Ureteropyeloscopic diagnosis and treatment of upper urinary tract urothelial malignancies

Objectives. To study the application of endoscopic techniques in treating upper urinary tract urothelial malignancies and to define subgroups that may benefit from these therapies. Methods. During a 3-year period, 20 patients with upper urinary tract transitional cell carcinoma were referred specifically for endoscopic therapy. Indications for treatment included a solitary kidney, bilateral disease, modest renal insufficiency, and/or other significant comorbidities. All patients underwent retrograde ureteropyeloscopy. Lesions were biopsied, and lower grade tumors were treated with electrocautery or laser energy. High-grade lesions not amenable to minimally invasive techniques were palliated or treated with standard open surgery. Surveillance was performed at 3 to 4-month intervals by urine cytology and repeat panendoscopy on a similar schedule to lesions of the bladder treated endoscopically. Results. Eleven patients (55%) were found to have low-grade, papillary transitional cell carcinoma of the upper urinary tract. Tumors ranged in size from less than 1 cm to filling the entire ureter. Ail papillary lesions were treated successfully using ureteroscopic techniques without any disease progression. Five small, low-grade recurrences (45%) were-defined and treated endoscopically, with a mean follow-up of 17.3 months. Three patients were found at the time of initial diagnostic ureteroscopy to have higher grade lesions and endoscopic treatment was chosen in light of their severe comorbidities. On subsequent imaging, 2 of the 3 patients were suspected of having progression and underwent open surgery, both had carcinoma-in-situ only in the specimen. No tumor progression has been defined in this group to date, with mean follow-up of 16.3 months. A final third group of 6 patients were found to have nonpapillary, high-grade lesions at diagnostic endoscopy and underwent standard surgical resection. The disease of 4 of these 6 patients has progressed with metastases. Conclusions. Papillary, low-grade, low-stage tumors of the upper urinary tract are amenable to endoscopic resection irrespective of size and location. Patients with high-grade lesions defined endoscopically should be offered radical surgery in light-of the high rate of disease progression. (C) 1999, Elsevier Science Inc.