Endoscopic ureteral procedures for one-step nephroureterectomy: experience in 100 cases.

Background And Purpose: Nephroureterectomy with perimeatal cystectomy is the gold standard for the treatment of urothelial upper urinary-tract carcinoma (UUTC). Ureteral endoscopic surgery has been proposed as a complementary step in nephroureterectomy, either open or laparoscopic, in order to obviate the low abdominal incision. Our goal was to establish the value of two techniques for endoscopic distal-ureteral management in one-step nephroureterectomy for UUTC.

Patients And Methods: Between June 1995 and January 2006, 100 nephroureterectomies with an endoscopic distal ureteral approach were performed for UUTC (stage pT(a) in 31 cases, pT1 in 27 cases, pT2 in 21 cases, pT3 in 18 cases, and pT(4) in 3 cases). The tumor was pyelocaliceal in 65 cases, ureteral in 18 cases, and both ureteral and pyelocaliceal in 17 cases. Among the patients, 72 underwent "pluck" transurethral detachment of the intramural ureter, and 28 were managed by ureteral stripping. The follow-up was performed by cystoscopy with urinary cytology, ultrasonography, and intravenous urography. The mean follow-up was 44 months (range 4-129 months).

Results: All but two of the procedures were completed successfully. In these two patients, ureteral stripping failed, and open surgery was performed. The complication rate was 2.8% for the pluck technique and 7.1% for ureteral stripping. During follow-up, 23 patients had bladder recurrences, 2 had renal fossa tumors, 3 had secondary lymph-node invasion, 2 had contralateral UUTC, and 1 had asynchronous liver metastases. The disease-specific mortality rate was 12%.

Conclusions: The endoscopic approach to the terminal ureter is safe and effective as part of one-step nephroureterectomy. Differences between the techniques with regard to operative time, complications, and oncologic outcome were not significant.