Ureteroscopic management of upper-tract urothelial cancer: an exciting nephron-sparing option or an unacceptable risk?

Purpose: To discuss the merits of the endoscopic management of upper-tract transitional-cell carcinoma (UTTCC). We present original data from our institution over an 8-year period and a review of some of the world literature. A discussion of the overall suitability of this modality for both clinician and patient is presented.

Patients And Methods: A retrospective chart review was performed comprising operative logs, departmental databases, and pathologic registers. These sources were analyzed, and data were collected on all patients who underwent ureteroscopic treatment of UTTCC. Patients with at least 6 months of follow-up were included in the study.

Results: Forty-five patients (mean age 65 yrs) were identified who had undergone ureteroscopic treatment for UTTCC with either therapeutic or palliative intent between 1998 and 2006. Of these, 19 procedures were performed electively in patients with normal contralateral kidneys. Those patients with low-volume, low-grade tumors on biopsy and negative results of urinary cytologic evaluation recovered well, with few recurrences. None of this group progressed to radical surgery. Of 12 patients never considered for radical surgery, only 1 died of the disease after a median follow-up of 15 months.

Conclusion: Elective ureteroscopic holmium:yttrium-aluminum-garnet laser ablation of UTTCC is a safe and effective treatment for a select group of patients. In our institution, patients with normal functioning contralateral kidneys are considered for endoscopic treatment and follow-up of their disease if disease is found to be of low grade and volume. Inadequacies in the staging of UTTCC mean that this may, in some cases, turn out to be suboptimal management, and therefore we maintain a low threshold for recommending radical surgery. For another group of patients with single kidneys, global renal dysfunction, or severe comorbidity, endoscopic treatment can prove a valuable palliative option even in those persons who have a large tumor bulk or relatively rapid disease recurrence.