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Urothelial Cell Carcinoma
Upper Urinary Tract Urothelial Tumour Management – Open or Laparoscopic?
a report by
Guillermo Urdaneta Pignalosa, Oscar Rodríguez Faba, Fernando Rodríguez Escovar and Juan Palou Redorta
Urological Oncology Unit, Urology Department, Fundació Puigvert, Barcelona
In patients with unilateral urothelial cell carcinoma (UCC) Results
circumscribed to the renal pelvis and a healthy functional contralateral Radical NU has been considered the optimal treatment for upper urinary
kidney, first-choice treatment is nephroureterectomy (NU). There tract UCC for the last 40 years. In 1952, Mc Donald et al.
4
published the
are several reasons for this: UCC is multifocal in nature; it has an endoscopic management of the distal ureter, and in 1991 Clayman et al.
5
increased ipsilateral recurrence risk and a low frequency of described the first LNU. Since then, multiple reports have been published
contralateral lesions; and metastatic spread and local invasion is seen using different approaches for the involved kidney and the distal ureter.
in early stages. Tumours of the upper two-thirds of the ureter are best The most representative reports comparing the open and laparoscopic
treated by radical NU (kidney, adrenal, ureter and bladder). If the approach are published in European Urology.
6,7
Obviously, these findings
tumour is in the distal third of the ureter, a partial ureterectomy with are in accordance with the learning curve, centre experience, surgical
reimplantation can also be performed. When ureter is left behind, team skills and patient selection. The global advantages of a laparoscopic
disease may recur in one-third of patients. However, an ureterectomy approach of the kidney are:
may be justified in the presence of a healthy functional solitary kidney
due to contralateral disease, nephropathy or bilateral upper urinary • no long incisions are required;
tract tumour. • shorter operative time;
• lower complication rates;
Conservative endoscopic treatment (ureteroscopy or percutaneous • less analgaesic use;
approach) may be considered in unifocal, papillary, low-grade tumours in • shorter hospital stay;
different locations of the upper tract, even though recurrence can be as • fewer mean days to deambulation;
8
and
high as 45%.
1, 2
NU remains the gold standard in the treatment of high- • fewer mean days to initiation of dietary tolerance.
stage and high-grade upper tract UCC, with an overall five-year survival
rate of 84%. In the past 15 years, with the advent of the laparoscopic The only advantage of the open approach is the absence of the
approach, NU has undergone clinical changes.
3
A debate exists about port-site metastasis that has been related to an advanced stage of
comparisons of open NU (ONU) and laparoscopic NU (LNU) in terms of the tumour, no use of endobag and positive margins. That is why, in
patient quality of life (QoL), complications and oncological outcomes. The LNU, we always use a specimen bag to retrieve the specimen. The
approach of the distal ureter is also controversial. This article will compare complications reported in a large case series of 482 procedures
different reports about the approach of NU in terms of QoL, (461 patients) included bleeding in 4.6% (22/481), re-intervention in
complications and oncological outcomes. The approach to the distal 3.1% (15/481), bowel injury in 0.6% (3/481), hypercarbia in 0.4%
ureter and our experience is discussed. (2/481), pulmonary embolism in 0.2% (1/481) and pleural lesion in
0.2% (1/481).
9
The conversion rate reported is very low and is always
Material and Methods related to organ injuries (colon, renal vein, etc.).
10
A PUBMED search was undertaken to look for publications that
contained the term nephroureterectomy. A review of the main papers As for the oncological results, these are not comparable. The important
was made in order to make some conclusions. Clinical studies were point is that the tumour stage and grade are independent prognostic
included and emphasis was placed on identifying good-quality studies. factors, regardless of the approach. If we analyse the similar procedure
with renal cell carcinoma, one non-randomised comparative study of 100
patients reported that there was no statistically significant difference in
Juan Palou Redorta is Chief of Urological Oncology at the Fundació Puigvert, Barcelona, and an
Associate Professor of Urology at the Universidad Autónoma de Barcelona. Professor Palou is a
the estimated five-year disease-free survival rate for laparoscopic and
member of the European School of Urology (ESU). His research is focused on clinical research in
open nephrectomy (95.5 versus 97.5%, respectively).
11
A case series of
oncology, mainly in urothelial cell carcinoma, laparoscopy and robotics. He has had several book
157 patients with renal cell carcinoma who had the laparoscopic
chapters published and has contributed to more than 200 papers in urological journals.
procedure reported an estimated five-year disease-free survival rate of
E: jpalou@fundacio-puiguert.es
91%.
12
Two non-randomised comparative studies
13,14
including 209
Guillermo Urdaneta Pignalosa is a Resident in Urology at the Fundació Puigvert, Barcelona.
patients with upper urinary tract urothelial cell carcinoma reported no
He is a junior member of the European Association of Urology (EAU) and was an investigator difference in recurrence rates between LNU ONU. The benefit of lymph
of the Tuberculosis Molecular Biology and Immunology Functional Group of the Foundation
node dissection (LND) for upper urinary tract tumours remains
Institute of Immunology of Colombia (FIDIC) between 2002 and 2003. His main interest is in
the molecular biology of genitourinary neoplasms.
controversial. The important factor is the performance of a complete
dissection in order to improve the pathological diagnosis and possibly
survival. The LND can be performed in LNU and ONU.
28 © TOUCH BRIEFINGS 2007