Percutaneous management of upper-tract transitional cell carcinoma

Standard management of upper tract transitional cell carcinoma is a nephroureterectomy; however, there is a distinct subgroup of patients who would be rendered dialysis dependent, or at high risk for functionally significant renal insufficiency, and for whom a nephron-sparing approach is warranted. Historically, the options for such "conservative" management have been limited to variations of open pyelotomy or partial nephrectomy. More recently, endourologic techniques have been applied to the treatment of these difficult patients. Though a ureteroscopic approach can occasionally be therapeutic, it may be precluded by the size or location of the tumor, or by a urinary diversion that makes ureteroscopic access difficult or impossible. Many of these patients can, however, be managed with a well planned percutaneous approach that provides excellent access to virtually the entire upper tract. The subsequent addition of topical BCG as an adjunct to percutaneous upper tract tumor resection may then be beneficial in decreasing the incidence of local recurrence.