Ureteroscopic Management of Upper Tract Urothelial Carcinoma

Abstract

INTRODUCTION AND OBJECTIVES: According to the EAU and NCCN guidelines, patients with large upper tract urothelial carcinoma (UTUC) tumors should be treated with radical nephroureterectomy (RNU). The purpose of this study was to evaluate the effectiveness of ureteroscopy (URS) with laser ablation as an alternative treatment for UTUC lesions larger than 2 cm. METHODS: A retrospective review was performed of all patients undergoing URS for UTUC at our institution from Jan 2001 to Dec 2010. A total of 347 patients underwent URS for evaluation and treatment of UTUC. Of these, 128 patients were identified as having initial UTUC tumor size of at least 2 cm. In this cohort, 31 patients underwent immediate RNU while 24 returned to their referring institutions, and one patient underwent percutaneous treatment. The remaining 72 patients were managed ureteroscopically. While 10 (13.9%) patients underwent palliative URS, 62 (86.1%) patients were treated with curative intent. Demographic data as well as tumor characteristics (including tumor size, location and grade) were obtained for all patients. In addition, patients' courses were reviewed for tumor recurrence, grade progression and for the development of locally advanced or metastatic disease. Subgroup analysis was performed for those patients ureteroscopically treated with curative intent. RESULTS: Among patients initially managed with intent to cure, mean age was 73.5 years (range 46-91), mean tumor size was 33.4mm (20-60). Location included: kidney 37 (59.7%), ureter 19 (30.6%) or both 6 (9.7%). Mean follow up was 36.7 months (3-132). Bladder tumors were diagnosed prior to, concomitant with, or after the diagnosis of UTUC in 27 (43.5%), 7 (11.3%) and 16 (25.8%) patients, respectively. Fifty one patients (82.3%) had tumor recurrence during the surveillance period. Mean time to first recurrence was 15.1 months. Seven (11.2%) patients progressed to high grade disease at a mean time of 34.4 months, and 4 (6.5%) developed metastatic disease at a mean time of 26 months. Seven eventually underwent RNU (3 grade progression, 2 extensive disease, 2 ureteral stricture/non-functioning kidney). CONCLUSIONS: Ureteroscopic treatment of low grade UTUC tumors larger than 2 cm provides reasonable oncologic control. Local recurrences are common and are usually amenable to endoscopic management. Strict ureteroscopic surveillance is essential.