ENDOUROLOGY & LAPAROSCOPY

Predictive factors for applicability and success with endoscopic treatment of upper tract urothelial carcinoma
Suh RS, Faerber GJ, Wolf Jr. JS
From the Department of Urology, University of Michigan, Ann Arbor, Michigan
J Urol. 2003; 170: 2209-16

• Purpose: We report on endoscopic treatment outcomes for upper tract urothelial carcinoma and identify predictive factors for success.
• Materials and Methods: A total of 61 renal units were referred for endoscopic treatment of an upper tract tumor, 69% of which did not have a traditional indication for nephron sparing approaches. Tumor pathology and operative findings were assessed retrospectively for treatment outcomes and influential factors.
• Results: Initial ureteroscopic inspection was undertaken in 53 renal units with resection attempted in 18 (34%) resulting in an 89% success rate with 16 treated. A percutaneous approach in 19 renal units (11 after ureteroscopy) was 100% successful in achieving tumor-free status, for a total of 35 renal units successfully treated endoscopically. Surveillance then began on 27 renal units with a recurrence rate of 88% and mean time to recurrence of 5.8 months (range 2 to 20). Of patients undergoing surveillance (31% of whom had high grade disease), 54% remain or have died of unrelated disease, during a mean followup of 21.0 months (range 3 to 48). Higher tumor grade, larger size, renal pelvis location (all p < 0.01) and multifocality (p = 0.05) significantly correlated with decreased recurrence-free survival, but did not predict failure of local control by endoscopic surveillance.
• Conclusions: Although endoscopic techniques can render most patients tumor-free, there is a high associated recurrence rate and many need repeat procedures. Recurrence-free survival is greater in patients with low grade, solitary or less bulky disease. However, rigorous surveillance after endoscopic resection can lead to success even in patients with high grade, multifocal or large volume disease, resulting in preservation of renal units.
  
  
• Editorial Comment
  Among a heterogeneous population of patients with upper tract urothelial carcinoma, two-thirds of whom did not have a traditional indication for renal preservation; tumor size was the most important factor in deciding whether or not to attempt endoscopic resection. Although disease recurrence is increased with higher grade, larger, multifocal or renal pelvic location, once the tumor is resected these factors do not significantly influence whether or not recurrences can be successfully managed with endoscopy. Over half of the patients who elected to enter surveillance were able to maintain their kidney and avoid extirpative surgery. The price for this is high, in terms of repeated procedures, but motivated patients benefit. The take home message is that even in the presence of high grade, multifocal or large volume disease, kidneys can be preserved.

Dr. J. Stuart Wolf Jr.
Associate Professor of Urology
University of Michigan
Ann Arbor, Michigan, USA