscopic appearance, and ureteroscopic biopsy with histologic examination of upper-tract transitional cell carcinoma

PURPOSE: To determine the accuracy of radiographic studies, ureteroscopy, biopsy, and cytology in predicting the histopathology of upper-tract transitional cell carcinoma (TCC). MATERIALS AND METHODS: From 1998 to 2006, 46 upper-tract lesions were diagnosed ureteroscopically and underwent nephroureterectomy, and 30 of them were subjected to direct ureteroscopic inspection and biopsy. Fresh samples were delivered to the cytopathology laboratory and histology samples were prepared whenever visible tissue was present. Radiological, ureteroscopic, cytology, and biopsy data were compared to the actual grades and stages of these 30 surgical specimens. RESULTS: Retrograde ureteropyelography was suggestive of malignancy in 29 of 30 cases, but did not predict the grade or stage accurately. Cytology was positive for malignancy in 21 of 30 cases (70%). Grading of ureteroscopic specimens was possible in all cases. At nephroureterectomy two cases were found to have no tumor (T(0)). Of the remaining 28 cases, the biopsy grade proved to be identical in 21 (75%). Grade 1 or 2 ureteroscopic specimens had a low-stage (T(0), T(a), or T(1)) tumor in 17 of 25 (68%); in contrast, 3 of 5 (60%) high-grade specimens had invasive tumor (T(2) or T(3)). For patients with grade 2 ureteroscopic specimens, combining exfoliated cell cytology and biopsy grade improved the accuracy in predicting high-stage and high-grade disease. CONCLUSIONS: This study confirms previous findings that ureteroscopic inspection and biopsy provides accurate information regarding the grade and stage of upper-tract TCC. Combining exfoliated cell cytology improves the predictive power of biopsy grade 2 disease for high-risk specimen grade and stage. Our data suggest that ureteroscopic findings may predict muscle invasion.     

Abnormal selective cytology results predict recurrence of upper-tract transitional-cell carcinoma treated with ureteroscopic laser ablation

BACKGROUND AND PURPOSE: Endoscopic management of transitional-cell carcinoma (TCC) of the upper urinary tract remains associated with a significant rate of recurrence. We evaluated the impact of selective upper-tract cytology findings on tumor recurrence and renal salvage rate after ureteroscopic laser tumor ablation. PATIENTS AND METHODS: From 1993 though 2003, 38 patients with upper-tract TCC underwent ureteroscopic laser tumor ablation. Cytology specimens were collected from the upper urinary tract prior to ablation. "Abnormal cytology" was defined as the presence of malignant or atypical cells. Patients with abnormal cytology results were compared with patients with those having negative findings for tumor recurrence and renal salvage rates using the X (2) test. RESULTS: Of the 38 patients, 26 (68.4%) experienced at least one recurrence at a mean follow-up of 37.2 months. Pretreatment upper-tract cytology results were available in 34 of these patients: 17 (50%) were negative, and 17 were abnormal. Sixteen of the patients (94.1%) with abnormal cytology results had tumor recurrence after ablation, compared with 8 of the 17 (47.1%) with negative cytology findings (P = 0.0026). Twelve patients (31.5%) underwent nephroureterectomy during follow-up: 8 of the 17 (47.1%) with abnormal cytology, and 4 of the 17 (23.5%) with negative cytology (P = 0.15). CONCLUSION: Abnormal selective cytology results were associated with a significantly higher rate of tumor recurrence and a trend toward increased renal loss in patients with upper-tract TCC treated with ureteroscopic ablation. These findings suggest a prognostic value for upper-tract cytology analysis in patients undergoing endoscopic therapy.     

Totally endoscopic management of upper tract transitional-cell carcinoma

BACKGROUND AND PURPOSE: Nephron-sparing therapy arose spurred by efforts to delay dialysis for patients with renal insufficiency or solitary kidneys. As technology has improved, complete endoscopic ablation of tumor via the holmium and Nd:YAG lasers has proven efficacious for cancer control. We have extended ureteroscopic treatment to patients with normal contralateral kidneys given the proper indications. For required extirpative therapy in cases of uncontrolled cancer, laparoscopic nephroureterectomy is rapidly becoming popular and appears to lend the same tumor control as open surgery while significantly lessening morbidity. We reviewed our experience with endourologic treatment and propose an algorithm for the management of upper tract TCC. PATIENTS AND METHODS: Over the period from August 1998 to May 2000, 70 patients underwent ureteroscopic evaluation, treatment, or both for TCC. During the same period, 24 patients had a hand-assisted laparoscopic nephroureterectomy (HALNU) performed. A thorough chart review was performed to determine pathologic data and management decision-making. RESULTS: Of the 70 patients evaluated ureteroscopically, 46 were examined for the first time, while the remaining 24 patients were already on the surveillance protocol. Of the 46 initially evaluated patients, 18 were referred for HALNU. Fifteen other patients were placed on surveillance. Of the 24 patients already on surveillance, only 1 required HALNU. The most common reasons for nephroureterectomy were bulky tumors that were ureteroscopically unresectable, high-grade disease, and patient preference. CONCLUSIONS: The combination of ureteroscopy and laparoscopy has made the management of upper tract TCC totally endoscopic, providing decreased morbidity while maintaining cancer control.     

Feasibility of conservative surgery for transitional cell cancer of the upper urinary tract

The controversy between the proponents of radical surgery for treatment of transitional cell cancer of the upper urinary tract (total nephroureterectomy) and those of conservative surgery (segmental resection) continues. In an in-depth analysis of a large group of patients presented in this article, an attempt has been made to rationalize a conservative surgical treatment approach for certain upper-tract tumors.     

Hand-assisted laparoscopic nephroureterectomy for upper urinary tract transitional cell carcinoma.

OBJECTIVE: We report our experience with hand-assisted laparoscopic nephroureterectomy (HALN) for upper urinary tract transitional cell carcinoma and compare our results with a contemporary series of open nephroureterectomy (ON) performed at our institution. METHODS: Between August 1996 and May 2003, 90 patients underwent nephroureterectomy for upper-tract transitional cell carcinoma (TCC). Thirty-eight patients underwent HALN, while 52 had an ON. End-points of comparison included operative time, estimated blood loss (EBL), intraoperative and postoperative complications, length of hospital stay, pathologic grade and stage of tumor, and tumor recurrence. RESULTS: The mean patient age was 72.3 and 70.6 years in the ON and HALN groups, respectively. Mean operative duration was 243 minutes (ON) and 244 minutes (HALN), with an EBL of 478mL in the open group versus 191 mL in the hand-assisted group (P<0.001). No intraoperative complications occurred, but postoperative complications occurred in 4% and 11% of the ON and HALN groups, respectively (P=0.21). The mean hospital duration was 7.1 days (ON) versus 4.6 days (HALN) (P<0.01). No difference existed in the pathologic grade or stage distribution of urothelial tumors between the 2 groups. The mean follow-up was 51.0 months in the ON group and 31.7 months in the HALN group. Recurrence of urothelial carcinoma occurred in 50% of patients who underwent ON and 40% treated by HALN (P=0.38) at a median interval of 9.1 and 7.7 months, respectively, after surgery. CONCLUSION: Hand-assisted laparoscopic nephroureterectomy is an effective modality for the treatment of upper urinary tract urothelial carcinoma. Patients benefited from less intraoperative blood loss and a shorter hospitalization with an equivalent intermediate-term oncologic outcome compared with that of the open approach.     

Current practice patterns in urologic management of upper-tract transitional-cell carcinoma

PURPOSE: To determine the current practice patterns in the management of upper-tract transitional-cell carcinoma (TCC) among a large group of urologists. MATERIALS AND METHODS: A survey was sent to 220 practicing members of the Society of Urologic Oncology (SUO) and the Endourological Society (ES) and members of the American Urological Association who did not belong to either society. The survey consisted of 16 focused questions pertaining to the surveillance and management of upper-tract TCC. The responses were used to create a database, which was then analyzed to determine practice trends. RESULTS: Eighty-four of the urologists responded, for a response rate of 38%. Fourteen responses were excluded because of multiple answers to a given question, so 70 were included in the final analysis. Eighty percent of the respondents were in academic practice. A CT urogram was the favored initial procedure for diagnosis of upper-tract TCC and an intravenous urogram was the next commonest choice (53% and 40%, respectively). Ureterorenoscopy was the surveillance tool of choice (70%) after conservative treatment of upper- tract TCC. Laparoscopic nephroureterectomy was the preferred procedure (73%) for a high-grade, large renal-pelvic TCC. Twenty-one percent of the endourologists recommended ureteroscopic ablation for a high-grade, large distal ureteral tumor. This was in sharp contrast to 77% of the respondents who favored a distal ureterectomy for the same clinical scenario. CONCLUSIONS: This study confirms that most urologists treating upper-tract TCC follow the principles reported in the published literature regarding the management of these patients. Further, most urologists, regardless of society affiliations or years in practice, favor minimally invasive techniques for the management of upper-tract TCC. This information may be useful in formulating clear guidelines for the management of this disease.     

Endoscopic and minimally invasive approaches to upper tract urothelial carcinoma

PURPOSE OF REVIEW: In recent years, minimally invasive techniques have been widely applied to urologic diseases affecting the upper and lower urinary tracts. Technologic advances in both laparoscopy and endoscopy provide an opportunity to improve the treatment of urothelial carcinoma outside the bladder. We review the recent studies relevant to the therapy for urothelial cell carcinoma of the upper urinary tract. RECENT FINDINGS: Despite the availability of improved ureteroscopes and newer ablative energy sources, endoscopic management of upper tract urothelial tumors must be approached cautiously. Factors that increase the risk of recurrent or progressive disease include stage, grade, and size. Although percutaneous access permits larger instruments and may improve tumor resection, the outcome is determined by tumor characteristics. Adjuvant therapies, both systemic and local, are still lacking and require further study. Laparoscopic nephroureterectomy is clearly feasible and reduces patient morbidity. The limited data available suggest that oncologic outcomes of laparoscopic nephroureterectomy are comparable to the open operation, although longer follow-up is required. The optimal method of distal ureterectomy, ensuring complete removal of susceptible urothelium, remains to be determined. Adequate care must be taken during specimen retrieval to prevent tumor seeding or spillage. SUMMARY: Urologists currently have multiple tools to aid in the management of upper urinary tract urothelial tumors with minimal morbidity. Cancer-specific outcomes should, however, remain the primary concern and the development of novel systemic therapies needs to parallel the advances in surgical techniques.     

Significance of Ureteroscopic Biopsy Grade in Patients with Upper Tract Urothelial Carcinoma

Background

The objective of this study was to assess the significance of the ureteroscopic biopsy grade for patients with upper tract urothelial carcinoma (UTUC).

Patients and Methods

This study included 40 patients who were diagnosed with a single focus of UTUC by ureteroscopic biopsy and subsequently underwent nephroureterectomy. The significance of the biopsy grade as a predictive factor for pathological outcomes of nephroureterectomy was retrospectively analyzed.

Results

Of these 40 patients, 19 (47.5%) and 21 (52.5%) were diagnosed with low and high grade UTUC, respectively. The ureteroscopic biopsy grade matched the pathological grade of surgically resected specimens in 35 of the 40 cases (87.5%), and there was a significant correlation between the biopsy and pathological grades (p < 0.001). Furthermore, the biopsy grade was also shown to be closely associated with the pathological stage (p < 0.001); that is, only 1 of the 19 patients (5.3%) with biopsy low grade UTUC were pathologically diagnosed as having muscle invasive disease, while 17 of the 21 patients (81.0%) with biopsy high grade UTUC appeared to show tumor invasion into muscle or deeper.

Conclusions

The grade of UTUC on ureteroscopic biopsy could provide accurate diagnostic information on the final pathology of nephroureterectomy specimens.Key Words: Upper tract urothelial carcinoma, Ureteroscopic biopsy, Urinary cytology     

Multifocality rather than tumor location is a prognostic factor in upper tract urothelial carcinoma

ObjectivesWhether a patient has urothelial carcinoma located within the renal pelvis or ureter remains a controversial prognostic indicator in clinical urology. We wished to evaluate whether tumor location is associated with recurrence in patients undergoing nephroureterectomy for upper tract urothelial cancer in a large volume patient cohort.Subjects and methodsWe created a retrospective database of patients from 7 academic centers throughout Canada who underwent nephroureterectomy for upper tract urothelial carcinoma. Patient demographics as well as pathologic and surgical factors were analyzed to evaluate any statistical association between tumor location and overall survival, disease-free survival, and disease-specific survival.ResultsA total of 1,029 patients had data available for analysis with a mean follow up of 3.2 years. Kaplan Meier 5-year disease-free survivals (DFS) were 46%, 37%, and 19% for renal pelvis tumors, ureteric tumors, and multifocal tumors respectively. There was no association between the location of the tumor and the DFS, however, disease involving both the ureter and renal pelvis was associated with lower DFS and overall survival (OS) (P < 0.001).ConclusionsTumor location does not appear to have any influence on the risk of recurrence of disease following nephroureterectomy in this large patient cohort. However, multifocal tumors involving both the ureter and renal pelvis had a significantly worse prognosis and should be considered for more aggressive management.     

Ureteropyeloscopy: the diagnostic and therapeutic approach to upper tract urothelial tumors

Summary Rigid transurethral ureteropyeloscopy allows many standard cystoscopic procedures to be extended into the upper urinary tract, including endoscopic diagnosis, surveillance, and occasionally primary treatment. This endoscopic method has been used to investigate 59 patients suspected to have urothelial malignancies of the ureter or renal pelvis. Of the 54 patients in whom the procedure was successfully completed (90%), 27 were found to have urothelial tumors of the ureter or renal pelvis. Nephroureterectomy was subsequently performed in 6 of these patients and segmental ureterectomy in 3 patients, enabling pathologic correlation with the endoscopic mapping. However, in 16 patients, ureteroscopy and biopsy revealed apparently localized, low-grade tumors which were treated by ureteroscopic fulguration or resection. The latter patients and the 3 patients who underwent segmental ureterectomy have undergone endoscopic surveillance every 3 months (average follow-up 16 months). The technique of ureteropyeloscopy permits endoscopic access into the ureter and renal pelvis enabling tissue diagnosis and better preoperative cancer staging without surgical exploration. Although follow-up is short, selected patients with low-grade tumors may be treated primarily by endoscopic means.     

Tumor Location Based Segmentation in Upper-Tract Urothelial Carcinoma Impacts on the Urothelial Recurrence-Free Survival: A Multi-Institutional Database Study

Introduction and ObjectivesThe predictive impact of primary tumor location for patients with upper-tract urothelial carcinoma (UTUC) in the presence of concomitant urothelial bladder cancer, along with urothelial recurrence after the curative treatment is still contentious. We evaluated the association between precise tumor location and concomitant presence of urothelial bladder cancer and urothelial recurrence-free survival in patients with UTUC treated by radical nephroureterectomy with a bladder cuff.MethodsA total of 1,349 patients with localized UTUC (Ta-4N0M0) from a retrospective multi-institutional cohort were studied. We queried four UTUC databases. This retrospective clinical series was of patients with localized UTUC managed by nephroureter-ectomy with a bladder cuff, for whom data were from the Nishinihon Uro-Oncology Collaborative Group registries. Patients with a history of chemotherapy or radiotherapy were excluded from the study. Associations between the location of the tumor and subsequent outcome following nephroureterectomy were assessed using COX multivariate analysis. The location of the tumor was verified by pathological samples. Urothelial recurrence was defined as tumor relapse in any local urothelium, and coded apart from distant metastasis. The median follow-up was 34 months.ResultsA total of 887 patients had an evaluation of the tumor location in which 475 patients had pelvic tumors (53.6%), 96 had ureteral tumors in the U1 segment (10.8%), 87 in the U2 segment (9.8%), and 176 in the U3 segment (19.8%). There were 52 patients who had multifocal tumors (5.9%) as follows: 8 (0.9%) in the pelvis and ureter, 11 (1.2%) in U1 + U2, 1 (0.1%) in U1 + U3, 27 (3.0 %) in U2 + U3, and 6 (0.7%) in U1 + U2 + U3. In all, 145 (16.3%) had concomitant bladder tumors. Logistic regression analysis of gender, age, hydronephrosis, cytology, performance status, grade, lymphovascular invasion, pT, pN, and tumor focality showed that tumor location was associated with the presence of concomitant bladder cancer (p = 0.004, HR = 1.265). When the tumor location was stratified into 8 segments, including multifocal tumors, only the U3 segment remained as a predictor for the presence of concomitant bladder cancer (p = 0.002, HR = 2.872). Kaplan-Meier analysis for unifocal disease showed that lower ureter tumors (a combination of U2 and U3) had a worse prognosis for urothelial recurrence than pelvic tumors or upper ureteral tumors (U1) (p < 0.001 for lower ureteral tumors versus pelvic tumors, p = 0.322 for upper ureteral tumor versus pelvic tumor by log rank). Multivariate analysis showed that lower ureter remained as a prognostic factor for urothelial recurrence after adjusting for gender, age, hydronephrosis, urine cytology, lymphovascular invasion, pT, and pN (p < 0.001, HR = 1.469), and a similar tendency was found when the analysis was run for patients without concomitant bladder tumors (p = 0.003, HR = 1.446). Patients with lower ureteral tumors had a higher prevalence of deaths (HR = 2.227) compared to patients with upper ureter tumors.ConclusionsThis multi-institutional study showed that the primary tumor locations were independently associated with the presence of concomitant bladder tumors and subsequent urothelial recurrence.Key Words: Upper-tract urothelial carcinoma, Prognosis, Tumor location     

Role of ureteroscopic biopsy in the management of upper urinary tract malignancy

BACKGROUND: The aim of the study presented here was to examine the accuracy of ureteroscopic biopsy in the diagnosis of upper urinary tract transitional cell carcinoma (TCC) and whether nephron-sparing management (holmium YAG laser, transurethral resection or partial ureterectomy) is possible or not based on pathological diagnosis. METHODS: Forty consecutive patients underwent ureteroscopic biopsy with the use of 3-Fr cold cup forceps. Pathological diagnosis of the biopsy sample and grade or stage of surgically resected tumors were compared. In patients with grade 1 or 2 TCC diagnosed by ureteroscopic biopsy, the disease-free and survival rates determined whether nephron-sparing management was performed or not. RESULTS: There were no major complications associated with ureteroscopic biopsy. The pathological grading of the biopsy specimen was almost the same as that of the surgically resected specimen. Eighty five percent of grade 2 or 3 TCC showed muscle invasive disease. There were no significant differences in the disease-free and survival rates between the nephroureterectomy and the nephron-sparing management groups, except for grade 3 or pT3 tumors. CONCLUSION: Ureteroscopic biopsy is safe and accurate if sufficient tissue sample is obtained. Ureteroscopic biopsy should be performed in patients who require nephron-sparing management. Nephroureterectomy can be avoided if the tumor is confirmed as low-grade.