OBJECTIVES: The objective of this articleis to perform a comprehensive exposition of the variousnon-endourological treatment options for upper urinarytract tumors in order to set the bases to choose the mostadequate surgical indication depending on tumors’ andpatients’ characteristics; we consider the various surgicalapproaches, and the historic evolution from the classicindication established by Albarran (radical nephroureterectomywith bladder cuff) to the current ones more conservative.We also consider the role of radiotherapy andchemotherapy in the treatment of these tumors.METHODS/RESULTS: We refer to the conclusions ofvarious authors and their large series published in theliterature, series considered classic already, and providesupport adding our experience by reviewing 223patients treated from 1977 to 2003 with a meanfollow-up of 45 months (maximum 238 months).CONCLUSIONS: We can state that it is acceptable toindicate less aggressive ways of treatment (nephroureterectomywithout bladder cuff, distal or partial ureterectomy, andconservative operations) if the oncological radicalityrequirements are met, remembering that site, tumorgrade and stage are determinant in the outcome.
OBJECTIVES: To do an update on theupper urinary tract tumors classification systems.METHODS/RESULTS: Bibliography review of thevarious classification systems appeared over the lastyears, comparing them and reviewing their associatedproblems.CONCLUSIONS: Current systematization advocatedby WHO and ISUP are the most adequate for patientstratification. However, there are problems for couplingtumors with characteristics in the limit between some oftheir categories, so that we consider it will be convenientto review them.
To perform the adequate treatment ofupper urinary tract lesions it is very important to have anexact diagnosis. When the suspicion of an upper tracturothelial tumor is established the initial evaluation iscarried out by imaging diagnostic tests (intravenousurography, pyelography, and others). The association ofradiological tests and urine cytologies allows us to getto a correct diagnosis in most cases. Upper urinary tractendoscopy solves some equivocal cases, but sometimesit is impossible to clarify the nature of the lesion in spiteof a comprehensive diagnostic effort. Therapeutic decisionshould be individualized in these cases.The objective of this article is to describe the various featuresof upper tract urothelial tumors in a variety of availableimaging tests, and to review all conditions that may havesimilar images, describing the characteristic radiologicalfindings for each of them.We discuss about differential diagnosis and perform acritical evaluation of the diagnostic difficulties thatoccasionally present upper urinary tract diseases.
OBJECTIVES: To review the currentusefulness of urinary cytology in the diagnosis of upperurinary tract urothelial tumor in relation to conservativeendoscopic treatment.METHODS: Bibliographic review of the published articlesabout urinary cytology of the upper urinary tract urothelialtumor and evaluation of the diagnostic efficacy obtainedin various series. Review of the cytological diagnosticcriteria for urothelial tumors.RESULTS: From 1960 to 2003, 26 series collectingresults of the cytological diagnosis of urothelial tumors of the ureter and renal pelvis have been published. Resultshave been variable with a diagnostic accuracy between23 and 100%. Such an ample variation depends onsampling techniques, preparation techniques, type oftumor, and the urologist’s and pathologist’s experience.The collection of the sample by direct endoscopicalvisualization significantly proves the diagnostic efficacyof cytology for upper urinary tract urothelial tumors.CONCLUSIONS: Urine cytology selectively obtainedfrom the upper urinary tract with endoscopical techniquesis a reliable method in the diagnosis of renal pelvis andureter neoplasias. Urine cytology has a sensitivity closeto 90% and specificity between 98-100% for carcinomain situ and high-grade urothelial neoplasias, so that itcan contribute in the therapeutic decision making processin a very effective manner. Despite its low sensitivity, itmay be useful in the diagnosis of low grade urothelialneoplasias when samples are selectively obtained bycatheterization, and it has not been excelled by any ofthe biomarkers molecular tests yet.
OBJECTIVES: To show the pathologiccharacteristics of upper urinary tract tumors with specialemphasis on the peculiarities due to anatomical site andsecondary to endoscopic treatment.METHODS: Bibliographic review and presentation ofour ten-year experience at the “Hospital Ramon y Cajal”Pathology Department in Madrid studying 203urothelial tumors of the ureter, renal pelvis and calyces.RESULTS: More than 95% of the upper urinary tracttumors in adults have their origin in the urothelium, andmost of them are either malignant or potentially malignant.Their biological behaviour is similar to bladder tumors,although they have some peculiarities due to their anatomicallocalization. Tumors at the renal calyces may be moreaggressive due to their particular way of intrarenaldissemination.CONCLUSIONS: Anatomical localization and properpathological study are the determinant factors toestablish prognosis and possible adjuvant treatment forupper urinary tract tumors after endoscopic resection.
Low grade and stage upper urinary tract tumors may be treated endoscopically by antegrade or retrograde approach. The approach mainly depends on tumor size and site. Generally, retrograde ureteroscopy is used for small size tumors of the ureter and kidney, whereas the antegrade approach is indicated for bigger tumors in the upper ureter or kidney, or those tumors which cannot be adequately managed in a retrograde manner because of their site (lower calyx) or previous urinary diversion. This article presents the techniques of retrograde ureteroscopy and percutaneous antegrade resection, as well as the equipment needed for adequate endoscopic treatment of the upper urinary tract urothelial tumors.
We develop the diagnostic methodologyto select patients with upper urinary tract urothelialtumors who are candidates for percutaneous endoscopictreatment.This treatment is indicated for low grade and stagelesions in the pyelocalyceal system (> 3 cm), lumbar ureter(> 1-2 cm) and for failures of the retrograde approach.In this protocol, we emphasize the performance ofintraoperative biopsy and pyelocalyceal mapping, aswell as the need of a second look to rule out residualtumor.
OBJECTIVES: Upper urinary tract tumorsaccount for 2-4% of urinary tract tumors and 5% ofurothelial tumors. The pyelocalyceal system (75%) anddistal third of the ureter are the most frequent localizations.Various series confirm a relatively benign course of lowgrade and stage tumors, with survivals around 80-66%for pyelic and ureteral tumors respectively. Tumor grade and stage are the most important factors for patientoutcome, more than type of treatment undertaken (classicradical nephroureterectomy vs. conservative surgery).With the development of endoscopic techniques andthe use of new equipment, both ureteroscopy andnephroscopy have gained a relevant role in the studyand treatment of upper urinary tract tumors in selectedgroups of patients.METHODS/RESULTS: We describe data from theliterature about the nature of urothelial tumors, diagnosticmethods, and indications of conservative management.We performed a retrospective chart review of patientsundergoing endoscopical procedures (ureteroscopy andnephroscopy) to rule out upper urinary tract urothelialtumors at the Hospital Ramon y Cajal in Madrid betweenJanuary 1996 and June 2003. We do a comparativeanalysis between our results and those referred in theliterature and a previous study in our department publishedin 1996.CONCLUSIONS: Both ureteroscopy and nephroscopyare effective and safe procedures in the diagnosis andtreatment of suspicious-looking lesions of the urinarytract, with a low complication rate. Main indicationsare small, papillary, and low grade tumors, confinedwithin the mucosa, with negative urinary cytology, inpatients with associated comorbidity, solitary kidney orbilateral tumors.
OBJECTIVES: The incidence of transitionalcell carcinoma of the renal pelvis and ureter is low, andthe standard treatment is nephroureterectomy with abladder cuff. However, there are special circumstances,from both patient and tumor characteristics, which aresubsidiary of a minimally invasive endoscopic treatment,such as percutaneous resection.Very satisfactory results have been obtained with thistechnique, which has been performed since 1985.Nevertheless, theoretically there exists a potential risk ofdisseminating tumor cells when performing this technique.The objective of this article is to review our experience,and that of other groups, performing percutaneousresection of upper urinary tract tumors, and to determinethe incidence tumor dissemination.METHODS: We performed a bibliographic search inMedline (PubMed) and reviewed the articles aboutupper urinary tract tumors treated by percutaneousresection. We also evaluated the incidence of tumordissemination related to surgery.RESULTS: Published data show a very low incidence oftumor dissemination after endoscopic resection by apercutaneous approach. Theoretically tumor disseminationcan be the result of dissemination to the blood orlymphatic circulation, or the implant of tumor cells in thecontiguous or distant urothelial mucosa, or propagationof these tumor cells to the retroperitoneal space or thenephrostomy track. CONCLUSIONS: Percutaneous endoscopic resectionof upper urinary tract urothelial tumors is a safe andeffective technique that enables a minimally invasiveand nephron sparing treatment.If some precautions are taken, this surgical techniquedoes not involve a significant risk for tumor cell dissemination.
Since Pérez-Castro and Martínez-Piñeiro initiated diagnostic and therapeutic ureteroscopy this technique has gained a place in the management of upper urinary tract tumors.Improvement of the equipment (rigid and flexible), better diagnosis and knowledge of outcomes and allows to treat a group of patients with transitional cell carcinoma of the ureter and pelvis by the conservative retrograde technique.In this article, we present an overview of indications and management of the Upper urinary tract tumor by ureteroscopy.
Conservative treatment of the transitionalcell carcinoma of the upper urinary tract by ureteroscopyis currently a therapeutic approach which is acceptedby urologists.Recurrences are frequent (0-65%), as well as in bladdertumors; the longer the follow-up of the series the higherthe recurrence. Multifocality, history of bladder tumor orrenal pelvis localization are prognostic factors for recurrence.The treatment of recurrences may be conservative orradical depending on grade, stage and multifocality.
OBJECTIVES: To evaluate the role of ureteroscopy (rigid and flexible) in the follow-up protocol for transitional cell tumors treated conservatively in our department by endourological procedures, and to review the articles on this topic available in the literature. METHODS: From February 1997 to June 2003,10 patients (12 renal units) with upper urinary tract urothelial tumor treated conservatively by endourological procedures were followed by cytology, cystoscopy, retrograde ureteropyelography, and ureteroscopy (rigid and flexible), quarterly during the first year, semi-annually during the second year, and yearly thereafter in order to detect tumor recurrence. RESULTS: Mean follow-up was 31.9 months (R 14-65). Two patients died: one because of a previous metacronous bladder tumor and the other after distant progression. One patient was lost to follow-up. A total of 42 ureteroscopies were performed (31 flexible and 11 rigid). Flexible ureteroscopy was performed in 6 patients and rigid ureteroscopy in three; neither was feasible in one patient so that follow-up was done by cytology, cystoscopy and urography. Tumor recurrence was detected in 2 patients but ureteroscopy did not inform about tumor stage. Flexible ureteroscopy failed in another patient in which rigid ureteroscopy was feasible. Although this latter was technically easier to perform, procedure discomfort was worse. CONCLUSIONS: The follow-up of transitional cell tumors of the upper urinary tract should be very strict because of the high risk of tumor relapse. Ureteroscopy, mainly flexible, is standing out as the most effective procedure to watch these tumors.
OBJECTIVES: Upper urinary tract tumorsare a rare condition. We review our experience in thediagnosis of upper urinary tract tumors and their recurrences, emphasizing the management of recurrences. METHODS: From January 1980 to June 2002 139endourological procedures were carried out in 94 patients with the working diagnosis of upper urinarytract tumor.RESULTS: The overall treatment failure rate was 18.7with ureteroscopy being the least efficient technique.CONCLUSIONS: In our experience, there is an indication for conservative endourological treatment insuperficial low grade G1-2 tumors smaller than 2 cm.
OBJECTIVES: We present our 11 yearexperience with 15 laparoscopic nephroureterectomyprocedures for upper urinary tract urothelial tumor.METHODS/RESULTS: The tumor site was pyelocalyceal in9 cases, ureteral in 4, and multifocal in one. All caseswere urothelial tumors grade II or III; stage was Ta-T1 in9 cases,T2 in three, T3 in two, and T4 in one.Transperitoneal approach was performed in 14 cases,whereas only one retroperitoneal. Hand assisted laparoscopywas performed in five cases. Seven specimens wereextracted after morcellation without any recorded tumorseeding attributable to this manoeuvre.We recorded one case of sudden death due to pulmonaryembolism 48 hours after the procedure, one case ofintestinal obstruction secondary to an ileal loop herniathrough the parietal orifice of one of the trocars, andone case of unstable angina pectoris. Two patients diedbecause of disease progression, one of them after bladderrecurrence.CONCLUSIONS: We think that hand assisted laparoscopyis a good indication for nephroureterectomy for upperurinary tract urothelial tumor.We propose a new procedure to avoid possible tumorcell spilling at the time of ureterectomy, which simplifiesthe operation very much at the same time.
OBJECTIVES: To perform a systematicreview on the expression and prognostic value of the p53 oncoprotein and Ki 67 proliferation marker in transitional cell carcinoma of the upper urinary tract.METHODS: A systematic review of cohort, prospectiveand retrospective studies from 1/1/1990 to11/24/2003 has been undertaken, performing abibliographic search both manual and electronic in themain databases. 632 works were found using the keywords“ureter, renal and pelvis tumor”, and 14 with “ureter,renal and pelvis tumor, and immunohistochemical”.RESULTS: 509 patients were studied; they were selectedfrom 7 retrospective studies about the usefulness of p53and Ki 67 in transitional cell carcinoma of the upper urinarytract published between 1995 and 2002 (threeSpanish studies, three Japanese and one NorthAmerican). Each one analyzes between 37 and 121cases, with a mean age of 66.8 years (range 63.0-74.7) and a predominance of male sex in 100% of thestudies. The pyelocalyceal site was the most frequent inthese series. Treatment is another issue taken intoconsideration in this papers, being nephroureterectomythe most frequently found. The p53 and Ki 67 percentageexpression in various studies has been related to clinicaland histological factors. Only 5 studies performed amultivariate analysis using Cox regression models.Three of them deal with Ki 67 and two with p53,although one of the p53 studies associates cyclin Edeterminations. Only two out of three studies about Ki67 were considered evaluable, because multivariateanalysis was not performed in the other one.CONCLUSIONS: 1) There are a few studies and they are very heterogeneous in terms of design, selection criteria, follow-up, and use of prognostic variables. 2) Theanalyzed studies establish that oncoprotein p53 andproliferation marker Ki 67 are prognostic factors fortransitional cell carcinoma of the upper urinary tract,and 3) To perform a meta-analysis was deemed notindicated because of the heterogeneicity of the studiesfound in our search.
OBJECTIVES: To study the state-of-the-art and potential applications of PET for urothelial tumors. METHODS: We introduce the basics of the PET technique and perform a systematic bibliographic review on the use of PET in these tumors. RESULTS: Clinical experience on PET in urothelial tumors is still limited. The main interest of this technique is detection and localization of lymph nodes and distant metastases. CONCLUSIONS: PET may be useful in staging, re-staging and for recurrences of upper urinary tract tumors, allowing avoiding more invasive diagnostic methods and more aggressive therapies; nevertheless more extensive clinical studies are necessary to support this indications.
OBJETIVE: We expose the arguments supporting radical and conservative surgery based on international bibliography and our own experience, with special citation of endoscopic surgery (percutane-ous and ureteroscopy). METHODS/RESULTS: We evaluate the criteria of multi-focality, cell seeding and number of recurrences sepa-rately, as well as the diagnostic difficulties establishing tumor grade and stage, by connecting the various tech-niques and their results.CONCLUSION: the choice between radical or conser-vative surgery for upper urinary tract TCC is conditioned by precise indications and the surgical technique cho-sen does not influence the final outcome of lowgrade/stage tumors.