Ureteral stump in the treatment of upper urothelial tumors, is it so important?

Vukotić V., Lazić M., Kojić D., Savić S., Babić U.,

Department of Urology, KBC “Dr Dragiša Mišović- Dedinje ”, Belgrade, Serbia


The most common tumors of the urinary tract are Transitional Cell Carcinomas (TCC), one of their important feature being the tendency of formation tumors either synchronously and/or metachronously in multiple foci throughout the urinary tract . Urothelial tumors of the upper urinary tract (renal pelvis and ureters- UUT) are rare, accounting for about 5% of all urothelial tumors. The natural history of these tumors shows that 60% of UUT-UCCs are found to be invasive at the time of diagnosis compared with only 15% of bladder tumors ; 60% of UUT-UCCs are invasive at diagnosis compared with only 15% of bladder tumors There are almost no tumors of low malignant potential in the upper urinary tract. Transitional cell carcinoma of the renal collecting system is traditionally managed by open nephroureterectomy with en bloc resection of a bladder cuff. Since lapaparoscopic nephroureterectomy (NUT) has recently emerged as a safe, minimally invasive approach to upper tract urothelial cancers, the most controversial and challenging feature is the oncologically correct management of the distal ureter and ureterl stump.

OWN RESULTS: We have performed our own study in order to find out risk factors influencing prognosis in term of survival in our patients treated with different types of open surgery for UUT TCC . In the 9 year period 124 patient were surgically treated for suspicious UUT TCC, which was histologically confirmed in 113 patients. 87 patient were followed , while 26 pts were lost for control. Statistical analysis was performed using SPSS for descriptive statists, life table and log rank tests for analysis of prognostic factors. Mean age of our patients was 67.32 years ( 42- 82), both sexes were equally distributed, left side being mostly affected ( 63:50). Bilateral tumors were present in 9 patients. Tumor was located only in pyelon in 31 pts, in ureter in 56, while pyelon and ureter were involved in 26 pts. The localisation of the tumor in ureter was lumbal (25 pts), illiac (15), pelvic (21), intramural (19). The most frequent grade of the tumor was Gr 2 (63 pts), Gr 1 was found in 27 pts, while gr 3 was found in 23 pts. The pT stage of the disease was 1 in 21 pts, 2 in 45, 3 in 37 and 4 in 10 pts. Open nefroureterectomy (ONU) was performed in 54 pts,through two incisions while only one pararectal incision was used in 30 pts. Subtotal nephrectomy was done in 33 pts, with later ureterectomy in 3. Tumor ablation was performed in 12 pts. In 6 pts partial cystectomy was performed along with NUT for intramural ureteral tumor. Lymophadenectomy was nor routinely performed. Of 87 patients who were evaluable for further assesment 43 died , 38 related to the UUT. Mean survival was 2.63 godine, 11 patients died in the first postoperative year. Grade was not associated with survival, while stage of the disease significantly influnced survival ( p<0.05). The type of any surgical procedure did not influence the survival . Diferent types of ONU ( one or two incisions) also did not made a difference in prognosis and survival, mean expected survival for two incisions being 4.99 years, for one incision 6.4 years .

DISCUSSION: Although the golden standard for the treatment of UUT is nephroureterctomy with bladder cuff excision, the result from diffferent studies are conflicting. Kwak et al did not found bladder cuff reccurences in patients who underwent nephroureterectomy without bladder cuff excision1. Ku concluded that most cancers that subsequently developed in the bladder were not muscle invasive, and, thus, the association of bladder cancer was not a poor prognostic factor 2 . Lughezzani after the analysis analyses of 2299 patients treated with nephroureterectomy (NU) or segmental ureterectomy (SU) for UUT TCC within Surveillance, Epidemiology and End Results registries found that the surgery type (NU with bladder cuff removal versus NU without bladder cuff removal ) did not affect the CSM -free rate3. Quite contrary to previous findings , Lughezzani analyzing 4210 patient with UUT from SEER database stress the importance of bladder cuff removal, unexpectadly especialy in patients with pT3/4 stage4.In a Canadian study involving 680 surgicaly treated patients about 25 % of them had incomplete ureteral resection, complete ureteral resection defined as pathologically measured ureteral length of 10 cm. According to their results patients with incomplete resection of ureter had worse survival5. Different approaches to the bladder cuff had comparable oncologic outcomes, with transurethral incision giving the same results as intra or extravesical incision in patients with primary UUT-UC without coexistent bladder tumors6

CONCLUSION: Since UUT TCC is rare but aggressive urologic cancer with a propensity for multifocality , it is questionable why just the ureteral stump should be of special interest. According to our results , as well as those of some other authors , complete NUT is not always necessary. Since it is clear that any kind of surgery alone is not curable for patients with advanced stage of disease effective adjuvant systemic therapy would be beneficial in order to improve the outcome of some patients. The major drawback is the small number of patients, so more multicentric studies or meta analysis should performed in order to bypass this limitation.

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