Ureteropyeloscopic diagnosis and treatment of upper urinary tract urothelial malignancies

Objectives. To study the application of endoscopic techniques in treating u pper 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 trans itional cell carcinoma were referred specifically for endoscopic therapy. I ndications for treatment included a solitary kidney, bilateral disease, mod est renal insufficiency, and/or other significant comorbidities. All patien ts 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 tre ated 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 tran sitional cell carcinoma of the upper urinary tract. Tumors ranged in size f rom less than 1 cm to filling the entire ureter. Ail papillary lesions were treated successfully using ureteroscopic techniques without any disease pr ogression. 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 l esions and endoscopic treatment was chosen in light of their severe comorbi dities. 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 patient s has progressed with metastases. Conclusions. Papillary, low-grade, low-stage tumors of the upper urinary tr act 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.