Endourological management of upper tract urothelial tumors

Advances in ureteroscopic and percutaneous techniques have made it possible to treat many upper tract malignancies by conservative, parenchyma sparing surgery. Percutaneous techniques generally allow for easier and better access to the renal pelvis and improved tumor resection. However, concerns for tumor spillage and nephrostomy tract seeding make the ureteroscopic approach best for initial management of accessible renal pelvic lesions, particularly when the diagnosis is unclear. Ureteral tumors, especially those arising in the lower third of the ureter, are technically easier to treat endoscopically than are renal pelvic tumors. Fulguration or laser photocoagulation may be used to ablate the tumor following cold-cup biopsy for histological diagnosis. Supplemental therapy using laser treatment of the tumor base, and postoperative instillation of BCG and mitomycin C offer great potential benefit in terms of improved tumor control. Confirmation of such benefit awaits the results of larger trials. Presently, standard nephroureterectomy remains the procedure of choice for most transitional cell carcinomas of the upper urinary tract in patients with a normal contralateral kidney. For those with a solitary kidney, renal insufficiency, bilateral tumors or severe intercurrent disease preventing a major open operation conservative management using endoscopic techniques is a viable alternative. Overall, it appears that grade and stage are far more important determinants of long-term out-come than the type of operation in those with transitional cell carcinoma of the upper urinary tract. For this reason, some physicians have recommended conservative management of low grade, noninvasive lesions even in the face of a normal opposite kidney. However, the majority of patients with upper tract urothelial tumors are best treated by nephroureterectomy, which leads to a low risk of local recurrence and obviates the need for rigorous postoperative upper tract surveillance.