ENDOSCOPIC URETERECTOMY DURING NEPHROURETERECTOMY FOR UPPER URINARY TRACT TRANSITIONAL CELL CARCINOMA Il. Saltirov, Ts. Petkov, G. Georgiev, K.Petkova Department of Urology and Nephrology, Military Medical Academy, Sofia Keywords: transitional cell carcinoma of the upper urinary tract, nephroureterectomy, transurethral endoscopic ureterectomy Author for contacts: Il. Saltirov, Military Medical Academy, Department of Urology and Nephrology, 3 G.Sofiiski Blvd., Sofia 1606, phone: +359 2 922 52 08, fax: +359 2 851 70 94 Abstract: Introduction: Radical nephroureterectomy with resection of a bladder cuff remains the gold standard in the treatment of upper urinary tract transitional cell tumors. McDonald is the first to describe a ureteral stripping technique with subsequent endoscopic resection of the bladder cuff around the ureteral orifice during nephroureterectomy, which is called transurethral endoscopic ureterectomy and is a less invasive alternative of open surgical ureterectomy in patients with transitional cell renal pelvic carcinoma. Objective: To evaluate the clinical outcome of transurethral endoscopic ureterectomy during nephroureterectomy for transitional cell carcinoma of the renal pelvis and calyces. Materials and methods: Between January 1997 and July 2009, 24 patients with transitional cell renal pelvic carcinoma underwent nephroureterectomy. Results: 21 patients underwent nephroureterectomy with transurethral endoscopic ureterectomy, and 3 patients standart two-incision nephroureterectomy, due to ureteral stripping failure. No postoperative complications and no postoperative bladder or locoregional recurrent tumors developed during follow-up. Conclusion: Transurethral endoscopic ureterectomy during nephroureterectomy for upper urinary tract transitional cell carcinoma is a less invasive surgical technique with several advantages compared to standard two-incision nephroureterectomy. A disadvantage of this technique is the risk of stripping failure, which does not hamper the open surgical removal of the ureter. 24
J Clin Med. 2010; 3(1):24-30 Original Article Introduction Transitional cell carcinomas of the upper urinary tract are relatively rare, accounting for only 5% of all urothelial tumors 11. Radical nephroureterectomy with resection of a bladder cuff around the ureteral orifice remains the gold standard in the treatment of upper urinary tract transitional cell carcinomas 5,15. This therapeutic approach is based on the biological behavior of these tumors which is characterized by multifocallity, high incidence of ipsilateral recurrence in the distal ureter and around the ureteral orifice in the bladder after partial resection, and a low incidence of contralateral disease. Nephroureterectomy can be done totally by open surgical technique, totally laparoscopically, or by a combination of open radical nephrectomy and transurethral endoscopic ureterectomy after ureteral intussusception during the nephrectomy. McDonald et al. are the first to describe the technique ureteral intussusception using Mayo vein stripper and subsequent endoscopic resection of the bladder cuff around the ureteral orifice during nephroureterectomy, without second lower abdominal incision 13,14. Several investigators later reported their results with this technique during nephroureterectomy with minor modifications 6,10,16. The transurethral endoscopic ureterectomy, as suggested by Dell Adami and Breda, consists in intussusception of the ureter using Chevassu ureteral catheter and subsequent transurethral resection of the bladder cuff around the everted ureteral orifice 6. Objective The objective of this study is to evaluate the results and clinical outcome of nephroureterectomy with transurethral endoscopic ureterectomy for transitional cell carcinoma of the renal pelvis and calyces. Materials and Methods From January 1997 to July 2009, 24 patients, diagnosed with transitional cell carcinoma of the renal pelvis and/or calyces and treated in the Department of Urology and Nephrology, Military Medical Academy, Sofia, were enrolled in this study. Patients with transitional cell carcinoma of the ureter or with synchronous bladder tumors were excluded from the study. 21 patients were treated by nephroureterectomy with transurethral endoscopic resection of the distal ureter, and 3 patients underwent a standard two-incision nephroureterectomy with bladder cuff (Fig. 1). Fig. 1. Groups of patients according to the type of ureter removal surgery during nephroureterectomy 21 (87.50%) 3 (12.50%) Transurethral endoscopic ureterectomy Classic open nephroureterectomy Urethrocystoscopy, intravenous urography, retrograde pyelography and/or ureteroscopy, were performed preoperatively in each case to rule out macroscopic tumors in the ureter, urinary bladder and urethra, as well as computed tomography scanning to confirm each patient s local disease (fig.2). Patients age was from 46 to 81 years (mean age 71.3 years). The patient and tumor characteristics are shown in Table 1. The surgical technique of nephroureterectomy with transurethral endoscopic ureterectomy comprised cystoscopy and endoscopic placement of a Chevassu ureteral catheter 5-7 CH. The patient was placed in a lateral decubitus position and under a standard flank 25
Fig. 2 incision the radical nephrectomy was performed. After the ureter had been sectioned, its extremity was tied to the catheter tip (fig.3). Fig. 3 The dissection of the ureter was then carried distally, initially under direct vision and below the iliac vessels digitally. Next, the ureteral catheter was retracted with slight tension through the urethra, until the ureter was totally inverted into the bladder. After closure of the lumbotomy and repositioning of the patient into the lithotomy position, a resectoscope was introduced alongside the ureter and the bladder wall around the everted ureteral orifice was endoscopically resected and the inverted ureter was extracted transurethrally with the bladder cuff (fig.4). 26
J Clin Med. 2010; 3(1):24-30 required conversion to standard open ureterectomy because of ureteral intussusception failure, due to previous ureteral and abdominal surgeries. The mean operative time was significantly shorter for endoscopic nephrectomy with transurethral ureterectomy - 163 ±61 minutes, compared to the classic open nephroureterectomy - 250 ±77 minutes. The mean duration of urethral catheterization was 5 days (4 to 6 days) and the mean hospital stay - 9 days (8 to 10 days). Histopathologic examination of the nephroureterectomy specimens revealed transitional cell carcinoma of the renal collecting system in all 24 patients. No multifocal tumors were observed. The pathologic staging and grading of tumors is shown on Table 2. Two patients with stage pt3 tumor developed visceral metastases and died on the 7 th and 11 th month, respectively. No intravesical or locoregional tumor recurrences were observed during the follow-up period. Discussion Fig. 4 Hemostasis was obtained using electrocautery at the resection site and a Foley catheter was left indwelling. The cases with ureteral stripping failure required conversion to open ureterectomy with additional lower abdominal incision. Postoperatively, all patients were followed up by cystoscopy and urinary cytology every 3 months in the first year and every 6 months in the second year, as well as annually by computed tomography to rule out locoregional tumor recurrence or disease progression. The mean follow-up period was 30 months (range of 3 to 60 months). Results Transurethral endoscopic ureterectomy was successfully performed in 21 of all 24 cases without any intra- or postoperative complications or urinary extravasation into the perivesical tissues. Three patients Nephroureterectomy remains the standard treatment of upper urinary tract transitional cell tumors, despite the development of some minimally invasive endoscopic and percutaneous techniques for selected cases 7. Classic open nephroureterectomy requires two surgical incisions - one for nephrectomy and another to dissect the distal ureter and bladder cuff. This therapeutic approach is based on the significantly higher risk of tumor recurrence in the remaining ureter if only nephrectomy is performed. Although the technique of transurethral endoscopic ureterectomy during nephroureterectomy for transitional cell carcinoma of the upper urinary tract was described by McDonald et al. more than five decades ago 13,14, only a few investigators have reported their experience with this surgical technique. Contraindications for this method are the presence of tumor in the distal ureter or a synchronous bladder tumor. Conditions that cause ureteral fixation to the iliac vessels or the pelvic wall (prior surgery, radiotherapy, retroperitoneal fibrosis) may lead to ureteral stripping failure and conversion to classic open ureterectomy. 27
At our department, the technique of transurethral endoscopic ureterectomy during nephroureterectomy in patients with transitional cell carcinoma of the renal pelvis was introduced in January 1997. For a period of 12 years, this technique was successfully performed in 21 patients and failed in only 3 cases (12.5%). No significant bleeding or other intra- and postoperative complications were observed, as reported by other authors 2,12. For a mean follow-up period of 30 months, no locoregional and superficial or muscle-invasive bladder recurrences were observed, compared to other reports of 19-30% rate of bladder recurrence 9 and 0-6.3% rate of locoregional recurrence 8. In the reported in the literature series of patients undergoing classic nephroureterectomy, the rate of locoregional and bladder recurrence was approximately 10% and 30%, respectively 3. Table 3 shows the reported experience of other investigators with transurethral endoscopic ureterectomy during nephroureterectomy. We observed a failure rate of 12.5%, which is within the range reported by other authors, and is a disadvantage of this technique. The main reason for ureteral stripping failure was the presence of adhesions from previous surgeries, but in none of these 3 cases disruption of the ureter was observed. At our department, to prevent the risk of ureteral intussusception failure, we use Chevassu catheter and we place 2 stitches through the ureteral tunica muscularis and adventitia, located 1.5 cm distally to the ligature of the ureter. The traction of these 2 ligatures proximally improves the ease of invagination of the extremity of the ureter ligated to the catheter in the ureteral lumen. A significant difference regarding the mean operative time, which is within the range of those previously reported by other investigators (mean operative time of 160-180 minutes), was observed between the endoscopic ureterectomy group and standard nephroureterectomy group, and is considered one of the major advantages of endoscopic ureterectomy 8,17. Our results with transurethral endoscopic ureterectomy are identical with those of classic open ureterectomy, and are within the range of those previously reported in published studies, without the disadvantages and complications of the totally open surgical technique. Conclusion Transurethral endoscopic ureterectomy during nephroureterectomy for transitional cell carcinoma of the upper urinary tract is a less invasive alternative 28
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