WASHINGTON, DC USA (UroToday.com) - According to SEER data, there has been a migration from more invasive to less invasive disease over time.
Nephroureterectomy results in 25% overtreatment by grade and 37% overtreatment by stage. Lower grade tumors are also more likely to be lower stage. Location of the tumor does not seem to influence grade or stage. An upper tract lesion should undergo evaluation with ureteroscopy, cytologies and biopsies. The pathologist and cytopathologist are key members of the team. Biomarkers may play a greater role in coming years. Accuracy is only 64% with 2-3 cold-cup biopsies, but increases to 100% with ≥6 cold-cup samples. Ureteroscopic biopsy does not negatively impact nephrouretetectomy. Pressure irrigation can theoretically result in tumor dissemination. Blue light imaging and narrow band imaging detect more tumors. Back light illumination as used in mobile phones are under development to permit even smaller endoscope size. Lasers can be used for ablation of small tumors, otherwise resection is needed. Percutaneous access should be through a tumor free calyx. Endo-surveillance can be done in the office if the ureteral orifice does not need dilation. It should be done 3 times per year, he advocated. Recurrence can be due to biological variables or incomplete resection. Tumors >1.5cm or multifocal have higher risk for recurrence and should be considered for adjuvant therapies. BCG can be used for CIS, but data is limited and one study found it of no benefit. In the Mayo clinic series, there is a 73% 5-year CSS but a 43% 5-year recurrence rate. The cost of dialysis is much greater if kidneys are removed. Improved endoscopic technology makes it rational for the transitional cell tumors that are not aggressive.
The EAU guidelines still consider nephroureterectomy as the gold standard, but endourology had a role.
Presented by Anup Patel, MD at the American Urological Association (AUA) Annual Meeting - May 14 - 19, 2011 - Walter E. Washington Convention Center, Washington, DC USA
Reported for UroToday by Christopher P. Evans, MD, FACS, Professor and Chairman, Department of Urology, University of California, Davis, School of Medicine.