[Endourologic treatment of transitional cell carcinoma of the upper urinary tract]

Nephrourete-rectomy with excision of a bladder cuff has been the standard treatment of the upper urinary tract transitional cell carcinoma. The very indolent behavior (GI, II, Ta, T1) of more than 50% and up to 82% of the upper urinary tract tumors treated with nephroureterectomy in different series in conjunction with the advent of sophisticated endourological techniques have permitted in certain cases alternative treatments using a conservative approach with either ureteropyeloscopy or percutaneous access. Ureteroscopy is reserved for ureteral tumors and small, simple tumors of the renal pelvis (< 1.5 cm) while large or multiple tumors of the renal pelvis are approached in a percutaneous way. During 14 years 64 patients with transitional cell carcinoma of the upper urinary tract were treated percutaneously at our department at Long Island Jewish Medical Center, 15 (23.5%) with grade I, 26 (40.6%) with grade II and 23 (35.9%) with grade III and IV. After a mean follow-up of 51 months, percutaneously treated patients had a tumor specific survival of 85.6%, being 100% for GI tumors, 96.1% for GII and 60.8% for GIII. Recurrence of grade I tumors were observed in 20%, 26.9% for grade II and 56.5% for Grade III. In conclusion, with a rigorous follow-up transitional cell carcinoma of the upper tract with low and moderate grades (GI, GII, Ta, T1) can be treated endorologically even in the presence of a normal contralateral kidney with low morbility and a long term efficiency comparable to a nephroureterectomy. An elective endorologic management for GIII tumors is not recommended. Endoscopic conservative surgery can be offered when the criteria of good prognosis are found for Ta (such as absence of carcinoma in situ, presence of diploidy, low p53 expression and a single tumor) and in the cases of a solitary kidney or chronic renal insufficiency or for poor surgical candidates for T1. Patients with stage T2-T3 should be offered a nephroureterectomy.