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Management of patients with upper urinary tract transitional cell carcinoma

Nature Clinical Practice Urology volume 4, pages 432–443 (2007)Cite this article

Abstract

Multiple therapeutic options are available for the management of patients with upper urinary tract transitional cell carcinoma (TCC). Radical nephroureterectomy with an ipsilateral bladder cuff is the gold-standard therapy for upper-tract cancers. However, less invasive alternatives have a role in the treatment of this disease. Endoscopic management of upper-tract TCC is a reasonable strategy for patients with anatomic or functional solitary kidneys, bilateral upper-tract TCC, baseline renal insufficiency, and significant comorbid diseases. Select patients with a normal contralateral kidney who have small, low-grade lesions might also be candidates for endoscopic ablation. Distal ureterectomy is an option for patients with high-grade, invasive, or bulky tumors of the distal ureter not amenable to endoscopic management. In appropriately selected patients, outcomes following distal ureterectomy are similar to that of radical nephroureterectomy. Bladder cancer is a common occurrence following the management of upper-tract TCC. Currently, there are no variables that consistently predict which patients will develop intravesical recurrences. As such, surveillance with cystoscopy and cytology following surgical management of upper-tract TCC is essential. Extrapolating from data on bladder TCC, both regional lymphadenectomy and neoadjuvant chemotherapy regimens are likely to be beneficial for patients with upper-tract TCC, particularly in the setting of bulky disease.

Key Points

  • While upper-tract transitional cell carcinoma (TCC) accounts for only 5% of urothelial malignancies, evidence suggests that the frequency of these lesions is increasing

  • Radical nephroureterectomy by either the open or laparoscopic approach is the gold-standard therapy for upper-tract TCC; however, less invasive alternatives such as endoscopic ablation or segmental ureterectomy also have a role in treatment

  • Although TCC represents malignant degeneration of the urothelium, molecular and genetic studies indicate differences in the biologic mechanisms underlying upper-tract and bladder urothelial carcinoma

  • Bladder cancer occurs in 15–50% of patients following upper-tract TCC, underscoring the necessity for regular postoperative interval cystoscopy and urinary cytology

  • Experience gained from the management of bladder TCC suggests that both neoadjuvant chemotherapy and regional lymphadenectomy should both have a role in the management of upper-tract TCC

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Figure 1: Algorithm for the management of upper-tract TCC
Figure 2: Trocar configuration and hand-assist device placement for (A) right and (B) left hand-assisted laparoscopic nephroureterectomy (HALN)

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  1. JD Raman is a Chief Resident in Urology and DS Scherr is an Assistant Professor of Urology at the New York Presbyterian Hospital–Weill Cornell Medical Center, New York, NY, USA.,

    Jay D Raman & Douglas S Scherr

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Raman, J., Scherr, D. Management of patients with upper urinary tract transitional cell carcinoma. Nat Rev Urol 4, 432–443 (2007). https://doi.org/10.1038/ncpuro0875

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