ANAHEIM, CA (UroToday.com) - Dr. Ralph deVere White, University of California, Davis moderated a session on "Are We Underutilizing Minimally Invasive Approaches for Upper Tract TCC?" at the annual SUO meeting at the AUA. The talk was presented by Dr. Stuart Wolf, University of Michigan

Dr. Wolf made an analogy between small renal tumors and small upper tract TCC. Why consider it? He pointed out that renal insufficiency and dialysis and a less than 20% 5-year survival in the elderly. He argued that for low-grade UTUC endoscopy should be an alternative to nephroureterectomy (NU) and ESRD. The diagnosis is made with ureteroscopy and a basket is what Dr. Wolf uses to acquire tissue. 85-100% of low grade tumors are non-invasive at the time of surgery. Ureteroscopy is preferable to percutaneous access in his opinion. He was not in favor of a "TUR" approach, rather he favored ablative techniques. A 6.9-7.5 Fr scope combined with a YAG laser, either Ho or YD. A 2 Fr electrode was his preference. Avoid circumferential ablation and use only as much water pressure as needed.

Percutaneous advantages include access for a larger scope and low pressure irrigation with second-look procedures and administration of chemotherapy. He said the lower pole is difficult for ureteroscopy and a good indication for a percutaneous approach. He prefers not to do the renal puncture in the calyx with the tumor, but does not sacrifice efficacy by accessing a different calyx than that of the tumor if he has to. He gets a nephrostogram at 24-48 hours and does a second look if he has concerns that there is residual tumor. The complication rate of the percutaneous approach is twice that of ureteroscopy (10% vs. 5%).

There is not good randomized evidence regarding use of chemotherapy in the upper tracts. Post endoscopy surveillance relies on ureteroscopy and usually under anesthesia. URS is performed at 3, 6, 12,18 months and then annually. The clock is reset at each recurrence. One must reconsider the concept of endoscopic treatment at every recurrence.

Compared with NU, endoscopic treatment in 110 patients resulted in 15 patients ultimately having a NU. Thus the majority did not need it. However, in his institutions' experience, 3 patients did recur with metastatic disease despite initially presenting with low-grade disease.

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Written by Christopher P. Evans, MD, a Contributing Editor with UroToday.

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