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Urologic Clinics of North America

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PRIMARY PERCUTANEOUS APPROACH TO UPPER URINARY TRACT TRANSITIONAL CELL CARCINOMA - 05/09/11

Doi : 10.1016/S0094-0143(05)70122-1 
Michel E. Jabbour, MD a, Arthur D. Smith, MD b
a Department of Urology, Hotel Dieu Hospital, Saint Joseph University Faculty of Medicine, Beirut, Lebanon (MEJ) 
b Department of Urology, Long Island Jewish Medical Center, Albert Einstein College of Medicine, New Hyde Park, New York (ADS) 

Resumen

Nephroureterectomy with excision of a bladder cuff has been the standard form of treatment of upper urinary tract transitional cell carcinoma (TCC) since it was established by Kimball and Ferris in 1934.42 Any technique that is short of total extirpation of the involved upper tract was considered to expose the patient to cancer-related risks because of the multifocality and the high recurrence rate of these tumors.31, 80 As many as two thirds of ureteropelvic tumors may show certain degrees of multiplicity, and less radical surgeries may end up with a urothelial recurrence rate of more than 65%.2, 48 The radical attitude was justified further by the low incidence of bilateral tumors (< 5%) and the limitations of upper tract endoscopic control.12, 26, 44, 77

Nephroureterectomy, however, is a major operation that may not be tolerated by many patients in the age range in which upper tract TCC is most common (60–80 years of age).16 The extent of its standard incision also cannot be minimized without compromising its efficiency.43, 46, 87, 91 Trying to simplify the technique by resecting the ureteral orifice and pulling on the ureter from a single loin incision has been associated with a significant rate of recurrences at the site of the resected orifice.31 A bigger dilemma was faced when dealing with patients with solitary kidneys—congenital or by a previous nephrectomy—with compromised renal function, or with bilateral urothelial tumors.10 Nephroureterectomy in these patients would result in an anatomic or functional anephric state, leading to chronic hemodialysis.80 Long-term hemodialysis is associated with significant morbidity and mortality, with a 5-year survival rate of only 19% in patients 65 to 74 years old.27 Although the incidence of bilateral TCC is generally low, Balkan nephropathy and occupational exposures are associated more commonly with multiple and bilateral upper urinary tract TCC than are tumors with other causes.50, 89 Balkan nephropathy also is accompanied by a certain degree of renal impairment, and urothelial tumors associated with it are generally of low grade and exhibit an indolent behavior.65 The previously mentioned circumstances and the possible need for nephrotoxic chemotherapy to control advanced disease raised a big question about how necessary and vital it is to treat every filling defect of the upper urinary system with nephroureterectomy, especially because 50% to 82% of upper tract tumors treated with nephroureterectomy in the different series were low-stage and low-grade (GI-II, Ta-T1).12, 14, 15, 48, 57, 69 The behavior of such tumors is usually indolent, and the risk for invasiveness and metastasis is low.35, 37, 56, 57

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Esquema


 Address reprint requests to Michel E. Jabbour, MD, Urology Department, Hotel Dieu Hospital, Beirut, Lenanon, e-mail: michelj@cyberia.net.lb


© 2000  W. B. Saunders Company. Publicado por Elsevier Masson SAS. Todos los derechos reservados.
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Vol 27 - N° 4

P. 739-750 - novembre 2000 Regresar al número
Artículo precedente Artículo precedente
  • LAPAROSCOPIC PARTIAL NEPHRECTOMY : The European Experience
  • Jens J. Rassweiler, Claude Abbou, Günter Janetschek, Klaus Jeschke
| Artículo siguiente Artículo siguiente
  • URETEROSCOPIC MANAGEMENT OF PATIENTS WITH UPPER TRACT TRANSITIONAL CELL CARCINOMA
  • Dean G. Assimos, M. Craig Hall, Jeffrey H. Martin

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