Conservative Nephron-Sparing Treatment of Upper-Tract Tumors

Division of Urology, Penn State Milton S. Hershey Medical Center, 500 University Drive, c4830B, Hershey, PA, 17033, USA.
Current Urology Reports (Impact Factor: 1.51). 01/2013; 14(2). DOI: 10.1007/s11934-013-0305-1
Source: PubMed


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.

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    ABSTRACT: To assess oncological outcome after first-line management of upper urinary tract urothelial cell carcinomas (UUT-UCCs) by exclusive flexible ureteroscopy. A retrospective review was performed for 35 patients treated between 2003 and 2007. All patients underwent retrograde flexible ureteroscopy for diagnosis, treatment (i.e., holmium:YAG vaporisation), and follow-up. The following data were reviewed: sex, age, ASA score, presence of a solitary kidney, unifocal or multifocal tumour, history of bladder cancer, tumour localisation, tumour size, stage and grade, outcome, recurrence, and progression. The mean age was 67 + or - 13.1 years (range: 38-88). The tumour involved the renal pelvis and the caliceal system in 19 cases (54%), the ureter in 8 cases (23%), and both in 8 cases (23%). Twelve patients (34%) had a history of bladder carcinoma. Tumour stage was superficial in 63% (57% were pTa and 6% were pT1) and not available in 37%. Tumour grade was low, high, and unavailable in 49, 14, and 37%, respectively. The median follow-up was 30 months (range: 12-66), and 21 patients had a recurrence (60%). The median survival rate without recurrence was 10 months (95% CI [5-22]). Four patients underwent nephroureterectomy during follow-up. No patient died of disease progression. The main limitation was the limited length of follow-up. Flexible endoscopic management can be advocated in selected cases of non-muscle invasive UUT-UCCs as an alternative to nephroureterectomy. Because of a high recurrence rate, long-term and stringent surveillance is needed, including iterative ureteroscopies at least every 3 months for 2 years.
    World Journal of Urology 04/2010; 28(2):151-6. DOI:10.1007/s00345-009-0494-x · 2.67 Impact Factor
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    ABSTRACT: We analyzed a series of 59 reno-ureteral units with upper tract urothelial carcinoma treated endourologically at our institution. Between January 1980 and January 1995, 54 of 185 patients with a clinically diagnosed upper tract tumor were considered candidates for endourological treatment. Of the patients 14 had either bilateral disease or a solitary kidney. The primary approach was ureteroscopy in 39 reno-ureteral units and percutaneous nephroscopy in 20. Superficial stage pTa, T1 or Tis disease was noted in 48 cases, infiltrating stage pT2 cancer in 4 and inverted papilloma in 4, while the tumor was impossible to classify in 3. A total of 32 patients received adjuvant supplemental therapy. Ureteroscopy failed in 11 cases (28.2%), with salvage by nephroureterectomy in 6 and percutaneous nephroscopy in 5. Primary nephroscopy failed in 3 cases (15%) that were salvaged by open surgery. Two patients died of unrelated causes postoperatively and 14 (26%) had intraoperative or late complications that were treated conservatively in 12. After a mean followup of 30.6 months (range 2 to 119), 2 patients died of progressive upper tract tumor, 2 died of concurrent bladder cancer and 2 died of a second cancer. Of 42 upper tracts treated solely by endourological means 10 (23.8%) had recurrences, which were treated endourologically in 6. Bacillus Calmette-Guerin and mitomycin C seemed to be effective at preventing recurrences, with recurrence rates of 12.5 and 14.2%, respectively, compared to 60% for thiotepa, and 40% for oral combination 5-fluorouracil and uracil. Endourological treatment of low grade, small, noninvasive tumors of the upper urinary tract is a feasible and safe alternative even in patients with a normal contralateral kidney.
    The Journal of Urology 09/1996; 156(2 Pt 1):377-85. DOI:10.1097/00005392-199608000-00011 · 4.47 Impact Factor
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    ABSTRACT: OBJECTIVE To assess the impact of tumour location within the ureter and the impact of surgical approach on recurrence-free survival (RFS) and cancer-specific survival (CSS) with regard to ureteric tumours. PATIENTS AND METHODS Data were retrospectively reviewed from 60 patients with isolated primary ureteric tumours, treated at a single tertiary referral centre. Patients were treated with radical nephroureterectomy (NU, n = 33), partial ureterectomy (n = 17) or endoscopic resection (ENDO, n = 10). Kaplan-Meier curves were used for the analysis of RFS and CSS after surgery, stratified by tumour location and surgical approach. RESULTS With a median follow-up of 2(months, tumour location was not associated with disease recurrence (P = 0.423). The ENDO group had shorter time to disease recurrence. There were no significant differences in the probability of CSS with regard to either tumour location or surgical approach (P = 0.523 and P = 0.904, respectively). CONCLUSIONS Tumour location or surgical approach were not significant predictors of oncological outcomes in patients with ureteric tumours. Although NU is standard treatment for invasive ureteric tumours, partial ureterectomy and ENDO can safely be performed in selected patients. Despite the risk of a shorter time to recurrence, ENDO can be recommended in low grade, non-invasive ureteric tumours. All urothelium-preserving approaches require thorough surveillance.
    BJU International 05/2012; 110(11B). DOI:10.1111/j.1464-410X.2012.11199.x · 3.53 Impact Factor
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