Evolving Management of Upper-Tract Transitional-Cell Carcinoma At a Tertiary-Care Center

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Abstract
Traditional management of upper-tract transitional-cell carcinoma (TCC) has been open nephroureterectomy. Minimally invasive options, including laparoscopic and endoscopic techniques, are being applied with increasing frequency, however. To assess the impact of these techniques on the current management of upper-tract TCC, we reviewed our experience managing this problem over the last 3 years. Since January 1998, 84 patients underwent definitive management of upper-tract TCC using open, laparoscopic, or endoscopic techniques. This study group includes 57 men and 27 women with a mean age of 69.9 years. Fifty-three patients (63.9%) were treated by laparoscopic nephroureterectomy. Twelve patients (14.5%) were treated endoscopically, with percutaneous resection in 7 patients and ureteroscopic resection in 5 patients. The indications for nephron-sparing management in these 12 patients included solitary kidneys in 6 patients, significant comorbidities in 4 patients, and bilateral disease in 1 patient. Endoscopic management was elective in one patient. Nineteen patients (22.9%) underwent open surgical procedures consisting of nephroureterectomy in 16 patients and distal ureterectomy with reimplantation in 3 patients. Advances in laparoscopy and endourology are significantly impacting the definitive management of upper-tract TCC. Patients with a normal contralateral kidney are currently offered laparoscopic nephroureterectomy, while those with an absent or functionally compromised contralateral kidney are generally managed with endoscopic resection. Although minimally invasive techniques have demonstrated advantages regarding postoperative pain, hospital stay, and return to regular activities, only critical long-term follow-up regarding rates of local and distant recurrence will determine the ultimate role of these techniques.