Fig. 11.1
A nephroureterectomy specimen
11.1.1.2 Laparoscopic Nephroureterectomy
Laparoscopic nephroureterectomy is now known to have equivalent oncologic results as open surgery and is gaining in popularity among urologists.
Notes: A single-dose mitomycin C intra-vesical instillation (40 mg) can be performed soon after nephroureterectomy as it was shown to prevent bladder recurrence at 1 year by 40 % [6]. Contrary to bladder cancer, there is no consensus yet about the role of neoadjuvant chemotherapy prior to RNU for high-risk upper tract TCC. A study has shown a 14 % complete remission and a significant rate of pathological downstaging associated with a neoadjuvant chemotherapy; however, further studies are lacking to corroborate this evidence [7].
11.1.2 Nephron-Sparing Management of Upper Tract Urothelial Carcinoma
This was initially limited to patients with a solitary kidney, bilateral disease, severe renal insufficiency or significant perioperative risk. Many authors still advocate the use of this approach. However improvement in technology and the imaging modalities may result in the expansion of endoscopic treatment to patients with normal contralateral kidneys [8–10].
Low-grade tumours which are unifocal, less than 1.5 cm in size and readily accessible within the kidney are suitable for nephron-sparing surgery by endoscopic resection or partial nephrectomy and segmental ureterectomy.
The different approaches for nephron-sparing surgery are as follows.
11.1.2.1 Endoscopic Management
The tumours in the renal collecting system can be approached either by ureterorenoscopy (retrograde approach) or percutaneously (antegrade approach).
(a)
Retrograde ureterorenoscopy can be performed either through a rigid or a flexible ureteroscope. This is usually suitable for tumours less than 1.5 cm in size. The lesion is biopsied and sent for histopathology. Cold cup forceps or stone baskets can be used for debulking. Deep resection should be avoided in the proximal ureter and renal pelvis due to their thin wall to avoid perforation and spillage of tumour cells. The small calibre of ureteroscopic instruments and working channels and the low irrigant flow are factors which make ureteroscopic resection technically difficult. Complications of ureteroscopic management occur in 8–13 % of cases which include perforation and ureteral stricture [11].
(b)
Percutaneous nephroureteroscopy allows larger instruments and facilitates better resection of larger tumours (>1.5 cm) of the renal pelvis and proximal ureter. The disadvantage of this approach is the violation of the urinary tract and risk of tumour spillage, although rare. A percutaneous tract is created and a larger sheath used to keep the intrapelvic pressure low. The tumour can be debulked by using forceps to remove its base and can be resected using a standard resectoscope. If the resection is technically difficult, the tumour is biopsied for diagnostic purposes and treated by holmium or neodymium laser sources through a nephroscope or with a flexible cystoscope. Complications of this method range from 21.4 to 31 % [12–14] which include bleeding, infection, pelviureteric junction obstruction, adjacent organ injury and pleural injury.
11.1.2.2 Partial Nephrectomy
Partial nephrectomy may be considered when the endoscopic approach is not feasible due to a polar location or high tumour grade, stage and size.
11.1.2.3 Segmental Ureterectomy
Segmental ureterectomy is usually considered for distal ureteric tumours which are high grade, invasive or bulky and are not suitable for endoscopic management. It may require a psoas hitch or a Boari bladder flap. Other indications are grade 1 and 2 tumours of the proximal or mid ureter that are too large for endoscopic surgery or grade 3 tumours when nephron-sparing surgery is desirable. After segmental resection, up to 4 cm gap can be managed by performing a direct end-to-end ureteric anastomosis, i.e. ureteroureterostomy.
11.2 Adjuvant Therapy After Organ-Sparing Surgery
The benefits of adjuvant therapy with chemotherapy and radiation are still debated. However, since clinical studies continue to report some improvement in disease-specific survival with both forms of treatment, either therapy may be used in patients undergoing nephron-sparing management of upper tract TCC. Patients’ consent and awareness about this is mandatory, and they should be under stringent surveillance [15].
BCG, mitomycin and epirubicin have been used for local instillation therapy. Focal radiation therapy has been tried to decrease the risk of local relapse after radical surgery for locally advanced non-organ-confined disease. The same systemic chemotherapy agents used in bladder TCC are prescribed here for metastatic disease or distant relapses.
11.3 Prognosis
The most significant prognostic factor for patients with upper tract urothelial carcinomas is the TNM stage [16, 17]. The 5-year specific survival is less than 50 % for pT2/pT3 and less than 10 % for pT4 [18, 19]. Histological features of high tumour grade, extensive tumour necrosis and lymphovascular invasion are associated with unfavourable prognosis.
11.4 Follow-Up
All patients should be evaluated at 3-month intervals during the first year by repeated cystoscopies and urine cytology following treatment with open or endoscopic methods. Ureteroscopy should also be performed after all conservative approaches. CT urography is also repeated at 3 and 6 months after a conservative approach or 6 monthly after a radical procedure during the first year. This close follow-up aims at an early detection of metachronous bladder tumours, local recurrences, metachronous tumours in the contralateral side and distant metastases. Subsequently, regular check-ups will be continued 6 monthly during the second year and then annually indefinitely.
< div class='tao-gold-member'>
Only gold members can continue reading. Log In or Register to continue
Related posts:
Stay updated, free articles. Join our Telegram channel
Full access? Get Clinical Tree
