Upper tract urothelial carcinoma (UTUC) has traditionally been managed by complete surgical resection (radical nephroureterectomy) without immediate concern for renal preservation. Increasing data support the role of nephron-sparing approaches, including ureteroscopic resection of ureteral or intrarenal UTUC lesions, whenever oncologically feasible. Imperative indications for conservative endoscopic management include a solitary renal unit, underlying renal insufficiency, and bilateral upper tract lesions. With improvements in endourologic equipment, such as reduced size, improved optics, and increased mobility, ureteroscopic management has become a valid option and has been extended to patients with normal contralateral kidneys. Although recurrences are common, long-term data support the oncologic success of this modality in properly selected patients. Progression to high-grade disease or a large unresectable tumor burden should still be managed with radical nephroureterectomy even in the face of rendering a patient anephric.
Successful endoscopic management of UTUC is ultimately dictated by the patient’s understanding and acceptance of the risk of recurrence and subsequent need for continued surveillance and retreatment. Therefore, the goal of ureteroscopy (URS) should be to diagnose the lesion visually, obtain tissue specimens for pathologic review, and ablate the lesion completely. The ideal patient has negative urine cytology, indicating low-grade disease, and a single, small upper tract lesion on a papillary stalk with normal anatomy. Complex cases for endoscopic management include sessile lesions, large tumor burden, circumferential tumors, lesions in a lower pole calyx (limiting endoscopic access), or abnormal anatomy (strictures, diverticula, or narrow infundibula).
Preoperative Planning
All patients require preoperative evaluation including urine studies (urinalysis, cytology, culture), blood work (electrolytes and blood urea nitrogen/creatine), and radiographic imaging. Computed tomography urograms and intravenous pyelography are the best studies available for delineating ureteral and intrarenal UTUC lesions. The urologist must be prepared for possible bladder tumor resection in all patients, especially those with a previous history.
General anesthesia with endotracheal intubation and paralysis is ideal, although spinal blockade or laryngeal mask anesthesia is adequate. Narcotics can be used to slow the patient’s respiratory rate when working on a moving target such as a tumor in the renal pelvis. Patients are placed in a dorsal lithotomy position with ample padding at all pressure points. The upper extremities are placed outside the radiation field to ensure unobscured views of both upper tracts. Monitors for endoscopy and fluoroscopy should be comfortably positioned for the surgeon. A laser generator capable of dual modalities such as holmium:yttrium-aluminum-garnet (Ho:YAG) and neodymium (Nd):yttrium-aluminum-garnet (Nd:YAG) is ideal because of their respective biophysical properties, specifically level of tissue penetration. A holmium laser with dual pulsed duration (usually 350 and 700 µsec) is advantageous to coagulate and resect neoplasms within the ureteral lumen. Holmium, with a shallow depth of penetration (0.5 mm), minimizes bleeding without adding significantly to stricture formation risk. Neodymium is preferred for coagulation of tumor in the intrarenal collecting system and is particularly useful for bulkier lesions given its greater depth of tissue penetration at 5 mm. Fluid irrigation should always be with sterile normal saline unless a flexible electrode for cauterization is used. Fluid irrigation during URS can be delivered by gravity, a pressurized bag, or a hand-controlled irrigation device. Ureteral access sheaths are generally not used because of the potential for shearing off small, untreated intraluminal ureteral lesions. Additionally, they very commonly cause abrasions, which can be mistaken for erythematous flat neoplasms such as carcinoma in situ (CIS). Some urologists prefer sheaths to minimize intraluminal pressure, but a totally decompressed system interferes with visualization and maneuverability. Safety guidewires are generally helpful to maintain ureteral access but must be used with care to avoid bleeding and tumor disruption. Containers with sterile normal saline for pathologic specimens should be prepared for frequent collections of tissue for cytology, histology, or cell block analysis.
Endoscopic Technique
An initial thorough cystoscopy with both 30- and 70-degree lenses is necessary to detect concomitant bladder tumors. Initial urine cytology of the bladder should be collected. Any bladder lesion seen should be managed after the upper tract has been adequately visualized or treated. Using approximately 30% iodinated contrast, a formal retrograde ureteropyelogram with a cone tip catheter is always useful in addition to preoperative imaging studies. Next, direct visualization of the intraluminal collecting system is performed without the use of initial wire placement or routine balloon dilation, which could instigate bleeding or tumor disruption ( Fig. 44.1 ). If distal ureteral pathology is anticipated, a small-diameter semirigid ureteroscope (6.9-Fr tip with 8.3-Fr shaft) is introduced. Alternatively, current flexible ureteroscopes, with firmer shaft durometers, can be directly placed into the ureteral orifice in many cases. If semirigid URS is used initially, the scope should be passed only to the level that can be reached easily.
After completion of the proximal excursion of the semirigid ureteroscope, a guidewire is placed to the level of the ureter that has already been inspected and left in place as the endoscope is removed. A flexible ureteroscope is then passed over the wire to the last visualized segment under fluoroscopic guidance. The guidewire is then removed and the endoscope is passed farther under direct vision to the renal pelvis. At this level, the collecting system is systematically visualized starting with the renal pelvis and then the major and minor calyces of the upper pole, midpole, and finally lower pole ( Fig. 44.2 ). Diluted contrast (20%–30% iodinated contrast) in the irrigant can help outline the renal collecting system under fluoroscopic visualization to ensure complete inspection.
Any lesion encountered during URS should be managed as the endoscope is passed retrograde unless retrograde studies reveal more significant proximal lesions. There is risk of shearing the tumor from the base as the ureteroscope passes. After thorough visualization of a ureteral lesion, a sample should be obtained for pathology. An adequate tissue specimen can be obtained using a flat-wire basket, a cup biopsy forceps, or occasionally a wire-prong grasper. The type of lesion dictates the ideal tool: flat (cup) or papillary (basket) ( Fig. 44.3 ).
A flat-wire basket is used to biopsy a papillary lesion in the ureter or kidney by opening it fully and placing the largest part of the basket onto the tumor and closing it snugly but not fully to avoid shearing the tumor. It is then withdrawn to avulse a sample of tumor. A very small sample can be withdrawn through the working channel, but with a larger sample (>1–2 mm), the entire unit—ureteroscope, basket, and tumor sample—is removed together similar to retrieving a stone ( Fig. 44.4 ).
Repeated tissue sampling mechanically debrides the lesion and increases the specimen yield. A ureteral or renal aspirate postbiopsy is obtained to increase tissue yield as well. Various forms of energy can be used to ablate and coagulate the remaining tumor and the biopsy site for hemostasis and complete tumor ablation. It is important to protect and maintain the integrity of the ureter and infundibula. The Ho:YAG and Nd:YAG lasers are the ideal modality to achieve these two goals ( Fig. 44.5, A and B ). When available, a holmium laser with dual pulse durations, 350 or 700 microseconds, should be used with the longer pulse for improved coagulation and hemostasis without deeper penetration. Whereas the holmium is initially set at 0.6 J with a rate of 10 Hz, the Nd:YAG laser is used at 30 watts continuous. Smaller laser fibers (200 or 365 microns) can be passed through the working channel of a small-diameter semirigid or flexible ureteroscope with little loss of deflection. When the laser is unavailable or the fiber cannot deflect onto a desired intraluminal location, a 2-Fr electrode is used to fulgurate the tumor.
