Conservative Management of Upper Urinary Tract Tumors

Abstract

Purpose: We determined the immediate and long-term results of endoscopic management of upper tract transitional cell in regard to rates of tumor recurrence and preservation of renal function.

Materials and Methods: From January 1990 to July 1999, 61 patients (mean age 66.2 years) underwent endoscopic management of upper tract cell carcinoma. Of the patients 20 (32%) had a solitary kidney. Tumors were resected in a one time procedure by ureteroscopy only in 31.5%, by percutaneous nephroscopy in 29% or both in 8%; multiple treatment was necessary in 31.5% of cases using percutaneous nephroscopy only.

Results: Immediate nephrectomy was done in six cases for high grade (three patients), insufficient local control (two cases) or patient’s choices (one case). There were six cases of benign tumors excluded from survival Kaplan Meier analysis. With a mean follow-up of 39.9 months, the rate of kidney preservation, recurrence free rate, global survival and specific survival rates were, respectively, 81%, 68%, 77%, and 84%.

Conclusions: Nephron sparing percutaneous management of upper tract cell carcinoma is applicable in a significant number of patients with a filling defect of upper urinary tract TCC. In carefully selected patients the results are at least comparable to other forms of management of tumor control and preservation of renal function.

Introduction

Upper urinary tract transitional cell carcinoma is an uncommon tumor. It is widely accepted that nephroureterectomy with removal of a bladder cuff is the standard treatment for non-metastatic disease because of high recurrence rates noted in less extensive surgical operations [1]. However, more recent epidemiological data on upper tract tumors show that in most cases these tumors are low grade and noninvasive with low recurrence and lymph node extension rates partly due to early detection [2], [3]. In these cases, a conservative approach of upper urinary tract TCC may be discussed accordingly to progression risk, patient co-morbidity, particularly regarding renal function and treatment feasibility.

Contemporary attempts at conservative surgery for upper tract transitional cell carcinoma have emerged in the recent years. Nephron sparing approaches include percutaneous nephroscopy and retrograde ureteroscopy with tumor resection or thermal destruction [4], [5], [6]. Retrospective analysis suggest that patients with low grade and low stage tumors benefit from a conservative management without increasing the risk of recurrence and metastasis [7], [8], [9]. We report our clinical experience on the endoscopic management of 61 consecutive patients with a filling defect of the upper urinary tract and no evidence of local invasion who had an endoscopic resection and were followed at our centre. In this study, we analysed rates of kidney conservation, risk of recurrences and progression with a mean follow-up of 39.9 months.