TY - CHAP
T1 - Percutaneous renal surgery for renal pelvic tumors
T2 - Overcoming the difficulties
AU - Duty, Brian
AU - Blute, Michael
AU - Okhunov, Zhamshid
AU - Smith, Arthur D.
AU - Okeke, Zeph
N1 - Publisher Copyright:
© 2013 Springer-Verlag London. All rights reserved.
PY - 2013/8/1
Y1 - 2013/8/1
N2 - 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.
AB - 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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U2 - 10.1007/978-1-84882-083-8_11
DO - 10.1007/978-1-84882-083-8_11
M3 - Chapter
AN - SCOPUS:84929909599
SN - 1848820828
SN - 9781848820821
SP - 107
EP - 114
BT - Difficult Cases in Endourology
PB - Springer-Verlag London Ltd
ER -