Upper tract transitional cell carcinoma accounts for roughly 5 % of all urothelial malignancies. Tumors of the renal collecting system and ureter rarely remain clinically silent. Most patients present with either hematuria and/or flank pain. A variety of diagnostic approaches may be utilized; however, computed tomography urography is currently the most sensitive and specific imaging modality. Urinary cytology continues to be important because of its sensitivity for high-grade lesions. Ureteroscopy has both a diagnostic and therapeutic role. Although ureteroscopic biopsies rarely provide accurate staging, multiple studies have demonstrated the strong correlation between tumor grade and stage. Percutaneous resection of collecting system tumors has traditionally been reserved for patients with a solitary kidney, bilateral tumors, renal insufficiency, or significant medical comorbidities. Multiple series have demonstrated a low recurrence rate (approximately 20 %) in patients with low-grade disease. Recurrence and renal preservation rates are much less favorable for patients with high-grade tumors. Two studies have compared the efficacy of percutaneous resection to nephroureterectomy. Both found equivalent oncologic outcomes in patients with low-grade disease. Percutaneous resection is well tolerated in the majority of patients. However, tract recurrences have been described in a few case reports. Therefore, it is imperative to ensure that the access sheath remains in the collecting system at all times to minimize tract exposure. The efficacy of bacillus Calmette-Guerin adjuvant therapy has not been conclusively demonstrated. Nevertheless, most authors still recommend the use of adjuvant therapy given the absence of level one data. Radical nephroureterectomy remains the treatment of choice for patients with high-grade disease who are surgical candidates. Elective percutaneous management should be considered in patients with low-grade disease given its equivalent oncologic efficacy, relative safety, and minimal impact on overall renal function.
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