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.     

The long-term outcome after laparoscopic nephroureterectomy: a comparison with open nephroureterectomy

OBJECTIVES: To assess the long-term outcome of the endourological management of upper tract transitional cell carcinoma (TCC) by laparoscopic nephroureterectomy (LNU) or open nephroureterectomy (ONU). PATIENTS AND METHODS: The records and pathology reports were reviewed retrospectively for 67 nephroureterectomy specimens (42 obtained by ONU and 25 by LNU). The grade, stage, lymph node status and site of the tumour were recorded for each patient. The primary end-point of the follow-up was disease-related death. RESULTS: Overall there was a high proportion of G2 (44%) and G3 (39%) disease, with a significant correlation between increasing grade and stage of TCC (r = 0.74, P < 0.001). Of the 25 patients who underwent LNU, 22 had pelvicalyceal or upper ureteric TCC and conversion to open surgery was required in three (12%). Of the TCCs in this group half were G3 and half were invasive (pT1-3). In the ONU group there were more ureteric tumours because of selection criteria and overall 16 (39%) were G3 and half were invasive. Information on nodal status was available in one LNU and two of the ONU reports. Within a mean follow-up of 32.9 months for LNU and 42.3 months for ONU, nine (21%) of the ONU group and four (16%) of the LNU group had died, with a mean survival of 15.1 and 17 months, respectively, after surgery (not significant). All of these deaths were associated with G3 pT1-3 disease. CONCLUSIONS: In this series the case mix and outcomes were similar for those undergoing LNU and ONU. As laparoscopic renal surgery is associated with less postoperative morbidity it would seem reasonable to offer LNU to all patients with upper tract TCC, where appropriate and when there is no evidence of local invasion or metastasis. Because of the strong correlation between grade and stage, preliminary ureteroscopic assessment and biopsy may influence the surgical approach adopted.     

Percutaneous management of renal pelvic urothelial tumors: long-term followup

PURPOSE: We present the long-term outcome of percutaneous resection of renal urothelial tumor. MATERIALS AND METHODS: A total of 24 patients underwent primary percutaneous resection of renal urothelial tumor. Patients with low stage pT0-1 disease were treated primarily with percutaneous surgery. All pelvicaliceal tumors were taken for biopsy and treated with percutaneous resection. Patients with multi-segmental pelvicaliceal system involvement, stage greater than pT1, high grade histology or additional ureteral tumors were considered for nephroureterectomy. Topical chemotherapy (mitomycin C or epirubicin) was administered via nephrostomy tube or intravesical instillation after Double-J stent (Medical Engineering Corp., New York, New York) insertion. Surveillance included upper tract cytology, nephroscopy or fiberoptic ureterorenoscopy. Long-term followup was correlated with histopathology. RESULTS: Of the 24 cases 2 had squamous cell carcinoma, 5 had grade III transitional cell carcinoma, 15 had grade I to II transitional cell carcinoma and 2 had no tumor. Control was established with initial percutaneous resection in 18 (75%) cases and second look nephroscopy in 4. Early recurrences were detected by excretory urography (IVP) in 3 cases, small pelvic recurrences by IVP in 2, fiberoptic ureterorenoscopy in 2 and bladder tumors by flexible cystoscopy in 3 after 1 year. A total of 10 nephroscopies were performed in 5 cases, 24 flexible uretereorenoscopies in 9 and IVP in 6. Three synchronous, grade I bladder tumors were managed conventionally. All patients with high grade disease died of malignancy except one (with no further treatment) and 6 of the 15 patients with low grade noninvasive transitional cell carcinoma underwent nephroureterectomy during followup either due to progression of disease, concomitant tumor or complications. Two patients with solitary kidneys died of renal failure unrelated to malignancy. High grade tumors or tumors greater than T1 were treated with nephroureterectomy early during management. There was no perioperative mortality and 9 (60%) of the low grade cases the kidneys were preserved at a mean followup +/- SD of 64 +/- 15 months. All excised tracks from patients who underwent nephroureterectomy and the renal fossae were free of tumor on histopathological examination. CONCLUSIONS: Percutaneous resection of transitional cell tumor should be considered primarily in patients with early stage disease excluding tumors crossing caliceal infundibula, ureteropelvic junction tumor, tumor extending over multiple calices and synchronous ureteral tumors. The long-term outcome of low grade tumors is good and they should be managed by either form of minimally invasive surgery. Nephron sparing is possible in a large percentage of low grade disease but high grade tumors should be treated with nephroureterectomy.     

Primary percutaneous approach to upper urinary tract transitional cell carcinoma

The optimal approach to upper tract TCC remains to be redefined. A routine nephroureterectomy for every filling defect in the upper urinary system, even in the case of a normal contralateral kidney, constitutes an unnecessary mutilation in more than two thirds of the cases. Nephroureterectomy does not reduce the need for a long-term cystoscopic follow-up because of the high rate of bladder tumor recurrence that may happen years later after nephroureterectomy. Relying solely on radiography and cytology, lacking sensitivity and specificity, to recommend a nephroureterectomy is against the principles of oncologic surgery, especially now that preoperative histologic proof is easy to obtain endoscopically without compromising cancer control. Ureteroscopy, rigid and flexible, provides a complete assessment of the upper urinary system. Biopsy specimens taken with ureteroscopy may be sufficient for grading but less adequate for staging of the tumor. The authors reserve ureteroscopy for ureteral tumors and small (< 1.5 cm) single tumors of the renal pelvis. They approach large or multiple tumors of the renal pelvis percutaneously, in which a full histologic assessment is possible along with a complete resection of the tumor. The decision on the therapeutic approach is made only after the final pathologic report is reviewed. Grade I and grade II superficial disease (Ta, T1) can be treated endoscopically with minimal morbidity and with an efficiency comparable with the standard more invasive nephroureterectomy (Table 5). The indications for endourologic treatment in these cases can be extended safely beyond a solitary kidney or a high surgical risk to include any healthy individual with a normal contralateral kidney who is willing to commit to a rigorous lifelong follow-up. Patients with grade II T1 lesions require a more vigilant follow-up. For grade III Ta disease, more caution should be exercised in selecting these patients for elective endourologic management. When criteria of good prognosis are found, such as absence of carcinoma in situ, presence of diploidy, low p53 expression and a single-tumor, endoscopic management can be offered [table: see text] with a closer follow-up and resorting always to immediate nephroureterectomy at the first evidence of upstaging. Because of the high incidence of recurrence and progression, elective endourologic management for grade III T1 tumors is not recommended. Endoscopic conservative surgery still can be offered in the cases of a solitary kidney or chronic renal insufficiency or for poor surgical candidates. Patients with localized stages (T2, T3) TCC should be offered immediate nephroureterectomy. The authors do not expect adequate endoscopic extirpation with muscle invasive tumors. Although the tissue removed may include deep layers, deep resection is precluded by the thin renal pelvic wall and the associated risk for perforation. Patients with more extensive disease (T3, T4) have a bad prognosis regardless of the form of therapy. Achieving local control percutaneously while preserving as many nephrons as possible for the future chemotherapy can be a reasonable option.     

Prognostic factors for upper tract transitional cell carcinoma: a retrospective review of 66 patients

OBJECTIVE: We assessed the prognostic factors on recurrence and disease-specific survival of patients treated for upper tract transitional cell carcinoma (TCC). METHODS: Data on 66 patients who were treated for upper tract TCC in a single centre over a 13-year period were analysed. Mean follow-up time was 49.2 months. Fifty-five out of 66 (83.3%) underwent nephroureterectomy with excision of a bladder cuff. Four (6.1%) patients had nephrectomy alone while three (4.5%) had renal-sparing surgery. Four patients did not receive surgery due to advanced age and other comorbidities. Age, sex, tumour location, stage and grade were analysed as prognostic factors for disease recurrence and disease-specific survival using log rank univariate analysis. RESULTS: Disease recurrence occurred in 45 (68.2%) patients at a median time of 11.0 months. Recurrences were found in the bladder in 27.3%, the contralateral renal pelvis in 4.5%, local retroperitoneum in 19.7%, distant sites in 13.6%, with simultaneous local and distant metastases occurring in 3.0%. Tumour stage was the only significant prognostic factor for recurrence. Presence of extraurothelial recurrence, stage and grade were significant prognostic factors for disease-specific survival. CONCLUSION: Tumour stage was the most consistent predictor of both disease recurrence and survival. These findings would guide the need for any adjuvant chemoradiotherapy.     

Rare presentation of renal cell carcinoma: Solitary sternal metastasis

Renal cell carcinoma (RCC) may present as metastatic disease. However, RCC with solitary sternal metastasis is rare. We report a rare case of RCC with synchronous solitary sternal metastasis. The patient underwent radical nephrectomy, sternal tumour resection and reconstruction as a one‐stage procedure. The role of open sternal biopsy is also described. Review of the literature was carried out and a reasonably lengthy survival was observed. We concluded that radical surgical resection and reconstruction may offer the best chance of survival in managing RCC with solitary sternal metastasis in renal cell carcinoma.     

The percutaneous treatment of upper urinary tract urothelial tumours

Summary This paper reports the management of eight upper urinary tract (UUT) transitional cell tumours (TCC) treated by percutaneous endoscopic resection (n=7) or laser coagulation. Two patients with small, solitary-low-grade TCC and negative urine cytology are free of recurrence after 2 years. Of the remainder, two died of TCC, two proceeded to nephroureterectomy for highgrade or recurrent invasive tumors, one underwent a second percutaneous resection of a recurrent superficial TCC and one was lost to follow-up. The patient who died from high-grade invasive TCC had tumour protruding from the nephrostomy track. We feel that percutaneous surgery has a very limited place in the management of UUT TCC and should be reserved for palliation of proven solitary, low-grade superficial tumours with negative cytology in patients requiring conservative treatment.     

Transitional cell carcinoma of the ureter: prognostic factors influencing progression and survival

OBJECTIVES: We retrospectively evaluated prognostic factors for progression-free and disease-specific survival in a large cohort of patients with transitional cell carcinoma (TCC) of the ureter. METHODS: A single-centre series of 145 consecutive patients treated with partial resection of the ureter or nephroureterectomy between 1975 and 2004 was evaluated. Median follow-up was 96 mo. Routine preoperative laboratory parameters as well as clinical and tumour-specific data were assessed. Univariate and multivariate statistical analyses were performed. RESULTS: Five-year disease-specific survival ranged from 96.1% for stages pTa to 28.6% for pT4. Grade1 tumours were associated with 5-yr disease-specific survival rates of 100% compared with 84% for G2, and 51.9% for G3 tumours, respectively. Univariate analyses identified pT stage and grade, tumour diameter, cM and pN categories, weight loss, the presence of synchronous tumour in the renal pelvis as well as elevated levels for humoral factors such as serum alkaline phosphatase (AP), white blood cell (WBC) count, platelet count, gamma-glutamyl transferase, creatinin, and blood urea nitrogen as prognostic factors. In multivariate analyses, tumour grade and WBC counts were predictive for low progression-free survival rates, whilst simultaneous tumour in the renal pelvis, high AP levels, and WBC counts were correlated with worse disease-specific survival. CONCLUSIONS: Our retrospective analysis provides clinical factors to identify patients with TCC of the ureter at high risk for progression and death of disease. Interestingly, humoral factors such as elevated serum AP levels and high WBC counts were demonstrated to be of paramount prognostic significance besides tumour stage, grade and multifocality.     

Surgical resection of metastatic renal cell carcinoma: The University of Iowa experience

The utility of surgical resection of solitary metastatic sites in renal cell carcinoma remains controversial. Additionally, the small literature detailing the role of surgical management suggests that patients who have surgical resection of metachronous metastases have a better outcome than those presenting synchronously. We reviewed the medical records of all patients with metastatic renal cell carcinoma who underwent nephrectomy at the University of Iowa Hospitals and Clinics between 1980 and 1993. Patients who had undergone surgical resection of metastatic disease, either at presentation or subsequent to their nephrectomy, were identified. Clinical parameters, time to treatment failure, and survival was evaluated. Eighteen patients underwent surgical resection of metastases, 7 were synchronous to their nephrectomy, and 11 developed metachronous metastases. Resected lesions in both groups included metastases to lung, bone, liver, brain, and soft tissue. The median survival of all patients from time of resection to death or last follow-up was 5.7 years (range, 2 days to 10.7+ years). Two patients remain alive, both with recurrent disease at 5.3 and 10.7 years. Mean time from nephrectomy to death was 2.69 years for the synchronous group and 5.97 years for the metachronous group (p = 0.0599). The role of surgical resection in metastatic renal cell carcinoma remains unproven. The survival of this population is significantly longer than that typical for the disease. In our experience there is no difference in time to treatment failure or survival between synchronous and metachronous resection of metastatic disease.     

A clinical investigation on renal pelvic and ureteral tumors]

Sixty-six patients with renal pelvic and ureteral tumors were treated in our hospital between June 1974 and June 1991. These cases consisted of 27 renal pelvic tumors, 31 ureteral tumors and 8 renal pelvic and ureteral tumors. Their ages ranged from 43 to 86 years old (average: 65). There were 46 males and 20 females. The surgical method involved total nephroureterectomy with a cuff for 44 patients, nephroureterectomy for 3, nephrectomy for 9, total nephroureterectomy with total cystectomy for 5 and partial ureterectomy for 2. Histologically, there were 60 transitional cell carcinomas (TCC), 2 squamous cell carcinomas (SCC) and 4 TCC with SCC. As for the pathological stage, 13 were pTa, 16 pT1, 12 pT2, 11 pT3, 13 pT4 and 1 pTX. Subsequent bladder tumors were found in 13 patients (19.7%). The overall survival rate at 1, 3 and 5 years were 80%, 68% and 52%, respectively according to the Kaplan-Meier's method. In this series, the pathological staging was the most important prognostic factor.     

Laser photoablation of renal pelvic tumours

We evaluated the clinical effects of the Zeiss OPMILAS (Oberkochen, Germany) multi–yttrium–aluminum–garnet (YAG) laser in the treatment of renal pelvic tumours as an alternative to nephroureterectomy. Four patients with evidence of transitional cell carcinoma (TCC) in the renal pelvis and a previous history of TCC of the bladder or opposite renal pelvis were treated with the Zeiss OPMILAS multi-YAG laser. Three patients underwent a retrograde ureteroscopic approach and 1 patient required percutaneous resection. Two wavelengths were used: 1060 nm continuous coagulative mode and 1440 nm pulsed ablative mode. The patients were followed for 12, 24, 76 and 84 months, respectively. Two patients showed no evidence of recurrence as determined by cystoscopy, retrograde pyelography and selective pelvic urine cytology. One patient experienced a recurrence of TCC requiring subsequent treatment. The ureteroscopic approach was associated with fewer complications and a more rapid recovery, compared with the percutaneous approach. All patients with solitary kidneys avoided dialysis.     

What are the oncological risks of minimal access surgery for the treatment of urinary tract cancer?

OBJECTIVES: A review of the oncological safety of minimal access surgery for the treatment of urinary tract cancers. The particular areas reviewed were port-site metastases, local tumour recurrence and long-term survival. METHODS: Review of the literature using Medline. RESULTS: There is a low rate of port-site metastases following laparoscopic surgery for urological malignancies, these are usually related to the stage and grade of the tumour. So far follow-up data shows that laparoscopic surgery for urological malignancy does not result in higher levels of local recurrence or shorter survival than open surgery. Percutaneous (PCN) and ureteroscopic (URS) resection of TCC of the upper urinary tract are acceptable forms of treatment for grade 1 and 2 TCCs even in patients with normal contralateral kidneys. However, for grade 3 TCC nephroureterectomy should be utilised because of increased risk of local recurrence (URS) and track seeding (PCN). CONCLUSIONS: Provided the principles of cancer surgery, combined with proper case selection are followed, minimal access surgery for urological cancer is safe and is rapidly emerging as the standard of care for many upper tract tumours.     

Long-term follow-up of ureteral stump tumors after nephrectomy for benign renal disease

OBJECTIVE: The occurrence of primary carcinoma of the ureteral stump after nephrectomy is rare. In this study, we evaluated the clinical characteristics of ureteral stump tumors after nephrectomy for benign renal disease. METHODS: During a 16-year period, 318 consecutive patients underwent simple nephrectomy for benign renal disease (216 cases) or for donation (102 cases). Eight of these 318 patients diagnosed as having an ureteral stump tumor were treated by ipsilateral ureterectomy with cuff excision of the bladder. Pathologic findings, tumor stages, and clinical characteristics were analyzed. RESULTS: The eight ureteral stump tumors comprised; 6 transitional cell carcinomas (TCCs) and 2 squamous cell carcinomas (SCCs). The mean interval between nephrectomy and ureteral stump tumor diagnosis was 76.5 months. Six of the 8 patients had pyonephrosis and two renal tuberculosis as original renal diseases. Four of the 6 TCCs were stage T1 and 2 stage T2. There was no concomitant bladder tumor at stump tumor diagnosis. Hematuria was the major presenting symptom in 3 of the 8 patients and 4 patients were diagnosed by follow-up imaging study. Two of the 6 ureteral stump TCC patients developed bladder TCC during follow-up. The 5-year survival rate of patients with ureteral stump tumor was 37.5%. T1G1 TCC was associated with a better survival than T2 or G2 TCC. No ureteral stump tumor occurred in cases of donor nephrectomy. CONCLUSION: This study demonstrate, that long-term closed observation is needed to detect ureteral stump tumor, particularly in patients that have undergo nephrectomy for a long-standing inflammatory renal disease such as pyonephrosis or tuberculosis. Hematuria is a major presenting symptom of ureteral stump tumor. However, a follow-up imaging study is also important for ureteral stump tumor detection. The prognosis is poor in cases developing ureteral stump SCC, bladder tumor recurrence, or a high-grade ureteral tumor.     

Laparoscopic nephroureterectomy. A new standard for the surgical management of upper tract transitional cell cancer

Laparoscopic nephroureterectomy for upper tract TCC still remains somewhat controversial. Unlike laparoscopic radical nephrectomy, which has become widely accepted, LNU is still in its earliest stages. Although there are obvious benefits for the patient who has LNU--less pulmonary complications, less postoperative discomfort, a shorter hospital stay, a better cosmetic result, and a brief convalescence--there are significant concerns. The longer operative time creates a negative financial and professional inducement to learn this technique. Operative times need to fall into the 4-hour range or less to make the procedure cost-effective. Analysis of the efficacy of laparoscopic nephroureterectomy as a curative treatment modality is important. In the short-run, LNU seems to provide similar results to open nephroureterectomy for upper TCC. Although concerns over port site seeding, bladder recurrence, and intraperitoneal seeding have been voiced, these problems have not occurred. The higher incidence of local recurrence noted in the authors' series, however, is of concern and remains an unsettled issue. Despite these local recurrences, the overall cancer survival for a given grade and stage of upper tract TCC seem to be similar to survivals recorded after open nephroureterectomy. Still, the number of LNU cases remains small, and follow-up is brief. These patients need to be monitored closely, with follow-up CT scans over the next decade. The authors believe that there are still several significant hurdles standing in the path of LNU before it can become a widely accepted procedure. Issues of cost, training, and long-term efficacy must be answered definitively. To obtain these types of data, it will be necessary to create a multi-institutional, cooperative study to obtain sufficient numbers of patients with a more than 5-year follow-up on which to base future recommendations.     

Renal cell carcinoma in the solitary kidney: an analysis of complications and outcome after nephron sparing surgery

PURPOSE: We evaluated surgical techniques, pathological features and extended outcomes in patients with renal cell carcinoma in a solitary kidney treated with surgical excision. MATERIALS AND METHODS: Between 1970 and 1998, 76 patients underwent nephron sparing surgery for sporadic renal cell carcinoma in a solitary kidney, including 63 with tissue specimens available for pathological review who comprised the cohort. Six (9.5%) patients had a congenitally absent kidney and 57 (90.5%) had previously undergone contralateral nephrectomy for renal cell carcinoma. The clinical and pathological features examined were patient age at nephron sparing surgery, sex, type of nephron sparing surgery (enucleation, partial nephrectomy or ex vivo resection), tumor size, nuclear grade, histological subtype and 1997 tumor stage. Overall cancer specific, local recurrence-free and metastasis-free survival as well as early (within 30 days of nephron sparing surgery) and late (30 days to 1 year after nephron sparing surgery) complications were assessed. Univariate and multivariate analyses were done to test for the associations of clinical and pathological features with outcome. RESULTS: Most patients were treated with enucleation (36.5%), standard partial nephrectomy (38.1%) or the 2 procedures (11.1%) and in 8 (12.7%) ex vivo tumor resection was done. The renal cell carcinoma histological subtypes were clear cell in 82.5% of cases, papillary in 15.9% and chromophobe in 1.6%. Grade was 1 to 3 in 10 (15.9%), 42 (66.7%) and 10 (15.9%) tumors, respectively. At 5 and 10 years the overall survival rate was 74.7% and 45.8%, the cancer specific survival rate was 80.7% and 63.7%, the local recurrence-free survival rate was 89.2% and 80.3%, and the metastasis-free survival rate was 69% and 50.4%, respectively. Tumor stage and nuclear grade were significantly associated with death from any cause, death from renal cell carcinoma and distant metastases on multivariate analysis. Notably no patient with papillary or chromophobe renal cell carcinoma died of renal cell carcinoma, or had recurrence or metastasis. The type of nephron sparing surgery was not significantly associated with outcome, although there were too few patients with recurrence to assess the association of the type of nephron sparing surgery with local recurrence. The most common early complication was acute renal failure in 12.7% of cases, while the most common late complications were proteinuria in 15.9% and renal insufficiency in 12.7%. CONCLUSIONS: The 1997 tumor stage and nuclear grade were significant predictors of death from any cause, death from renal cell carcinoma and distant metastases in patients treated with nephron sparing surgery for renal cell carcinoma involving a solitary kidney. Nephron sparing surgery in a solitary kidney can be performed safely and with minimal morbidity.     

Results of the treatment of carcinoma of the renal pelvis and ureter

Twenty-one patients with renal pelvic carcinoma and eighteen patients with ureteral carcinoma were treated with surgical therapy. In 14 of the 39 patients, we performed nephroureterectomy with a bladder cuff (NUpB), nephroureterectomy with total cystectomy (NUtB) in 12, nephrectomy with partial ureteric resection (NpU) in 8 and others in 5. Following surgery, 8 had recurrences and metastasis and 21 died with carcinoma and 10 survived without evidence of disease. The 5-year survival rate of the patients with renal pelvis carcinoma is 33.5% and 52.0% in ureteral carcinoma.     

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.     

Renal fossa recurrence after radical nephrectomy: Current management,and oncological outcomes

Introduction and objectivesKidney cancers represent 2% of cancers worldwide; the most common type is renal clear cell carcinoma (RCC). Surgical treatment remains the only effective therapy for localized renal cell carcinoma. Approximately 20% to 38% of patients undergoing radical nephrectomy (RN) for localized RCC will have subsequent disease progression, with 0.8% to 3.6% of local recurrences within the ipsilateral retroperitoneum (RFR). The main objective of this study is to evaluate prognostic features, oncological outcomes, and current management for renal fossa recurrence in patients with history of RN for RCC.Materials and methodsWe retrospectively analyzed 733 patients who underwent open or laparoscopic RN for unilateral T1-T4 N0 M0 RCC between 2010 and 2016 at the Urology Department of Hospital Italiano de Buenos Aires.ResultsDuring the mentioned period, of a total of 733 RNs (open/laparoscopic), 561 patients with RCC were included in the study. After a median follow-up time of 24 months (12–36) (interquartile range), 21 (3.74%) patients out of 561, developed renal fossa recurrence. Of these, 13 (2.31%) patients were diagnosed with isolated local renal fossa recurrence and different treatment approaches were adopted; 11 patients underwent open surgical resection, 1 patient laparoscopic surgical resection, and 1 case was treated with cryoablation.Regarding cancer-specific survival, estimated 4-year cancer-specific survival in patients without RFR, with isolated RFR (iRFR) and not isolated RFR (niRFR) was 82.7% (CI 95% 70.2–95.2), 69.2% (IC 44.2–94.2) and 0%, respectively (log rank test P < 0.0001 being niRFR group different to others. Non isolated RFR was a death risk factor with a HR of 11.4 (4.8–27.2) compared with iRFR or no recurrence. Overall, 51% (IC 26.6–71.2) of patients with any RFR died at 4 years follow-up.ConclusionAlthough RFR is a rare condition, in the absence of distant metastatic disease, aggressive surgical resection should be our aim. High pathological tumoral stage at original nephrectomy and high tumoral grade are independent risk factors for RFR. This group of patients needs closer follow-up to detect earlier recurrences and decide a treatment strategy.     

Tumours of the ureter and renal pelvis treated with resection and renal autotransplantation: a study with up to 20 years of follow-up

OBJECTIVE: To report long-term follow-up data from patients treated with resection of urothelial neoplasms of the upper urinary tract combined with autotransplantation of the kidney. PATIENTS AND METHODS: In a clinical and histopathological review of 23 patients who had 25 autotransplantations, they were followed for 7-20 years or until death. Nine patients had either a solitary kidney or bilateral renal pelvic tumours (group A) and 14 had a normal contralateral kidney (group B). RESULTS: Seven operations were unsuccessful, ending in nephrectomy. Of the nine patients in group A two with high-grade renal pelvic tumours survived with no dialysis and recurrences for 127 and 238 months, respectively. Three patients required haemodialysis 0-3 times weekly for 27, 85 and 108 months, respectively. Three patients with low-grade disease developed invasive recurrences in the autotransplanted kidney after 16, 27 and 90 months, respectively, and later died from the disease. One patient died in an accident after 14 months. Of the 14 patients in group B, one developed a deeply invasive recurrence in the autotransplanted kidney after 86 months, despite frequent controls. CONCLUSIONS: In patients with a normal contralateral kidney resection and renal autotransplantation is not indicated and might even be harmful, compared to standard nephroureterectomy. The operation might be beneficial in patients with solitary kidneys but other treatments should first be considered, including open or endoscopic resection, and nephroureterectomy and haemodialysis.     

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.