Broadening experience with the retrograde endoscopic management of upper urinary tract urothelial malignancies

Abstract

OBJECTIVE To evaluate the results of the retrograde endoscopic treatment of upper urinary tract urothelial malignancies (UUTUM) in an attempt to preserve renal function while also obtaining an acceptable oncological result. PATIENTS AND METHODS Since 1995, 63 patients who were referred for retrograde endoscopic management of UUTUM were evaluated and treated. All patients had an initial diagnostic ureteroscopy and biopsy to obtain histopathological grading. Additional imaging studies were obtained to exclude metastatic disease. The treatment was directed by tumour grade at presentation and medical comorbidity. Tumour volume and multifocality did not exclude patients from vigorous endoscopic treatment. Tumours were resected with electrocautery, holmium‐YAG and Nd:YAG laser. Follow‐up endoscopic surveillance was initially at 3‐month intervals, with increasing intervals in patients with repeatedly negative findings. RESULTS The tumour grade at presentation was high in 14 (22%), moderate in six (10%), low in 35 (55%) and carcinoma in situ in eight (13%), with 13 (20%) presenting with or subsequently developing bilateral disease. Twenty patients had a nephroureterectomy as they were not amenable to endoscopic treatment. Medical comorbidities necessitated palliative endoscopic therapy of high‐grade tumour in six patients; the remaining 35 had low‐grade tumour and were managed with retrograde endoscopic therapy. Recurrent low‐grade disease was identified in 24 with a mean (range) time to recurrence of 15 (3–63) months. There was concurrent low‐grade bladder cancer in 21 (60%) of the patients. The mean (range) follow‐up was 32 (3–84) months. No patient with low‐grade tumour progressed in grade or stage, and all but one who presented with high‐grade tumour progressed. CONCLUSION The retrograde endoscopic management of UTTUMs is particularly useful for patients who present with low‐grade lesions, providing good oncological control and preserving renal function. These patients require a careful and consistent follow‐up, as many will develop recurrent disease. Treatment of higher‐grade lesions is at best palliative.

Is There a Role for FISH in the Management and Surveillance of Patients with Upper Tract Transitional-Cell Carcinoma?

“…The previously described "no touch" technique of wireless navigation of the upper tract from ureteral orifice to intrarenal collecting system was used in all cases where technically feasible. 14,15 Selective upper-tract specimens were collected by aspiration or washings with normal saline through the ureteroscope or with the 5F open-ended catheter used during radiography.…”

Endoscopic Management of Upper Tract Urothelial Carcinoma

“…In contrast, 20 of 22 (91%) of renal units with initial tumours less than 1.5 cm were rendered tumour free and only 5 (25%) tumour free kidneys had recurrences [10]. This finding was echoed by Johnson et al who found that patients presenting with tumours >1.5 cm in size had a higher incidence of recurrence and recurred earlier [11]. Johnson et al confirmed the aggressive nature of high grade disease.…”

Update of the ICUD-SIU consultation on upper tract urothelial carcinoma 2016: treatment of low-risk upper tract urothelial carcinoma

“…Recurrence rates in the upper tract following endoscopic treatment of UTUC have been reported in 30–70% of patients [68, 69]. Topical adjuvant agents might decrease the risk of local recurrence as suggested by several reported case series [57].…”