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Surgical Treatment of Upper Tract Urothelial Carcinoma
Ishaan Sangwan • Oct 9, 2022 • 34 hits
Upper tract urothelial carcinoma is a rare entity with a lack of prospective data to guide clinical decisions. The disease is often treated aggressively, and has high morbidity and mortality. Due to the lack of good data, management relies heavily on expert opinion.
Dr. Shariat, one of the leaders in the field who led the charge on building multicenter data sets, joins Dr. Bagrodia to discuss surgical management of upper tract urothelial carcinoma on the BackTable Urology Podcast. We’ve provided the highlight reel in this article, but you can listen to the full podcast below.
The BackTable Urology Brief
• While there has historically been a high rate of seeding while obtaining percutaneous biopsies for upper tract urothelial carcinoma, new techniques have minimized these risks.
• Historically, upper tract cancers have seen aggressive treatment, leading to 20-25% patients getting unnecessary radical intervention.
• A kidney sparing endoscopic approach is possible for patients that have unifocal, small, low grade, and non-invasive disease.
• A partial ureterectomy is also a rare option for sicker patients, although recurrence and seeding risks remain high.
Table of Contents
(1) Obtaining Biopsies for Upper Tract Urothelial Carcinoma
(2) Kidney Sparing Approach for Upper Tract Urothelial Carcinoma
(3) Partial Ureterectomy for Upper Tract Urothelial Carcinoma
Obtaining Biopsies for Upper Tract Urothelial Carcinoma
In the past, obtaining percutaneous biopsy specimens of upper tract urothelial carcinoma used to be anathema as the risk of seeding was considered too high. However, with new biopsy techniques, such as the coaxial technique, this risk has been minimized. Dr. Bagrodia recommends against nephrostomy tubes to further minimize risk. If getting to the lesion endoscopically is an option, that is also preferable to a percutaneous biopsy. The decision to get a biopsy is ultimately dependent on the tumor, with the risks of a biopsy being justified if the tumor looks infiltrative.
[Dr. Shahrokh Shariat]
When you and I were in training together, percutaneous biopsies, we didn't want to do that because ureteroscopies became a really fashionable great thing. And we certainly were very scared and ureter carcinoma is such that the biopsy core could lead to metastasis or seeding there. So I wouldn't really see a big benefit if you can stay within the system. But do I think, is it a devil, as it used to be in the past? No, because our biopsy technique and everything has changed and I'm not sure, but the question is if we can get endoscopically to it, and if the cytology is negative and you can get to it endoscopically because you need some tissue proof of the cancer before you deliver the therapy. I will try to go endoscopically and not get it by cutaneous biopsy, but I wouldn't feel as terrible as I used to feel in the past, I have to admit. What do you think?
[Dr. Aditya Bagrodia]
Yeah, absolutely. I think once upon a time, anything percutaneous, as it pertains to upper tract was anathema that, you know, you're going to get roasted. If it's an infiltrative mass and say our oncologist really wants some tissue prior to treatment, I'm pretty much okay with it. I think with the coaxial techniques it's safe and the risk of seeding is fairly minimal. I wouldn't feel comfortable leaving a nephrostomy tube in. I don't like that strategy. I think the likelihood of seeding that track is pretty real, but older sicker patients save them an anesthetic, do it under local. I do think there's maybe a bit more of a role and a bit more of this kind of dogma surrounding upper tract. And I know this is kind of getting into the weeds on some of the practical things, but this is what, you know, these are the decisions we have to make, I suppose. So, you know, my, my stance is if it's infiltrative, you just need to get a tissue diagnosis. It's pretty reasonable. And as you're clearly aware, sometimes you go in and the imaging suggests there's going to be something super obvious and you don't see anything. And you know, whether that's growing extra luminally into the parenchyma, et cetera, can be a bit of a bit of a quandary.
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Kidney Sparing Approach for Upper Tract Urothelial Carcinoma
Taking a radical approach to upper tract urothelial carcinoma lowers the risk for metastases and progression, but often leads to unnecessary interventions that have detrimental effects due to the loss of kidney function. There is a relatively restrictive set of criteria for the cancers that can be managed by a kidney sparing endoscopic approach. The tumor must be unifocal, and of a size that can be managed endoscopically. The current cutoff is 2 cm, but the criteria is imperfect, and slightly larger tumors may still be manageable endoscopically. The cytology must be negative, and the disease must not show signs of invasiveness on CT. If these criteria are met, the patient may be a candidate for a kidney sparing strategy.
[Dr. Shahrokh Shariat]
So the upper tract is sort of classified in two groups. It's high-risk and low-risk, and this is a moving target. And you mentioned the early papers, with Jay Ramond and so on, we tried to come up with an idea, and Jay was with us at UT Southwestern and trying to come up with an idea of how we can categorize a tumor that is safe to treat with kidney sparing, that we wouldn't lose any because the standard of care was radical nephrectomy for every patient. And we've seen 20 to 25% of patients got unnecessarily radical intervention. We get treatments, not only surgical detriments or a side effect, but also kidney function detriments long-term. So, which patients can we safely spare the kidney, without an increased risk of metastasis and progression, but accepting a high risk of reintervention without metastasis? So the criteria that are currently set forth are very restrictive. A low risk tumor that is sort of, we believe safe for kidney spending approach is a unifocal disease.
But we all know if you have three little TA tumors next to each other, that's not what we mean. Unifocal we mean renal pelvis and ureter. Why? Because the likelihood, if you have a multi-focal disease at different locations, it's more likely to be a higher risk disease that is misclassified as low risk disease. Number two, the tumor size has to be in some sort of volume that is manageable endoscopically. With a modern instrument, with a whole retroflection everything, with access sheath and so on, we can get to all the locations and probably can achieve an adequate specimen. So it's two centimeters currently the cutoff, but we know that the two centimeters is not ideal, like there are three centimeter lesions that could be managed. There are one centimeter lesions that are difficult to manage. The cytology needs to be negative because a high-grade cytology is an indication for high risk disease. And, the biopsy specimen, at least I want to know the grade of the tumor. Right. And on the CT, as you mentioned, no indication for invasiveness. If all those criteria are fulfilled, we feel safe to move with, what do we call it conservative? But conservative is the wrong word its a kidney sparing strategy.
Partial Ureterectomy for Upper Tract Urothelial Carcinoma
A partial ureterectomy, most often a distal ureterectomy, can be a rare tissue sparing option for sicker patients if performed well and followed up carefully. A comprehensive ureteroscopy must be performed after in order to ensure that the rest of the upper tract is clear. It can also be a technically difficult surgery if the tumor extends all the way to the bladder cuff, and it’s important to weigh the benefits against the risk of seeding the peritoneum. Dr. Shariat endorses the use of intraoperative chemotherapy to prevent seeding, but emphasizes that there is not yet good evidence for this approach.
[Dr. Aditya Bagrodia]
I mean, [distal ureterectomies] are rare, it's an older sicker patient and the things that I typically try to teach the residents and fellows are make sure you clear the remainder of the upper tract. You know, they need to get a comprehensive ureteroscopy at some point. And then, I think it can be tricky, say it's a distal ureterectomy, I like to clip above and ideally below. But if it really extends down to the bladder cuff, when you're doing the bladder cuff, I think technically to really get through the perivesical fat, get through the detrusor, have your mucosa out, isolate that. So you're not having tumor spilled and where you're literally holding your you've got your stay stitch in so that you're not having any tumor spill into the peritoneum for instance, or putting yourself at a higher risk of a low local bladder recurrence, any kind of surgical tricks on that Shahrokh?
[Dr. Shahrokh Shariat]
We have tried to look at what is the best management of the distal ureter, doing radical nephroureterectomy, but could be also applied to just distal ureterectomy. What consistent data shows us but I'm not really sure what to make out of it is, number one is you need to remove the whole distal ureter with adequate bladder call. Okay. We kind of all agree with that. That's common sense, but interestingly older, early strategies that we've used to bypass that laparoscopically, doing something stapling across, have been inadequate to consistently achieve a bladder cuff that has sufficient acquisition to ensure that we have a lower risk of intravesical recurrence, which is the end point in many of these tumors.The metastasis in survival, but the intravesical recurrence rate and, you know, in the high-grade tumors also obviously the audit to endpoints. I like to see the superior vesical artery. I like to see the ureter. I like to dissect this all out. If I don't see that I've not dissected far enough and you're always in for a major surprise. How far are you? You feel like you are at the end and you’re still not there. So for me, even robotically. It sounds kind of crazy and overkill, and this is what we've found in all our data. But I think this has to do with selection bias. I open the bladder and I like to look at it from the bladder. So, you know, retro flexing under your ureter, making sure its all out. And I don't like that extravesicular approach, for myself to make sure, but I agree that it, in any concept, it cannot be inferior if you remove the whole specimen, putting the stay suture, as you said. The seeding is always the problem. So you want to ensure that you don't have seeding and one strategy that at UT Southwestern, you and I have learned, and I like a lot, but there's no evidence for that is giving chemotherapy during the surgery. So you start with giving the chemotherapy, you let it in the bladder, you put the three-way catheter, you wash up until you get to that part. It's already out of the system. You may lower them, but you have to make sure you don't have a bladder cancer. The one thing you also want to also make sure you don't do is sew other ureter, you have to have a visualization of the other ureter. Right? So closing that up and making sure that you have a good closure, because that will also determine when you're going to give the postoperative single shot chemotherapy dose. I love the strategy you mentioned, clipping the ureter specifically, radical nephroureterectomy, and immediately clip below the tumor and to decrease it.
Dr. Shahrokh Shariat
Prof. Dr. Shariat heads the University Clinic for Urology at the Vienna General Hospital in Austria.
Dr. Aditya Bagrodia
Dr. Aditya Bagrodia is an associate professor of urology and genitourinary oncology team leader at UC San Diego Health in California and adjunct professor of urology at UT Southwestern.
Cite This Podcast
BackTable, LLC (Producer). (2022, March 23). Ep. 35 – Diagnosis and Management of Upper Tract Urothelial Carcinoma [Audio podcast]. Retrieved from https://www.backtable.com
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