Korean J Urol.  2013 Jul;54(7):426-432.

Endoscopic Management of Upper Urinary Tract Urothelial Carcinoma

• Park BH
• Jeon SS

Abstract

Upper urinary tract urothelial carcinoma (UTUC) is relatively uncommon. Radical nephroureterectomy with an ipsilateral bladder cuff excision has been the gold standard treatment for UTUC. However, recent advances in technology have made possible the increased use of endoscopic management for the treatment of UTUC. The definitive goal of endoscopic management of UTUC is cancer control while maintaining renal function and the integrity of the urinary tract. Endoscopic management includes both the retrograde ureteroscopic and antegrade percutaneous approaches. The endoscopic management of UTUC is a reasonable alternative for patients with renal insufficiency or a solitary functional kidney, bilateral disease, or a significant comorbidity that precludes radical surgery. Select patients with a functional contralateral kidney who have low-grade, low-stage tumors may also be candidates for endoscopic management. The careful selection of patients is the most important point for the successful endoscopic management of UTUC. It is crucial that patients are compliant and motivated, because a lifetime protocol of strict surveillance is necessary. Adjuvant topical therapy with Bacillus Calmette-Guerin or mitomycin C can be used after endoscopic management of UTUC in an attempt to reduce recurrence. In this article, we review current endoscopic techniques, indications for endoscopic treatment, clinical outcomes of endoscopic management, adjuvant topical therapy, and surveillance in patients with UTUC.

Keyword

Adjuvant treatment; Endoscopy; Percutaneous resection; Transitional cell carcinoma; Ureteroscopy

MeSH Terms

Bacillus
Carcinoma, Transitional Cell
Comorbidity
Endoscopy
Humans
Kidney
Mitomycin
Recurrence
Renal Insufficiency
Ureteroscopy
Urinary Bladder
Urinary Tract
Mitomycin

Reference

1. Cho DS, Hong SY, Kim YK, Kim SI, Kim SJ. Prognostic factors in transitional cell carcinoma of the upper urinary tract after radical nephroureterectomy. Korean J Urol. 2011. 52:310–316.

2. Roupret M, Babjuk M, Comperat E, Zigeuner R, Sylvester R, Burger M, et al. European guidelines on upper tract urothelial carcinomas: 2013 update. Eur Urol. 2013. 63:1059–1071.

3. Lughezzani G, Sun M, Perrotte P, Shariat SF, Jeldres C, Budaus L, et al. Gender-related differences in patients with stage I to III upper tract urothelial carcinoma: results from the Surveillance, Epidemiology, and End Results database. Urology. 2010. 75:321–327.

4. Margulis V, Shariat SF, Matin SF, Kamat AM, Zigeuner R, Kikuchi E, et al. Outcomes of radical nephroureterectomy: a series from the Upper Tract Urothelial Carcinoma Collaboration. Cancer. 2009. 115:1224–1233.

5. Cho KS, Cho NH, Choi YD. Pattern of recurrence and the prognostic factors of upper urinary tract transitional cell carcinoma. Korean J Urol. 2006. 47:124–130.

6. Cutress ML, Stewart GD, Wells-Cole S, Phipps S, Thomas BG, Tolley DA. Long-term endoscopic management of upper tract urothelial carcinoma: 20-year single-centre experience. BJU Int. 2012. 110:1608–1617.

7. Adamis S, Varkarakis J. Minimally invasive approach in the management of upper-urinary-tract tumours. Scand J Urol Nephrol. 2011. 45:381–387.

8. Daneshmand S, Quek ML, Huffman JL. Endoscopic management of upper urinary tract transitional cell carcinoma: long-term experience. Cancer. 2003. 98:55–60.

9. Cutress ML, Stewart GD, Zakikhani P, Phipps S, Thomas BG, Tolley DA. Ureteroscopic and percutaneous management of upper tract urothelial carcinoma (UTUC): systematic review. BJU Int. 2012. 110:614–628.

10. Xu AD, Ng CS, Kamat A, Grossman HB, Dinney C, Sandler CM. Significance of upper urinary tract urothelial thickening and filling defect seen on MDCT urography in patients with a history of urothelial neoplasms. AJR Am J Roentgenol. 2010. 195:959–965.

11. Moore K, Khastgir J, Ghei M. Endoscopic management of upper tract urothelial carcinoma. Adv Urol. 2009. 620604.

12. Raman JD, Scherr DS. Management of patients with upper urinary tract transitional cell carcinoma. Nat Clin Pract Urol. 2007. 4:432–443.

13. Bader MJ, Sroka R, Gratzke C, Seitz M, Weidlich P, Staehler M, et al. Laser therapy for upper urinary tract transitional cell carcinoma: indications and management. Eur Urol. 2009. 56:65–71.

14. Tawfiek ER, Bagley DH. Upper-tract transitional cell carcinoma. Urology. 1997. 50:321–329.

15. Cornu JN, Roupret M, Carpentier X, Geavlete B, de Medina SG, Cussenot O, et al. Oncologic control obtained after exclusive flexible ureteroscopic management of upper urinary tract urothelial cell carcinoma. World J Urol. 2010. 28:151–156.

16. Chen GL, Bagley DH. Ureteroscopic surgery for upper tract transitional-cell carcinoma: complications and management. J Endourol. 2001. 15:399–404.

17. Soderdahl DW, Fabrizio MD, Rahman NU, Jarrett TW, Bagley DH. Endoscopic treatment of upper tract transitional cell carcinoma. Urol Oncol. 2005. 23:114–122.

18. Potter SR, Chow GK, Jarrett TW. Percutaneous endoscopic management of urothelial tumors of the renal pelvis. Urology. 2001. 58:457–459.

19. Painter DJ, Denton K, Timoney AG, Keeley FX. Ureteroscopic management of upper-tract urothelial cancer: an exciting nephron-sparing option or an unacceptable risk? J Endourol. 2008. 22:1237–1239.

20. Boorjian S, Ng C, Munver R, Palese MA, Vaughan ED Jr, Sosa RE, et al. Impact of delay to nephroureterectomy for patients undergoing ureteroscopic biopsy and laser tumor ablation of upper tract transitional cell carcinoma. Urology. 2005. 66:283–287.

21. Nakada SY, Clayman RV. Percutaneous electrovaporization of upper tract transitional cell carcinoma in patients with functionally solitary kidneys. Urology. 1995. 46:751–755.

22. Palou J, Piovesan LF, Huguet J, Salvador J, Vicente J, Villavicencio H. Percutaneous nephroscopic management of upper urinary tract transitional cell carcinoma: recurrence and long-term followup. J Urol. 2004. 172:66–69.

23. Roupret M, Traxer O, Tligui M, Conort P, Chartier-Kastler E, Richard F, et al. Upper urinary tract transitional cell carcinoma: recurrence rate after percutaneous endoscopic resection. Eur Urol. 2007. 51:709–713.

24. Argyropoulos AN, Tolley DA. Upper urinary tract transitional cell carcinoma: current treatment overview of minimally invasive approaches. BJU Int. 2007. 99:982–987.

25. Rastinehad AR, Ost MC, Vanderbrink BA, Greenberg KL, El-Hakim A, Marcovich R, et al. A 20-year experience with percutaneous resection of upper tract transitional carcinoma: is there an oncologic benefit with adjuvant bacillus Calmette Guérin therapy? Urology. 2009. 73:27–31.

26. Martinez-Pineiro JA, Garcia Matres MJ, Martinez-Pineiro L. Endourological treatment of upper tract urothelial carcinomas: analysis of a series of 59 tumors. J Urol. 1996. 156(2 Pt 1):377–385.

27. Ristau BT, Tomaszewski JJ, Ost MC. Upper tract urothelial carcinoma: current treatment and outcomes. Urology. 2012. 79:749–756.

28. Jarrett TW, Sweetser PM, Weiss GH, Smith AD. Percutaneous management of transitional cell carcinoma of the renal collecting system: 9-year experience. J Urol. 1995. 154:1629–1635.

29. Audenet F, Traxer O, Bensalah K, Roupret M. Upper urinary tract instillations in the treatment of urothelial carcinomas: a review of technical constraints and outcomes. World J Urol. 2013. 31:45–52.

30. Thompson RH, Krambeck AE, Lohse CM, Elliott DS, Patterson DE, Blute ML. Elective endoscopic management of transitional cell carcinoma first diagnosed in the upper urinary tract. BJU Int. 2008. 102:1107–1110.

31. Sowter SJ, Ilie CP, Efthimiou I, Tolley DA. Endourologic management of patients with upper-tract transitional-cell carcinoma: long-term follow-up in a single center. J Endourol. 2007. 21:1005–1009.

32. Fajkovic H, Klatte T, Nagele U, Dunzinger M, Zigeuner R, Hubner W, et al. Results and outcomes after endoscopic treatment of upper urinary tract carcinoma: the Austrian experience. World J Urol. 2013. 31:37–44.

33. Pak RW, Moskowitz EJ, Bagley DH. What is the cost of maintaining a kidney in upper-tract transitional-cell carcinoma? An objective analysis of cost and survival. J Endourol. 2009. 23:341–346.

34. Lucas SM, Svatek RS, Olgin G, Arriaga Y, Kabbani W, Sagalowsky AI, et al. Conservative management in selected patients with upper tract urothelial carcinoma compares favourably with early radical surgery. BJU Int. 2008. 102:172–176.

35. Johnson GB, Fraiman M, Grasso M. Broadening experience with the retrograde endoscopic management of upper urinary tract urothelial malignancies. BJU Int. 2005. 95:Suppl 2. 110–113.

36. Deligne E, Colombel M, Badet L, Taniere P, Rouviere O, Dubernard JM, et al. Conservative management of upper urinary tract tumors. Eur Urol. 2002. 42:43–48.

37. Keeley FX Jr, Bibbo M, Bagley DH. Ureteroscopic treatment and surveillance of upper urinary tract transitional cell carcinoma. J Urol. 1997. 157:1560–1565.

38. Goel MC, Mahendra V, Roberts JG. Percutaneous management of renal pelvic urothelial tumors: long-term followup. J Urol. 2003. 169:925–929.

39. Clark PE, Streem SB, Geisinger MA. 13-year experience with percutaneous management of upper tract transitional cell carcinoma. J Urol. 1999. 161:772–775.

40. Patel A, Soonawalla P, Shepherd SF, Dearnaley DP, Kellett MJ, Woodhouse CR. Long-term outcome after percutaneous treatment of transitional cell carcinoma of the renal pelvis. J Urol. 1996. 155:868–874.

41. Fuglsig S, Krarup T. Percutaneous nephroscopic resection of renal pelvic tumors. Scand J Urol Nephrol Suppl. 1995. 172:15–17.

42. Giannarini G, Kessler TM, Birkhauser FD, Thalmann GN, Studer UE. Antegrade perfusion with bacillus Calmette-Guérin in patients with non-muscle-invasive urothelial carcinoma of the upper urinary tract: who may benefit? Eur Urol. 2011. 60:955–960.

43. Patel A, Fuchs GJ. New techniques for the administration of topical adjuvant therapy after endoscopic ablation of upper urinary tract transitional cell carcinoma. J Urol. 1998. 159:71–75.

44. Keeley FX Jr, Bagley DH. Adjuvant mitomycin C following endoscopic treatment of upper tract transitional cell carcinoma. J Urol. 1997. 158:2074–2077.

45. Hayashida Y, Nomata K, Noguchi M, Eguchi J, Koga S, Yamashita S, et al. Long-term effects of bacille Calmette-Guérin perfusion therapy for treatment of transitional cell carcinoma in situ of upper urinary tract. Urology. 2004. 63:1084–1088.

46. Miyake H, Eto H, Hara S, Okada H, Kamidono S, Hara I. Clinical outcome of bacillus Calmette-Guérin perfusion therapy for carcinoma in situ of the upper urinary tract. Int J Urol. 2002. 9:677–680.

47. Irie A, Iwamura M, Kadowaki K, Ohkawa A, Uchida T, Baba S. Intravesical instillation of bacille Calmette-Guérin for carcinoma in situ of the urothelium involving the upper urinary tract using vesicoureteral reflux created by a double-pigtail catheter. Urology. 2002. 59:53–57.

48. Thalmann GN, Markwalder R, Walter B, Studer UE. Long-term experience with bacillus Calmette-Guerin therapy of upper urinary tract transitional cell carcinoma in patients not eligible for surgery. J Urol. 2002. 168(4 Pt 1):1381–1385.

49. Okubo K, Ichioka K, Terada N, Matsuta Y, Yoshimura K, Arai Y. Intrarenal bacillus Calmette-Guérin therapy for carcinoma in situ of the upper urinary tract: long-term follow-up and natural course in cases of failure. BJU Int. 2001. 88:343–347.

50. Nonomura N, Ono Y, Nozawa M, Fukui T, Harada Y, Nishimura K, et al. Bacillus Calmette-Guérin perfusion therapy for the treatment of transitional cell carcinoma in situ of the upper urinary tract. Eur Urol. 2000. 38:701–704.