Endoscopic management of upper urinary tract transitional cell carcinoma

Daneshmand, Siamak; Quek, Marcus L.; Huffman, Jeffry L.

doi:10.1002/cncr.11446

Cited by 128 publications

(64 citation statements)

References 22 publications

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“…The current study reports a similar sample size to other papers published, [8][9][10][11][12][13] but with a longer followup. This allows us to assess the long -term effects after conservative treatment.…”

Section: Discussionsupporting

confidence: 84%

Conservative treatment of upper urinary tract carcinoma: Long-term results

Andrada

García

Fúnez

et al. 2017

CUAJ

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Introduction: We sought to assess the long-term results of conservative treatment for upper urinary tract carcinoma (UUTC) with regard to tumour recurrence and preservation of renal unit. Methods: From October 1987 to January 2014, 65 patients (median age 68 years) were diagnosed with UUTC and underwent endoscopic and open surgical techniques. Thirteen patients had bilateral disease and one had a single kidney. The primary approach was endoscopic in 37 reno-ureteral units (20 percutaneous resections, 17 ureteroscopies ). Open surgery was performed in 19 cases. A total of 20 patients received mitomycin C. Results: Superficial stage pTa or T1 was noted in 37 patients, infiltrating stage pT2 and pT3 in seven and inverted papilloma in one. The stage of the tumour was impossible to classify in 20. With a median followup of 75.12 months (interquartile range [IQR] 144.71-17.41), the kidney preservation, recurrence, specific survival, and global survival rates were 78.5% (51/65), 40.0% (26/65), 92.3% (60/65), and 69.2% (45/65), respectively. From the patients who had recurrence, 15 were salvaged with radical nephroureterectomy (RNU). The bladder tumour recurrence rate after the surgery was 30.76% (20/65). At the end of the followup, five patients had died of UUTC progression and 16 from other causes. Postoperative complications included one case of fistula, one case of stricture, and one case of nephrectomy due to bleeding. Conclusions: In selected cases, conservative management is a safe and feasible alternative to RNU, with the advantage of renal unit preservation. IntroductionUpper urinary tract carcinoma (UUTC) is uncommon and accounts for 5-10% of all urothelial carcinomas.1,2 Radical nephroureterectomy (RNU) with excision of the bladder cuff is the gold standard treatment for localized disease, regardless of the location of the tumour in the upper urinary tract.An interest in the conservative surgery, including endoscopic ablation and segmental resection, has emerged in recent years as an alternative for patients with UUTC and renal insufficiency, solitary functional kidney, comorbidities, or bilateral tumour, accounting for approximately 2-5% of UUTC patients. 3The elective cases for nephron-sparing surgery are considered in patients with low-grade, low-stage, unifocal, small tumours. In addition, the patient has to accept close followup because of the risk of recurrence, which is the main disadvantage of this treatment. 4 After RNU, the presence of a solitary kidney can lead to a renal insufficiency stage, which is associated with an increase in cardiovascular events and, therefore, in overall mortality. 4 It is well-documented that glomerular filtration rate decreases after RNU, with a mean of 24%, according to the outcomes of a recent multicentre analysis by Kaag et al. 5 These changes in renal function may affect eligibility for adjuvant cisplatin based-therapy. 5 Moreover, multifocal recurrence of UUTC in the contralateral side has renewed the interest in conservative treatment in elective cases. F...

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Section: Discussionsupporting

confidence: 84%

Conservative treatment of upper urinary tract carcinoma: Long-term results

Andrada

García

Fúnez

et al. 2017

CUAJ

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“…The endoscopic approach relies on the use of laser techniques to ablate and/or resect the tumour, which may compromise adequate pathologic evaluation, thus subjecting patients to higher instances of under-treatment. [7][8][9] By comparison, segmental or complete ureteral resection allows for full thickness excision of the involved ureter and peri-ureteral tissue, as well as allows us to perform lymph node dissection to complete pathologic staging. In our 45 patients undergoing SU or TU for upper tract urothelial carcinoma, all had adequate pathologic specimen for analysis, and pT3 disease was identified in 7 (15.5%) patients and positive lymph nodes in 3 (6.7%).…”

Section: Discussionmentioning

confidence: 99%

Oncologic outcomes and prognostic impact of urothelial recurrences in patients undergoing segmental and total ureterectomy for upper tract urothelial carcinoma

Pedrosa¹

2015

CUAJ

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Introduction:We evaluated the impact of urothelial recurrences in a cohort of patients undergoing segmental (SU) and total ureterectomy (TU) as an alternative to nephroureterectomy (NU) for upper tract urothelial carcinoma. Methods: Between 1999 and 2012, patients who underwent SU, TU and NU for treatment of upper tract urothelial carcinoma were evaluated. Demographic, surgical, pathologic and oncologic data were collected. Recurrence-free (RFS) and disease-specific survival (DSS) were analyzed using Kaplan-Meier and multivariable Cox methods. Results: A total 141 patients were evaluated, 35 underwent SU, 10 TU and 96 NU. Patients who underwent TU were more likely to have bilateral disease (p < 0.01), solitary kidney (p < 0.01), and multifocal disease (p = 0.01). Organ-confined (p < 0.01) and lowgrade disease (p < 0.01) were more common in the TU and SU groups compared with NU. At a median follow-up of 56.9 months (range: 0.2-181.1) disease relapse occurred in 88 (55.3%) patients. Localized recurrence occurred in 31.1% of SU/TU group compared to 27.1% (p = 0.62) of the NU group. Neither total nor segmental ureterectomy demonstrated significantly worse RFS (p = 0.26 and p = 0.81), CSS (p = 0.96 and p = 0.52) or overall survival (p = 0.59 and p = 0.55) compared with complete NU. Localized urothelial recurrence did not confer increased risk of cancer-specific (p = 0.73) or overall mortality (p = 0.39). The paper's most important limitations include its retrospective nature and its relatively small number of patients. Conclusion:No significant survival differences were demonstrated between surgical approaches for upper tract urothelial cancer. Localized urothelial recurrence after surgical treatment for upper tract urothelial cancer does not affect mortality in this population. TU with ileal-substitution may provide an alternative option for patients with extensive ureteral disease and poor renal function.

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“…54 Additionally, tumour stage and multifocality correlate with recurrence after nephron-sparing procedures. 44,47,52,56 Due to a lack of adequately powered studies, additional prognostic factors following nephron-sparing procedures are presently unknown. …”

Section: Prognostic Variablesmentioning

confidence: 99%

“…70 In a retrospective series of 30 patients, the mean time to recurrence was 7 months and ranged from 6 to 72 months. 52 …”

Section: Bladder Recurrencesmentioning

confidence: 99%

“…In a retrospective series of 30 patients who underwent ureteroscopic or percutaneous management of UTUC, 90% developed upper tract recurrences necessitating a mean 3.3 endoscopic procedures per patient and nephroureterectomy in 33%. 52 In a systematic review by Cutress and colleagues, upper urinary tract recurrences occurred in 53% of patients. 70 Upper tract recurrence rates among patients with low-and high-grade tumours were 48% and 60%, respectively.…”

Section: Extravesical Recurrencesmentioning

confidence: 99%

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