0022-5347 /92/1482-0275$03.00 /0 Vol. 148, 275-277, August 1992
THE JOURNAL OF UROLOGY
Printed in U.S.A.
Copyright© 1992 by AMERICAN UROLOGICAL ASSOCIATION, INC.
URETEROSCOPIC TREATMENT OF UROTHELIAL CARCINOMA OF THE URETER AND RENAL PELVIS H, BARTON GROSSMAN,* STEPHEN L. SCHWARTZ AND JOHN W. KONNAK From the Section of Urology, Department of Surgery, University of Michigan Medical Center, Ann Arbor, Michigan
ABSTRACT
From June 1987 to September 1990, 12 patients were evaluated for ureteroscopic treatment of upper urinary tract neoplasms. Four patients were not considered candidates because of technical reasons. Each of these patients was treated by nephroureterectomy. A total of 8 patients underwent ureteroscopic therapy with a neodymium:YAG laser 1 to 11 times (median 2) for the treatment of 3 proximal ureteral or pelvic lesions and 7 distal ureteral lesions. One patient had local progression and 1 failed subsequent laser treatment for technical reasons. Both of these individuals were salvaged with an operation. Three patients were without recurrence for 15, 21 and 36 months. Two patients had multiple superficial local recurrences and continue to be managed endoscopically without local progression for 12 and 32 months. One patient was asymptomatic 16 months after treatment but he has refused followup evaluation. Of 7 patients with ureteral tumors who were believed to be candidates for endoscopic therapy 5 have had the tumors controlled by this method of treatment. Only 1 renal pelvic tumor has been successfully treated. Most patients with tumors in the renal pelvis are not candidates for rigid endoscopic therapy because of the tumor size and location. In selected individuals ureteroscopic laser treatment of upper urinary tract transitional cell carcinoma can achieve local control with renal preservation. KEY WORDS:
endoscopy, ureteral neoplasms, kidney neoplasms, kidney pelvis
Urothelial cancer of the upper urinary collecting system is traditionally treated by nephroureterectomy with excision of a cuff of bladder. Successful attempts at renal preservation in patients who have a solitary kidney or decreased renal function has led to the extension of this method of therapy to individuals with normal contralateral kidneys. Renal preservation is most commonly accomplished by segmental ureteral resection and has yielded survival results comparable to those obtained with nephroureterectomy. 1 Excision of renal pelvic tumors has also been described through a percutaneous approach. 2 Modern ureteroscopic instrumentation has permitted improved accuracy in the diagnosis and staging of upper tract tumors, and offers another approach for the treatment of selected upper tract neoplasms. We have found laser therapy of selected upper tract tumors to be effective and well tolerated. We describe our experience with transureteral endoscopic laser therapy of upper urinary tract transitional cell carcinoma. MATERIALS AND METHODS
From June 1987 to September 1990, 12 patients were evaluated as potential candidates for ureteroscopic treatment of upper urinary tract neoplasms. The patients studied included 8 men and 4 women between 62 and 93 years old. Of the patients 9 had previous diagnoses of transitional cell carcinoma of the bladder and were detected on routine followup protocols, while 2 had previous diagnoses and treatment of upper tract transitional cell carcinoma, and 1 had no history of urothelial carcinoma. Each patient presented with 1 or a combination of signs and symptoms, including hematuria, upper tract filling defects or obstruction, endoscopic visualization of tumor and/ or positive urine cytology studies. Indications for renal preserving treatment included 1 or more of the following conditions: solitary kidney, poorly functioning contralateral renal unit, renal insufficiency, advanced patient age, concomitant prohibAccepted for publication December 2, 1991. * Requests for reprints: 1500 E. Medical Center Drive, Ann Arbor, Michigan 48109-0330.
iting medical diseases, patient refusal to undergo an open operation and superficial disease with a normal contralateral kidney. Each patient underwent rigid ureteroscopy with a Wolf 9.5F or 1 l.5F ureteroscope while under general or regional anesthesia. Most procedures (6 of 12) used the 9.5F ureteroscope without ureteral dilation. Dilation of the distal ureter with ureteral bougies was performed in 3 patients: 1 case was unsuccessful and 2 were dilated to lOF and 14F. In the remaining 3 patients the ureteral orifice was resected or incised. Biopsy to document the presence of cancer was performed when a previous tissue diagnosis had not been obtained. Rigid ureteroscopy was preferred because of the superior clarity of the system. Care was taken to avoid violation of the ureter or renal pelvis to prevent possible tumor spillage and implantation. A ureteral catheter was often passed through the ureteroscope to allow for continuous decompression of the upper system while surveying the upper tract. The neodymium:YAG laser was used with a 600 µ. quartz fiber passed through the working channel of the ureteroscope. This instrument necessitated tangential or oblique treatment of most ureteral and renal pelvic neoplasms. Tumors were lased with 30 watts of continuous power until evidence of thermal coagulation was observed. One patient required several treatments to eradicate completely a sizable renal pelvis tumor. A Double-Jt stent was placed in instances of major tumor treatment and this was removed several days later. Patients were followed at 3-month intervals with repeat ureteroscopy or retrograde pyelography and every 6 to 12 months with excretory urography. Followup was obtained on all patients. RESULTS
Of the 12 patients evaluated for ureteroscopic therapy of urothelial neoplasia of the upper urinary tract 4 were not candidates for this treatment because of technical reasons. All 4 patients were treated with nephroureterectomy: 2 had upper
t Medical Engineering Corp., New York, New York. 275
276
GROSSMAN, SCHWARTZ AND KONNAK
Laser treatment summary Pt. No.-Age
Indication
Location
Pathology
Times Treated
1-74
Elective
Lt. distal ureter
Grade 2 with multifocal CIS
2-93
Solitary kidney
Rt. distal ureter
Grades 2-3 infiltrative
3-77 4-62
Elective Contralat. hypoplastic kidney
Lt. distal ureter Lt. distal ureter
Grade 2 Grade 1
5-78
Age, illness
Rt. distal ureter
Papillary
6-84
Solitary kidney
Lt. renal pelvis
Grades 1-2
3
7--72 8-67
Elective Elective
Lt. proximal and distal ureter Rt. proximal and distal ureter
Grade 1 Grade 1
1 3
2
2 11
Outcome 1 recurrence, could not negotiate ureter ureteroscopically, nephroureterectomy, then lost to followup Rt. distal segmental ureterectomy with cutaneous ureterostomy, died 4 mos. later of congestive heart failure (tumor-free) No recurrence for 36 mos. Multiple recurrences treated with laser without progression 2 recurrences treated successfully, without recurrence for 21 mos. After primary treated no recurrences for 15 mos. Well, refused followup Recurrences at 4 and 12 mos. treated with laser
FIG. 1. Transitional cell carcinoma in left renal pelvis of patient 6 before (A) and 6 months after (B) laser therapy. After 3 treatments tumor was ablated and did not recur for 15 months.
pole tumors that could not be visualized adequately by ureteroscopy and 2 had tumors that were judged to be too extensive for ureteroscopic laser therapy. The remaining 8 patients underwent ureteroscopic laser therapy of upper tract urothelial tumors (see table). Of these patients 2 ultimately required more definitive therapy. Patient 1 had 1 laser treatment but subsequently failed an attempt at ureteroscopic therapy for technical reasons and he underwent nephroureterectomy. Patient 2 underwent 2 ureteroscopic laser treatments but the tumor progressed locally. He was treated with distal ureterectomy and cutaneous ureterostomy. Of the 6 patients who were treated solely by ureteroscopic laser therapy 4 were or are currently being treated for noninvasive bladder cancer. All upper tract tumors were low grade and superficial. Patient 6 required 3 laser sessions to treat the sizable renal pelvis tumor adequately (fig. 1). She was free of tumor recurrence 15 months after the last treatment. Three patients were rendered tumor-free for 15 to 36 months. Two patients continue to have active disease and continue to be managed endoscopically without evidence of tumor progression. One patient was asymptomatic 16 months after treatment but has refused followup evaluation. There have been no serious complications and no ureteral strictures.
DISCUSSION
Nephroureterectomy with excision of a cuff of bladder is the standard therapy for localized urothelial carcinoma of the upper urinary tract in a healthy individual with otherwise normal
bilateral renal function. This is particularly true with neoplasms of high stage and/or grade. Segmental resection of the ureter is the most common alternative to nephroureterectomy and has the advantage of preserving renal function. When these 2 approaches are compared it is apparent that prognosis is more dependent on the stage and grade of the tumor than on the method of therapy. 3 The increasing use of endoscopic approaches to the upper urinary tract has provided alternative means to treat urothelial neoplasms of the renal pelvis and ureter. A variety of techniques have been used with differing methods of access (percutaneous and transureteral) and treatment (resection, diathermy and laser). The percutaneous route has been used effectively by several groups. 2• 4- 7 The advantage of the percutaneous approach is the relatively easy access to all parts of the upper urinary tract and the ability to use a variety of instruments through a large treatment port. Although a theoretical disadvantage is the possibility of tumor spill and seeding of neoplasm along the nephrostomy tract, in practice this does not appear to be a problem, which may reflect good technique by experienced surgeons as well as excellent patient selection. The data from cystotomies for the treatment of bladder cancer suggest that high grade tumors would be more likely to implant and cause subsequent satellite tumors. 8 Ureteroscopic approaches have also been applied to the treatment of upper tract tumors. 9 - 12 Rigid ureteroscopy was the preferred method of endoscopic access. Although these investigators used a variety of therapeutic approaches, the neodymium:YAG laser was used most frequently. While many tumors
UROTHELIAL CANCER OF URETER AND RENAL PELVIS ,--
Nephrouretcrectorny
3.
Segmental resection
2
-
3
4.
-
4
-
-
5.
-
5 6
6.
7
\ o
-
8
= laser treatment I 7.
42
8.
FIG. 2. Summary of patients with upper tract urothelial carcinoma
9.
()
6
12
18
24
30
36
Months treated by laser (o). Patient 7 is asymptomatic but has refused followup evaluation.
so treated did not recur with short to medium followup, Huffman et al reported that repeated fulguration (5 recurrences in 1 patient) of superficial tumors was possible. 9 We preferred the transureteral approach because of the theoretical risks of wound implantation. Similar to the previously reported experience with this technique, we use rigid ureteroscopy and neodymium:YAG laser therapy. However, we rarely dilate the upper tract and prefer to use a 9.5F rigid ureteroscope passed under direct vision. We believe that this is less likely to cause alterations in the ureteral mucosa and that it provides better surveillance of the ureter. This technique does have limitations, and a complete survey of the entire renal pelvis and calices is virtually impossible with this instrument. A complete visual survey of the renal pelvis can be more readily accomplished with flexible ureteroscopy. Almost all treatments have been on an outpatient basis and most patients have been treated on more than 1 occasion. Only when extensive laser treatment has been performed is a ureteral stent inserted. There have been no complications related to the ureteroscopy or laser treatment in these patients. A summary of the data is presented in figure 2. Of the patients considered possible candidates for endoscopic treatment only 66% subsequently underwent ureteroscopy and neodymium:YAG laser therapy. Two patients ultimately failed this approach and required additional surgical therapy resulting in an overall definitive treatment rate of 50%. Of these 6 patients 3 were free of disease 15 to 36 months following therapy, 2 had had multiple superficial recurrences (2 and 10 times) in the distal ureter, and continue with surveillance and repeat laser therapy, and 1 has refused further evaluation but was asymptomatic 16 months after treatment. We believe that ureteroscopic laser therapy is an appropriate treatment for selected patients with low grade superficial urothelial tumors of the upper tract. Of 7 patients with ureteral tumors who were believed to be candidates for endoscopic therapy 5 have been controlled by this technique. Only 1 renal pelvic tumor has been successfully treated. Most patients with tumors in the renal pelvis are not candidates for rigid endoscopic therapy because of the tumor size and location. In the appropriate patient this treatment is analogous to conventional endoscopic treatment of the more common superficial, noninvasive bladder cancer. Close followup is required just as with the treatment of superficial bladder cancer.
10.
11.
12.
277
of renal pelvic transitional celi carcinoma. Brit. J. Urol., 58: 245, 1986. Bloom, N. A., Vidone, R. A. and Lytton, B.: Primary carcinoma of the ureter: a report of 102 new cases. J. Urol., 103: 590, 1970. Orihuela, E. and Smith, A. D.: Percutaneous treatment of transitional cell carcinoma of the upper urinary tract. Urol. Clin. N. Amer., 15: 425, 1988. Tasca, A. and Zattoni, F.: The case for a percutaneous approach to transitional cell carcinoma of the renal pelvis. J. Urol., 143: 902, 1990. Guz, B., Streem, S. B., Novick, A. C., Montie, J.E., Zelch, M. G., Geisinger, M. A. and Risius, B.: Role of percutaneous nephrostomy in patients with upper urinary tract transitional cell carcinoma. Urology, 37: 331, 1991. Schmeller, N. T. and Hofstetter, A.G.: Laser treatment ofureteral tumors. J. Urol., 141: 840, 1989. van der Werf-Messing, B.: Carcinoma of the bladder treated by suprapubic radium implants. The value of additional external irradiation. Eur. J. Cancer, 5: 277, 1969. Huffman, J. L., Bagley, D. H., Lyon, E. S., Morse, M. J., Herr, H. W. and Whitmore, W. F., Jr.: Endoscopic diagnosis and treatment of upper-tract urothelial tumors. A preliminary report. Cancer, 55: 1422, 1985. Schilling, A., Bowering, R. and Keiditsch, E.: Use of the neodymium-YAG laser in the treatment of ureteral tumors and urethral condylomata acuminata. Clinical experience. Eur. Urol., suppl. 1, 12: 30, 1986. Blute, M. L., Segura, J. W., Patterson, D. E., Benson, R. C., Jr. and Zincke, H.: Impact of endourology on diagnosis and management of upper urinary tract urothelial cancer. J. Urol., 141: 1298, 1989. Martinez-Pineiro, J. A.: Re: impact of endourology on diagnosis and management of upper urinary tract urothe!ial cancer. Letter to the Editor. J. Urol., 144: 750, 1990.
EDITORIAL COMMENT The authors illustrate the advantages and also the limitations in the treatment of urothelial neoplasms by ureteroscopy. Of the 12 patients considered for such treatment 6 either had immediate or eventual open surgical treatment of the neoplasm. The others, however, underscore the fact that endourology can be important not only for the diagnosis but for the treatment of these lesions. Careful patient selection is important and one must be aware of the limitations necessitated by the armamentarium, particularly in the staging of these tumors. For obvious reasons biopsies revealed superficial tissue only. The neodymium: YAG laser would seem to be clearly advantageous in this situation in that one can depend on a certain depth of penetration. However, as the authors note, the fact that the laser must of necessity be used at an angle with the rigid instrument may obviate this potential advantage. I certainly concur that the rod lens optics available in rigid ureteroscopes makes for superior visualization but the availability of small, flexible ureteroscopes, particularly an 8.5F ureteroscope, enables the urologist to inspect directly areas of the collecting system and makes it possible to access some cases that are inaccessible using the rigid units. With such flexible instruments management of some upper tract lesions should be possible. Successful endoscopic management of an apparently solitary neoplasm in the ureter, or possibly the renal pelvis, should not blind the operator to the frequent multicentricity of such urothelial neoplasms. Careful followup of these patients is absolutely essential, at a minimum by excretory urography or retrograde pyelography and by repeated ureteroscopy if necessary. Given a choice, I agree that ureteroscopic management of urothelial neoplasms is probably safer than percutaneous management of these problems. Joseph W. Segura Department of Urology Mayo Clinic Rochester, Minnesota
REPLY BY AUTHORS
REFERENCES 1. Zincke, H. and Neves, R. J.: Feasibility of conservative surgery for
transitional cell cancer of the upper urinary tract. Urol. Clin. N. Amer., 11: 717, 1984. 2. Woodhouse, C.R. J., Kellett, M. J. and Bloom, H.J. G.: Percutaneous renal surgery and local radiotherapy in the management
Doctor Segura has appropriately indicated that careful followup is mandatory because urothelial tumors can be multifocal in space and time. If endoscopic therapy is used we would recommend at least 1 followup ureteroscopic study. We have seen a patient in whom diffuse transitional cell carcinoma was easily documented by ureteroscopy and subsequent nephroureterectomy but who had normal upper tracts by a good quality excretory urogram.
THE JOURNAL OF UROLOGY
Printed in U.S.A.
Copyright© 1992 by AMERICAN UROLOGICAL ASSOCIATION, INC.
URETEROSCOPIC TREATMENT OF UROTHELIAL CARCINOMA OF THE URETER AND RENAL PELVIS H, BARTON GROSSMAN,* STEPHEN L. SCHWARTZ AND JOHN W. KONNAK From the Section of Urology, Department of Surgery, University of Michigan Medical Center, Ann Arbor, Michigan
ABSTRACT
From June 1987 to September 1990, 12 patients were evaluated for ureteroscopic treatment of upper urinary tract neoplasms. Four patients were not considered candidates because of technical reasons. Each of these patients was treated by nephroureterectomy. A total of 8 patients underwent ureteroscopic therapy with a neodymium:YAG laser 1 to 11 times (median 2) for the treatment of 3 proximal ureteral or pelvic lesions and 7 distal ureteral lesions. One patient had local progression and 1 failed subsequent laser treatment for technical reasons. Both of these individuals were salvaged with an operation. Three patients were without recurrence for 15, 21 and 36 months. Two patients had multiple superficial local recurrences and continue to be managed endoscopically without local progression for 12 and 32 months. One patient was asymptomatic 16 months after treatment but he has refused followup evaluation. Of 7 patients with ureteral tumors who were believed to be candidates for endoscopic therapy 5 have had the tumors controlled by this method of treatment. Only 1 renal pelvic tumor has been successfully treated. Most patients with tumors in the renal pelvis are not candidates for rigid endoscopic therapy because of the tumor size and location. In selected individuals ureteroscopic laser treatment of upper urinary tract transitional cell carcinoma can achieve local control with renal preservation. KEY WORDS:
endoscopy, ureteral neoplasms, kidney neoplasms, kidney pelvis
Urothelial cancer of the upper urinary collecting system is traditionally treated by nephroureterectomy with excision of a cuff of bladder. Successful attempts at renal preservation in patients who have a solitary kidney or decreased renal function has led to the extension of this method of therapy to individuals with normal contralateral kidneys. Renal preservation is most commonly accomplished by segmental ureteral resection and has yielded survival results comparable to those obtained with nephroureterectomy. 1 Excision of renal pelvic tumors has also been described through a percutaneous approach. 2 Modern ureteroscopic instrumentation has permitted improved accuracy in the diagnosis and staging of upper tract tumors, and offers another approach for the treatment of selected upper tract neoplasms. We have found laser therapy of selected upper tract tumors to be effective and well tolerated. We describe our experience with transureteral endoscopic laser therapy of upper urinary tract transitional cell carcinoma. MATERIALS AND METHODS
From June 1987 to September 1990, 12 patients were evaluated as potential candidates for ureteroscopic treatment of upper urinary tract neoplasms. The patients studied included 8 men and 4 women between 62 and 93 years old. Of the patients 9 had previous diagnoses of transitional cell carcinoma of the bladder and were detected on routine followup protocols, while 2 had previous diagnoses and treatment of upper tract transitional cell carcinoma, and 1 had no history of urothelial carcinoma. Each patient presented with 1 or a combination of signs and symptoms, including hematuria, upper tract filling defects or obstruction, endoscopic visualization of tumor and/ or positive urine cytology studies. Indications for renal preserving treatment included 1 or more of the following conditions: solitary kidney, poorly functioning contralateral renal unit, renal insufficiency, advanced patient age, concomitant prohibAccepted for publication December 2, 1991. * Requests for reprints: 1500 E. Medical Center Drive, Ann Arbor, Michigan 48109-0330.
iting medical diseases, patient refusal to undergo an open operation and superficial disease with a normal contralateral kidney. Each patient underwent rigid ureteroscopy with a Wolf 9.5F or 1 l.5F ureteroscope while under general or regional anesthesia. Most procedures (6 of 12) used the 9.5F ureteroscope without ureteral dilation. Dilation of the distal ureter with ureteral bougies was performed in 3 patients: 1 case was unsuccessful and 2 were dilated to lOF and 14F. In the remaining 3 patients the ureteral orifice was resected or incised. Biopsy to document the presence of cancer was performed when a previous tissue diagnosis had not been obtained. Rigid ureteroscopy was preferred because of the superior clarity of the system. Care was taken to avoid violation of the ureter or renal pelvis to prevent possible tumor spillage and implantation. A ureteral catheter was often passed through the ureteroscope to allow for continuous decompression of the upper system while surveying the upper tract. The neodymium:YAG laser was used with a 600 µ. quartz fiber passed through the working channel of the ureteroscope. This instrument necessitated tangential or oblique treatment of most ureteral and renal pelvic neoplasms. Tumors were lased with 30 watts of continuous power until evidence of thermal coagulation was observed. One patient required several treatments to eradicate completely a sizable renal pelvis tumor. A Double-Jt stent was placed in instances of major tumor treatment and this was removed several days later. Patients were followed at 3-month intervals with repeat ureteroscopy or retrograde pyelography and every 6 to 12 months with excretory urography. Followup was obtained on all patients. RESULTS
Of the 12 patients evaluated for ureteroscopic therapy of urothelial neoplasia of the upper urinary tract 4 were not candidates for this treatment because of technical reasons. All 4 patients were treated with nephroureterectomy: 2 had upper
t Medical Engineering Corp., New York, New York. 275
276
GROSSMAN, SCHWARTZ AND KONNAK
Laser treatment summary Pt. No.-Age
Indication
Location
Pathology
Times Treated
1-74
Elective
Lt. distal ureter
Grade 2 with multifocal CIS
2-93
Solitary kidney
Rt. distal ureter
Grades 2-3 infiltrative
3-77 4-62
Elective Contralat. hypoplastic kidney
Lt. distal ureter Lt. distal ureter
Grade 2 Grade 1
5-78
Age, illness
Rt. distal ureter
Papillary
6-84
Solitary kidney
Lt. renal pelvis
Grades 1-2
3
7--72 8-67
Elective Elective
Lt. proximal and distal ureter Rt. proximal and distal ureter
Grade 1 Grade 1
1 3
2
2 11
Outcome 1 recurrence, could not negotiate ureter ureteroscopically, nephroureterectomy, then lost to followup Rt. distal segmental ureterectomy with cutaneous ureterostomy, died 4 mos. later of congestive heart failure (tumor-free) No recurrence for 36 mos. Multiple recurrences treated with laser without progression 2 recurrences treated successfully, without recurrence for 21 mos. After primary treated no recurrences for 15 mos. Well, refused followup Recurrences at 4 and 12 mos. treated with laser
FIG. 1. Transitional cell carcinoma in left renal pelvis of patient 6 before (A) and 6 months after (B) laser therapy. After 3 treatments tumor was ablated and did not recur for 15 months.
pole tumors that could not be visualized adequately by ureteroscopy and 2 had tumors that were judged to be too extensive for ureteroscopic laser therapy. The remaining 8 patients underwent ureteroscopic laser therapy of upper tract urothelial tumors (see table). Of these patients 2 ultimately required more definitive therapy. Patient 1 had 1 laser treatment but subsequently failed an attempt at ureteroscopic therapy for technical reasons and he underwent nephroureterectomy. Patient 2 underwent 2 ureteroscopic laser treatments but the tumor progressed locally. He was treated with distal ureterectomy and cutaneous ureterostomy. Of the 6 patients who were treated solely by ureteroscopic laser therapy 4 were or are currently being treated for noninvasive bladder cancer. All upper tract tumors were low grade and superficial. Patient 6 required 3 laser sessions to treat the sizable renal pelvis tumor adequately (fig. 1). She was free of tumor recurrence 15 months after the last treatment. Three patients were rendered tumor-free for 15 to 36 months. Two patients continue to have active disease and continue to be managed endoscopically without evidence of tumor progression. One patient was asymptomatic 16 months after treatment but has refused followup evaluation. There have been no serious complications and no ureteral strictures.
DISCUSSION
Nephroureterectomy with excision of a cuff of bladder is the standard therapy for localized urothelial carcinoma of the upper urinary tract in a healthy individual with otherwise normal
bilateral renal function. This is particularly true with neoplasms of high stage and/or grade. Segmental resection of the ureter is the most common alternative to nephroureterectomy and has the advantage of preserving renal function. When these 2 approaches are compared it is apparent that prognosis is more dependent on the stage and grade of the tumor than on the method of therapy. 3 The increasing use of endoscopic approaches to the upper urinary tract has provided alternative means to treat urothelial neoplasms of the renal pelvis and ureter. A variety of techniques have been used with differing methods of access (percutaneous and transureteral) and treatment (resection, diathermy and laser). The percutaneous route has been used effectively by several groups. 2• 4- 7 The advantage of the percutaneous approach is the relatively easy access to all parts of the upper urinary tract and the ability to use a variety of instruments through a large treatment port. Although a theoretical disadvantage is the possibility of tumor spill and seeding of neoplasm along the nephrostomy tract, in practice this does not appear to be a problem, which may reflect good technique by experienced surgeons as well as excellent patient selection. The data from cystotomies for the treatment of bladder cancer suggest that high grade tumors would be more likely to implant and cause subsequent satellite tumors. 8 Ureteroscopic approaches have also been applied to the treatment of upper tract tumors. 9 - 12 Rigid ureteroscopy was the preferred method of endoscopic access. Although these investigators used a variety of therapeutic approaches, the neodymium:YAG laser was used most frequently. While many tumors
UROTHELIAL CANCER OF URETER AND RENAL PELVIS ,--
Nephrouretcrectorny
3.
Segmental resection
2
-
3
4.
-
4
-
-
5.
-
5 6
6.
7
\ o
-
8
= laser treatment I 7.
42
8.
FIG. 2. Summary of patients with upper tract urothelial carcinoma
9.
()
6
12
18
24
30
36
Months treated by laser (o). Patient 7 is asymptomatic but has refused followup evaluation.
so treated did not recur with short to medium followup, Huffman et al reported that repeated fulguration (5 recurrences in 1 patient) of superficial tumors was possible. 9 We preferred the transureteral approach because of the theoretical risks of wound implantation. Similar to the previously reported experience with this technique, we use rigid ureteroscopy and neodymium:YAG laser therapy. However, we rarely dilate the upper tract and prefer to use a 9.5F rigid ureteroscope passed under direct vision. We believe that this is less likely to cause alterations in the ureteral mucosa and that it provides better surveillance of the ureter. This technique does have limitations, and a complete survey of the entire renal pelvis and calices is virtually impossible with this instrument. A complete visual survey of the renal pelvis can be more readily accomplished with flexible ureteroscopy. Almost all treatments have been on an outpatient basis and most patients have been treated on more than 1 occasion. Only when extensive laser treatment has been performed is a ureteral stent inserted. There have been no complications related to the ureteroscopy or laser treatment in these patients. A summary of the data is presented in figure 2. Of the patients considered possible candidates for endoscopic treatment only 66% subsequently underwent ureteroscopy and neodymium:YAG laser therapy. Two patients ultimately failed this approach and required additional surgical therapy resulting in an overall definitive treatment rate of 50%. Of these 6 patients 3 were free of disease 15 to 36 months following therapy, 2 had had multiple superficial recurrences (2 and 10 times) in the distal ureter, and continue with surveillance and repeat laser therapy, and 1 has refused further evaluation but was asymptomatic 16 months after treatment. We believe that ureteroscopic laser therapy is an appropriate treatment for selected patients with low grade superficial urothelial tumors of the upper tract. Of 7 patients with ureteral tumors who were believed to be candidates for endoscopic therapy 5 have been controlled by this technique. Only 1 renal pelvic tumor has been successfully treated. Most patients with tumors in the renal pelvis are not candidates for rigid endoscopic therapy because of the tumor size and location. In the appropriate patient this treatment is analogous to conventional endoscopic treatment of the more common superficial, noninvasive bladder cancer. Close followup is required just as with the treatment of superficial bladder cancer.
10.
11.
12.
277
of renal pelvic transitional celi carcinoma. Brit. J. Urol., 58: 245, 1986. Bloom, N. A., Vidone, R. A. and Lytton, B.: Primary carcinoma of the ureter: a report of 102 new cases. J. Urol., 103: 590, 1970. Orihuela, E. and Smith, A. D.: Percutaneous treatment of transitional cell carcinoma of the upper urinary tract. Urol. Clin. N. Amer., 15: 425, 1988. Tasca, A. and Zattoni, F.: The case for a percutaneous approach to transitional cell carcinoma of the renal pelvis. J. Urol., 143: 902, 1990. Guz, B., Streem, S. B., Novick, A. C., Montie, J.E., Zelch, M. G., Geisinger, M. A. and Risius, B.: Role of percutaneous nephrostomy in patients with upper urinary tract transitional cell carcinoma. Urology, 37: 331, 1991. Schmeller, N. T. and Hofstetter, A.G.: Laser treatment ofureteral tumors. J. Urol., 141: 840, 1989. van der Werf-Messing, B.: Carcinoma of the bladder treated by suprapubic radium implants. The value of additional external irradiation. Eur. J. Cancer, 5: 277, 1969. Huffman, J. L., Bagley, D. H., Lyon, E. S., Morse, M. J., Herr, H. W. and Whitmore, W. F., Jr.: Endoscopic diagnosis and treatment of upper-tract urothelial tumors. A preliminary report. Cancer, 55: 1422, 1985. Schilling, A., Bowering, R. and Keiditsch, E.: Use of the neodymium-YAG laser in the treatment of ureteral tumors and urethral condylomata acuminata. Clinical experience. Eur. Urol., suppl. 1, 12: 30, 1986. Blute, M. L., Segura, J. W., Patterson, D. E., Benson, R. C., Jr. and Zincke, H.: Impact of endourology on diagnosis and management of upper urinary tract urothelial cancer. J. Urol., 141: 1298, 1989. Martinez-Pineiro, J. A.: Re: impact of endourology on diagnosis and management of upper urinary tract urothe!ial cancer. Letter to the Editor. J. Urol., 144: 750, 1990.
EDITORIAL COMMENT The authors illustrate the advantages and also the limitations in the treatment of urothelial neoplasms by ureteroscopy. Of the 12 patients considered for such treatment 6 either had immediate or eventual open surgical treatment of the neoplasm. The others, however, underscore the fact that endourology can be important not only for the diagnosis but for the treatment of these lesions. Careful patient selection is important and one must be aware of the limitations necessitated by the armamentarium, particularly in the staging of these tumors. For obvious reasons biopsies revealed superficial tissue only. The neodymium: YAG laser would seem to be clearly advantageous in this situation in that one can depend on a certain depth of penetration. However, as the authors note, the fact that the laser must of necessity be used at an angle with the rigid instrument may obviate this potential advantage. I certainly concur that the rod lens optics available in rigid ureteroscopes makes for superior visualization but the availability of small, flexible ureteroscopes, particularly an 8.5F ureteroscope, enables the urologist to inspect directly areas of the collecting system and makes it possible to access some cases that are inaccessible using the rigid units. With such flexible instruments management of some upper tract lesions should be possible. Successful endoscopic management of an apparently solitary neoplasm in the ureter, or possibly the renal pelvis, should not blind the operator to the frequent multicentricity of such urothelial neoplasms. Careful followup of these patients is absolutely essential, at a minimum by excretory urography or retrograde pyelography and by repeated ureteroscopy if necessary. Given a choice, I agree that ureteroscopic management of urothelial neoplasms is probably safer than percutaneous management of these problems. Joseph W. Segura Department of Urology Mayo Clinic Rochester, Minnesota
REPLY BY AUTHORS
REFERENCES 1. Zincke, H. and Neves, R. J.: Feasibility of conservative surgery for
transitional cell cancer of the upper urinary tract. Urol. Clin. N. Amer., 11: 717, 1984. 2. Woodhouse, C.R. J., Kellett, M. J. and Bloom, H.J. G.: Percutaneous renal surgery and local radiotherapy in the management
Doctor Segura has appropriately indicated that careful followup is mandatory because urothelial tumors can be multifocal in space and time. If endoscopic therapy is used we would recommend at least 1 followup ureteroscopic study. We have seen a patient in whom diffuse transitional cell carcinoma was easily documented by ureteroscopy and subsequent nephroureterectomy but who had normal upper tracts by a good quality excretory urogram.
