Urothelial Tumors of the Renal Pelvis and Ureters Treatment & Management

  • Author: Daniel M Kaplon, MD; Chief Editor: Bradley Fields Schwartz, DO, FACS   more...
 
Updated: Oct 27, 2011
 

Medical Therapy

The medical treatment of superficial upper tract urothelial tumors consists of topical instillation of the chemotherapeutic agents mitomycin C, thiotepa, or bacille Calmette-Guérin (BCG). These agents can be administered either percutaneously, through a ureteral catheter, or intravesically (in patients with vesicoureteral reflux). Topical instillation therapy is most appropriate in patients with multiple superficial disease, carcinoma in situ, bilateral disease, and/or limited renal function. The safety of these agents as adjuvant therapy has been well studied in bladder cancer; however, their efficacy in decreasing recurrence rates, delaying tumor progression, and improving survival rates has not been firmly established in upper urinary tract cancer. Furthermore, the administration of these agents often requires hospitalization and skilled nursing to prevent hyperperfusion and systemic absorption.

  • Superficial (Ta, T1), grades 1-3, and carcinoma in situ
    • Adjuvant topical treatments include retrograde or percutaneous instillation of mitomycin, thiotepa, doxorubicin (Adriamycin), and BCG.
    • The efficacy of these agents in treating upper tract urothelial carcinoma is not well established because of the small retrospective studies with heterogeneous patients and tumor characteristics.
    • BCG is an attenuated form of Mycobacterium tuberculosis, and its use carries a small but significant risk of BCG sepsis. To prevent systemic side effects, BCG should not be used in patients with hematuria. Recurrence rates in the literature following percutaneous retrograde administration of BCG have ranged from 12.5%-28.5% after a follow-up period of between 4 and 59 months.
    • Keeley and Bagley reported on the use of mitomycin administered via a retrograde catheter in 19 patients.[7] They noted a 54% recurrence rate at a mean follow-up of 30 months. No patient had disease progression. This is the most common route of instillation.
    • O’Brien et al found that when a single postoperative intravesical dose of mitomycin C was administered after nephroureterectomy for transitional cell carcinoma, the risk of a bladder tumor was reduced by 40% in the first year following surgery.[8]
    • See reported on the efficacy and safety of Adriamycin as adjuvant therapy in 12 patients.[9] Of the 10 patients evaluated, 50% had disease-free upper tracts at 4-53 months. In this series, Adriamycin was given via continuous infusion to improve dwell time and efficacy. No treatment-related toxicities were observed.
    • Bropirimine has also been used as an oral agent, with limited success.
    • Prospective randomized studies are needed to determine the efficacy and optimal use of these agents as adjuvant therapy for superficial upper tract transitional cell carcinoma (TCC).
  • Muscle invasive (T2) and locally advanced (T3-T4) disease
    • Chemotherapy
      • MVAC (methotrexate, vinblastine, doxorubicin, cisplatin) was once considered standard treatment. However, this combination yields only a modest survival advantage, and optimal dosing is often limited owing to severe toxicity.
      • The response rates, time to progression, and survival rates associated with gemcitabine with cisplatin are similar to those of MVAC, but with less toxicity. Gemcitabine with cisplatin is now considered first-line therapy.
    • Adjuvant and neoadjuvant chemotherapy
      • Neoadjuvant combination chemotherapy (gemcitabine, paclitaxel, carboplatin) is under phase II investigation in patients with advanced urothelial tumors.
      • The efficacy of neoadjuvant chemotherapy for lower tract urothelial carcinoma may apply to upper tract disease; however, randomized studies have not been performed.
    • Radiation
      • In contrast to lower tract disease, radiation generally plays a palliative role in controlling pain and hemorrhage associated with advanced upper tract urothelial carcinoma.
      • Czito et al (2004) reported on the use of adjuvant radiotherapy after resection of T3 or T4 and/or node-positive upper tract TCC. In this retrospective analysis of 31 patients treated from 1970-1997, radiation with concurrent cisplatin chemotherapy improved 5-year survival rates.
      • Prospective studies are needed to better define the role of radiation therapy in the multimodal management of upper tract TCC.
  • Metastatic and node-positive disease
    • Chemotherapy
      • MVAC has been the standard treatment; however, the survival advantage is minimal to moderate, and optimal dosing is often limited owing to severe toxicity.
      • The response rates, time to progression, and survival rates associated with gemcitabine with cisplatin are similar to those of MVAC, but with less toxicity. Gemcitabine with cisplatin is now considered first-line therapy.
      • Sorafenib, an antiangiogenesis molecule and inhibitor of multiple kinases, including Ras kinase, is being evaluated in phase II clinical trials in patients with advanced or metastatic TCC of the bladder, ureter, or renal pelvis. The drugs are effective in advanced renal and other cancers. Members of the Ras kinase superfamily are commonly mutated in TCC and important in proliferation.
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Surgical Therapy

Nephroureterectomy with excision of the bladder cuff is considered the standard therapy in patients with renal pelvis TCC, regionally extensive disease, and high-grade or high-stage lesions.

Segmental ureterectomy coupled with ureteral reimplantation is indicated in patients with ureteral tumors located in the distal ureter, generally of lower grade and stage. Unfortunately, because of the multifocal nature of TCC, the ipsilateral recurrence rate is 25% or greater after segmental ureterectomy.

Renal-sparing surgery, including segmental ureterectomy and endoscopic therapy, maintains a vital role in the management of upper tract urothelial tumors. Typically, patients with small, low-grade superficial lesions are the best candidates for this approach. Some investigators use this approach more frequently in patients with a solitary kidney, bilateral disease, compromised renal function, synchronous tumors, or greater baseline operative risk.

  • Open radical nephroureterectomy
    • Nephroureterectomy is the criterion standard for large, high-grade (grade 3) tumors of the renal pelvis and proximal ureter that are organ-confined or locally advanced. Nephroureterectomy is also recommended for multifocal, recurrent, grade 1-2 tumors, which are found to be less amenable to ureteroscopic management.
    • This procedure involves removal of the kidney, ureter, and bladder cuff via a thoracoabdominal or flank approach with a separate lower quadrant Gibson incision.
    • Care is taken to excise the entire distal ureter and bladder cuff to prevent local recurrence.
    • Lymphadenectomy, which requires little additional operative time, is performed for staging purposes and potentially offers a therapeutic benefit.
  • Laparoscopic nephroureterectomy
    • The indications and oncologic surgical principles for laparoscopic nephroureterectomy are similar to those of the open approach.
    • Pure laparoscopic transperitoneal and retroperitoneal approaches, as well as hand-assisted laparoscopic approaches, have been described. The optimal technique depends largely on surgeon experience.
    • Laparoscopic nephroureterectomy is the preferred approach of 73% of urologists surveyed for the treatment of large, high-grade renal pelvic/upper-ureteral TCC.
    • Optimal management of the bladder cuff remains controversial. Some investigators prefer hand-assisted laparoscopic en bloc excision of the distal ureter with closure of cystotomy defect.
    • Operative time is comparable with that of the standard open procedure.
    • Laparoscopic nephroureterectomy offers the benefits of minimally invasive surgery, including less blood loss, decreased narcotic analgesia requirements, shorter hospitalization, rapid return to normal activity, and improved cosmetic result.
    • A recent series found that laparoscopic nephroureterectomy offers 5-year disease-specific survival rates comparable to those of open radical nephroureterectomy.[10]
  • Distal ureterectomy: High-grade and/or large distal ureteral tumors are most commonly managed with distal ureterectomy with ureterovesical reimplant.
  • Ureteroscopic treatment
    • Ureteroscopy offers a renal-preserving alternative to traditional nephroureterectomy and is used in patients with compromised renal function, bilateral upper tract disease, or other medical contraindications to nephroureterectomy. Ureteroscopic ablation is now the preferred choice for low-grade upper tract TCC.
    • Ureteroscopy allows biopsy and treatment of tumors along the entire upper urinary tract. Cold-cup biopsy forceps or a flat-wire basket is used for tissue diagnosis and to determine tumor grade to plan for future intervention.
    • The use of Nd:YAG and Ho:YAG lasers, as well as small 2F-3F electrosurgical devices enable ureteroscopic resection, coagulation, and ablation of upper tract tumors under direct vision.
    • In 2007, Krambeck et al examined 90 patients with upper tract TCC managed endoscopically who had a history of bladder cancer. They found that the recurrence-free survival rate at 5 years was only 29% in this group. The authors of this study recommended a low threshold for more aggressive surgical intervention upon stage and grade migration.[11]
    • The following are technical considerations for ureteroscopic treatment of upper tract tumors:[12]
      • Obtain adequate tissue during initial biopsy for accurate diagnosis and grade.
      • Minimize the risk of stricture with the use of laser rather than the more deeply penetrating electrosurgical devices when ablating ureteral tumors.
      • Drain the bladder with a small catheter or use a ureteral access sheath to improve flow and visibility, which can be limited by bleeding.
      • Facilitate resection by slowing the patient’s respiratory rate, which decreases movement and stabilizes the operative field during resection and ablation.
  • Percutaneous treatment
    • Percutaneous therapy allows the use of larger scopes with improved maneuverability and visibility to ablate larger tumors in the renal pelvis and upper ureter. Percutaneous access may be used to administer topical therapeutic agents such as BCG, mitomycin, or Adriamycin. This approach is an acceptable alternative to nephroureterectomy in patients with low-to-moderate–grade grade disease. However, as with all organ-preserving strategies, vigilant follow-up surveillance is required.
    • Percutaneous techniques allow a renal-sparing approach and are well suited for large-volume disease of the kidney, renal pelvis, and proximal ureter.
    • Percutaneous access to the diseased renal unit is established, followed by tract dilation to allow the passage of nephroscopes, laser fibers, biopsy forceps, and electrosurgical devices to completely resect and ablate tumors under direct vision.
    • This approach allows better visibility and passage of larger scopes and instruments to facilitate biopsy and treatment of larger and more bulky tumors than ureteroscopy allows.
    • Percutaneous access also allows for a deeper resection and more accurate staging than ureteroscopy for tumors of the renal pelvis and kidney.
    • Tumor seeding of the nephrostomy tract, although rare, has been reported and is associated with high-grade lesions.
    • Recurrence rates by grade are as follows: grade I, 18%; grade II, 33%; and grade III, 50%.
  • Lymph node dissection: A recent study demonstrated a significant survival advantage in patients undergoing extensive regional lymphadenectomy at the time of open nephroureterectomy.[13]
  • Partial nephrectomy: This is rarely performed for large, low-grade cancers.
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Follow-up

Follow-up is largely determined by tumor grade and stage. Tighter follow-up intervals are warranted in patients with higher-grade or higher-stage lesions. Surveillance ureteroscopy under local anesthesia in the clinic is feasible and well tolerated in selected patients. The high rate of recurrence mandates a strict postoperative surveillance for any renal-sparing treatment strategy used to manage upper-tract urothelial tumors.

A standard surveillance protocol consists of cystoscopy and selective urine cytology at 3-month intervals postoperatively for the first year and every 6 months during the second year. Excretory urography or retrograde ureteropyelography can be performed at 3- to 6-month intervals to evaluate the upper tract. Ureteroscopy is the most sensitive tool in detecting recurrence and is performed routinely at 3-month intervals initially, with the frequency increasing to 6 months after the first year. At 2-5 years, cystoscopy and ureteroscopy are continued at 6-month intervals.

  • As mentioned above, ureteroscopy is the preferred surveillance tool in detecting recurrences after endoscopic ablation of upper tract TCC.
  • Ureteroscopy with biopsy and cytology yields a sensitivity of 93.4% and specificity of 65.2%. In the same series, surveillance with retrograde pyelography had a sensitivity and specificity of 71.7% and 84.7%, respectively.[14]
  • Voided urine cytology and microscopic hematuria yield a low sensitivity but reasonable specificity in detecting upper tract recurrences.
  • Upon any recurrence, the endoscopic cycle is restarted.
  • The contralateral collecting system is studied radiographically once yearly with retrograde pyelography or IVP and cytology.
  • Surveillance cystoscopy and imaging of the contralateral upper tract is also required to detect recurrences in patients treated with nephroureterectomy.
  • Several novel markers in addition to urine cytology may be helpful in detecting recurrent urothelial carcinoma. A recent prospective study reported urinary fibrinogen/fibrin degradation products (FDPs), bladder tumor antigen (BTA), and urine cytology to yield sensitivities of 100%, 50%, and 29%, respectively, in detecting upper-tract TCC. Specificity was 83%, 62%, and 59% for FDP, BTA, and cytology, respectively.[15]

For excellent patient education resources, visit eMedicine's Cancer and Tumors Center and Kidneys and Urinary System Center. Also, see eMedicine's patient education articles Bladder Cancer, Blood in the Urine, Intravenous Pyelogram, and Cystoscopy.

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Complications

Complications related to nontreatment

  • Disease progression
  • Obstruction
  • Bleeding
  • Infection
  • Metastasis
  • Death
  • See images below.CT scan demonstrating bulky right renal pelvis traCT scan demonstrating bulky right renal pelvis transitional cell carcinoma (TCC) replacing the majority of the renal parenchyma. A pericaval lymph node metastasis is noted. Courtesy of Andrew J. Taylor, MD, University of Wisconsin Medical School. CT scan demonstrating metastatic transitional cellCT scan demonstrating metastatic transitional cell carcinoma (TCC) of the right adrenal gland. A heterogeneous adrenal mass is noted adjacent to the spine. The superior portion of the right kidney is observed. Courtesy of Andrew J. Taylor, MD, University of Wisconsin Medical School.

Treatment-related complications

  • Open nephroureterectomy: The potential risks of surgery include bleeding, infection, injury to surrounding bowel or viscera, and abdominal wall laxity due to neurapraxia. Open procedures are associated with an increased risk of postoperative pulmonary complications relative to the laparoscopic approach.
  • Laparoscopic nephroureterectomy: Bleeding, infection, injury to surrounding bowel or viscera, and port site hernia are several complications to fully discuss with patients during the informed consent process.
  • Endoscopic surgery: Ureteral perforation, delayed ureteral stricture, extraluminal tumor spillage, and tumor propagation are some of several complications associated with endoscopic surgery. In addition, the reliability in staging tumors is lacking with this approach. Percutaneous surgery carries a risk of immediate and delayed bleeding, a theoretical risk of tumor seeding, and a risk of pleural cavity violation, potentially resulting in hydrothorax that will necessitate chest tube drainage.
  • Medical therapy: Instillation of topical chemotherapeutic agents is associated with collecting system scarring, obstruction, systemic absorption, sepsis, and toxic agranulocytosis due to heightened perfusion pressures. Medical therapy carries a complication profile that is similar to that of nontreatment.
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Outcome and Prognosis

Total nephroureterectomy (5-year survival by stage)

  • Stage Tis, Ta, T1 - 91%
  • Stage T2 - 43%
  • Stage T3/T4 or N1/N2 - 23%
  • Stage N3/M1 - 0%

On multivariate analysis, only stage and age were significant prognostic factors for survival. The type of surgical procedure (radical vs renal-sparing) approached significance. Most evidence suggests that, for small, low-grade/low-stage tumors, a renal-sparing procedure and nephroureterectomy achieve equivalent results. In one recent study of ureteroscopic management of 23 patients with mostly low-to-intermediate–grade upper tract tumors, all patients were alive without evidence of disease progression with a 35-month mean follow-up period.[16] Evidence demonstrates that patients with grade III lesions cannot be cured with anything short of radical surgery.

Advanced age has heretofore been thought to bring a dire prognosis for patients with upper tract urothelial carcinoma who undergo radical nephroureterectomy; however, a study by Chromecki et al found that a high percentage of elderly patients who underwent the procedure were cured, leading to the belief that chronological age alone is an unreliable criteria for outcome in older patients.[17]

For patients with a higher body mass index who were treated with radical nephroureterectomy, a study by Ehdaie et al found overall survival rates were diminished.[18]

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Future and Controversies

  • Laparoscopic nephroureterectomy (with or without hand assist) is poised to become the procedure of choice for renal pelvis or high-grade tumors.
  • Endoscopic ablative procedures will be used more commonly for low-grade, low-stage disease and in patients in whom renal-sparing therapy is indicated.
  • New agents for topical instillation therapy of upper tract urothelial tumors are being developed.
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Contributor Information and Disclosures
Author

Daniel M Kaplon, MD  Fellow in Endourology, Laparoscopy, and Robotics, Department of Urology, University of Wisconsin Medical School

Daniel M Kaplon, MD is a member of the following medical societies: American Urological Association

Disclosure: Nothing to disclose.

Coauthor(s)

David F Jarrard, MD  Professor of Urology and Molecular and Environmental Toxicology, University of Wisconsin School of Medicine and Public Health

David F Jarrard, MD is a member of the following medical societies: American Urological Association

Disclosure: Johnson and Johnson Consulting fee Consulting

John N Papadopoulos, MD  Staff Physician, Department of Urology, Veterans Administration Hospital and Meriter Hospital

Disclosure: Nothing to disclose.

Specialty Editor Board

Leonard Gabriel Gomella, MD, FACS  The Bernard W Godwin Professor of Prostate Cancer Chairman, Department of Urology, Associate Director of Clinical Affairs, Kimmel Cancer Center, Jefferson Medical College of Thomas Jefferson University

Leonard Gabriel Gomella, MD, FACS is a member of the following medical societies: American Association for Cancer Research, American College of Surgeons, American Medical Association, American Society for Laser Medicine and Surgery, American Urological Association, Sigma Xi, Society for Basic Urologic Research, Society of University Urologists, and Society of Urologic Oncology

Disclosure: GSK Consulting fee Consulting; Astra Zeneca Honoraria Speaking and teaching; Watson Pharmaceuticals Consulting fee Consulting

Francisco Talavera, PharmD, PhD  Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

Dan Theodorescu, MD, PhD  Paul A Bunn Professor of Cancer Research, Professor of Surgery and Pharmacology, Director, University of Colorado Comprehensive Cancer Center

Dan Theodorescu, MD, PhD is a member of the following medical societies: American Cancer Society, American College of Surgeons, American Urological Association, Medical Society of Virginia, Society for Basic Urologic Research, and Society of Urologic Oncology

Disclosure: Key Genomics Ownership interest Co-Founder-50% Stock Ownership

J Stuart Wolf Jr, MD, FACS  The David A Bloom Professor of Urology, Director, Division of Endourology and Stone Disease, Department of Urology, University of Michigan Medical School

J Stuart Wolf Jr, MD, FACS is a member of the following medical societies: American College of Surgeons, American Urological Association, Catholic Medical Association, Endourological Society, Society for Urology and Engineering, Society of Laparoendoscopic Surgeons, Society of University Urologists, and Society of Urologic Oncology

Disclosure: Nothing to disclose.

Chief Editor

Bradley Fields Schwartz, DO, FACS  Professor of Urology, Director, Center for Laparoscopy and Endourology, Department of Surgery, Southern Illinois University School of Medicine

Bradley Fields Schwartz, DO, FACS is a member of the following medical societies: American College of Surgeons, American Urological Association, Association of Military Osteopathic Physicians and Surgeons, Endourological Society, Society of Laparoendoscopic Surgeons, and Society of University Urologists

Disclosure: Nothing to disclose.

Additional Contributors

The authors and editors of eMedicine gratefully acknowledge the contributions of previous coauthor Michael N Wilkin, MD, to the development and writing of this article.

References

  1. Raman JD, Scherr DS. Management of patients with upper urinary tract transitional cell carcinoma. Nat Clin Pract Urol. Aug 2007;4(8):432-43. [Medline].

  2. Rouprêt M, Fromont G, Azzouzi AR, Catto JW, Vallancien G, Hamdy FC, et al. Microsatellite instability as predictor of survival in patients with invasive upper urinary tract transitional cell carcinoma. Urology. Jun 2005;65(6):1233-7. [Medline].

  3. Roupret M, Catto J, Coulet F, Azzouzi AR, Amira N, Karmouni T, et al. Microsatellite instability as indicator of MSH2 gene mutation in patients with upper urinary tract transitional cell carcinoma. J Med Genet. Jul 2004;41(7):e91. [Medline].

  4. Smith SD, Wheeler MA, Plescia J, Colberg JW, Weiss RM, Altieri DC. Urine detection of survivin and diagnosis of bladder cancer. JAMA. Jan 17 2001;285(3):324-8. [Medline].

  5. Sarosdy MF, Kahn PR, Ziffer MD, Love WR, Barkin J, Abara EO. Use of a multitarget fluorescence in situ hybridization assay to diagnose bladder cancer in patients with hematuria. J Urol. Jul 2006;176(1):44-7. [Medline].

  6. Hall MC, Womack S, Sagalowsky AI. Prognostic factors, recurrence, and survival in transitional cell carcinoma of the upper urinary tract: a 30-year experience in 252 patients. Urology. Oct 1998;52(4):594-601. [Medline].

  7. Keeley FX Jr, Bagley DH. Adjuvant mitomycin C following endoscopic treatment of upper tract transitional cell carcinoma. J Urol. Dec 1997;158(6):2074-7. [Medline].

  8. O'Brien T, Ray E, Singh R, Coker B, Beard R. Prevention of bladder tumours after nephroureterectomy for primary upper urinary tract urothelial carcinoma: a prospective, multicentre, randomised clinical trial of a single postoperative intravesical dose of mitomycin C (the ODMIT-C Trial). Eur Urol. Oct 2011;60(4):703-10. [Medline].

  9. See WA. Continuous antegrade infusion of adriamycin as adjuvant therapy for upper tract urothelial malignancies. Urology. Aug 1 2000;56(2):216-22. [Medline].

  10. Waldert M, Remzi M, Klingler HC, Mueller L, Marberger M. The oncological results of laparoscopic nephroureterectomy for upper urinary tract transitional cell cancer are equal to those of open nephroureterectomy. BJU Int. Jan 2009;103(1):66-70. [Medline].

  11. Krambeck AE, Thompson RH, Lohse CM, Patterson DE, Segura JW, Zincke H, et al. Endoscopic management of upper tract urothelial carcinoma in patients with a history of bladder urothelial carcinoma. J Urol. May 2007;177(5):1721-6. [Medline].

  12. Nakada SY, Pearle MS. Advanced Endourology: The Complete Clinical Guide. Humana Press; 2005:277-8.

  13. Kondo T, Nakazawa H, Ito F, Hashimoto Y, Toma H, Tanabe K. Impact of the extent of regional lymphadenectomy on the survival of patients with urothelial carcinoma of the upper urinary tract. J Urol. Oct 2007;178(4 Pt 1):1212-7; discussion 1217. [Medline].

  14. Chen GL, El-Gabry EA, Bagley DH. Surveillance of upper urinary tract transitional cell carcinoma: the role of ureteroscopy, retrograde pyelography, cytology and urinalysis. J Urol. Dec 2000;164(6):1901-4. [Medline].

  15. Siemens DR, Morales A, Johnston B, Emerson L. A comparative analysis of rapid urine tests for the diagnosis of upper urinary tract malignancy. Can J Urol. Feb 2003;10(1):1754-8. [Medline].

  16. Chen GL, Bagley DH. Ureteroscopic management of upper tract transitional cell carcinoma in patients with normal contralateral kidneys. J Urol. Oct 2000;164(4):1173-6. [Medline].

  17. Chromecki TF, Ehdaie B, Novara G, et al. Chronological age is not an independent predictor of clinical outcomes after radical nephroureterectomy. World J Urol. Aug 2011;29(4):473-80. [Medline].

  18. Ehdaie B, Chromecki TF, Lee RK, et al. Obesity adversely impacts disease specific outcomes in patients with upper tract urothelial carcinoma. J Urol. Jul 2011;186(1):66-72. [Medline].

  19. Anderstrom C, Johansson SL, Pettersson S. Carcinoma of the ureter: a clinicopathologic study of 49 cases. J Urol. Aug 1989;142(2 Pt 1):280-3. [Medline].

  20. Babaian RJ, Johnson DE. Primary carcinoma of the ureter. J Urol. Mar 1980;123(3):357-9. [Medline].

  21. Bagley DH. Ureteroscopic treatment of upper urinary tract neoplasms. In: Smith AD, ed. Smith's Textbook of Endourology. ed. St. Louis, Mo: Quality Medical Publishing; 1996:474.

  22. Batata MA, Whitmore WF, Hilaris BS. Primary carcinoma of the ureter: a prognostic study. Cancer. Jun 1975;35(6):1626-32. [Medline].

  23. Bazeed MA, Scharfe T, Becht E. Local excision of urothelial cancer of the upper urinary tract. Eur Urol. 1986;12(2):89-95. [Medline].

  24. Bellman GC, Sweetser P, Smith AD. Complications of intracavitary bacillus Calmette-Guerin after percutaneous resection of upper tract transitional cell carcinoma. J Urol. Jan 1994;151(1):13-5. [Medline].

  25. Bloom NA, Vidone RA, Lytton B. Primary carcinoma of the ureter: a report of 102 new cases. J Urol. May 1970;103(5):590-8. [Medline].

  26. Blute ML, Segura JW, Patterson DE. Impact of endourology on diagnosis and management of upper urinary tract urothelial cancer. J Urol. Jun 1989;141(6):1298-301. [Medline].

  27. Boorjian S, Ng C, Munver R, Palese MA, Vaughan ED Jr, Sosa RE. Impact of delay to nephroureterectomy for patients undergoing ureteroscopic biopsy and laser tumor ablation of upper tract transitional cell carcinoma. Urology. Aug 2005;66(2):283-7. [Medline].

  28. Brown JA, Strup SE, Chenven E, Bagley D, Gomella LG. Hand-assisted laparoscopic nephroureterectomy: analysis of distal ureterectomy technique, margin status, and surgical outcomes. Urology. Dec 2005;66(6):1192-6. [Medline].

  29. Cairns P, Proctor AJ, Knowles MA. Loss of heterozygosity at the RB locus is frequent and correlates with muscle invasion in bladder carcinoma. Oncogene. Dec 1991;6(12):2305-9. [Medline].

  30. Chahal R, Taylor K, Eardley I, Lloyd SN, Spencer JA. Patients at high risk for upper tract urothelial cancer: evaluation of hydronephrosis using high resolution magnetic resonance urography. J Urol. Aug 2005;174(2):478-82; quiz 801. [Medline].

  31. Cordon-Cardo C, Zhang ZF, Dalbagni G, Drobnjak M, Charytonowicz E, Hu SX, et al. Cooperative effects of p53 and pRB alterations in primary superficial bladder tumors. Cancer Res. Apr 1 1997;57(7):1217-21. [Medline].

  32. Cote RJ, Dunn MD, Chatterjee SJ, Stein JP, Shi SR, Tran QC, et al. Elevated and absent pRb expression is associated with bladder cancer progression and has cooperative effects with p53. Cancer Res. Mar 15 1998;58(6):1090-4. [Medline].

  33. Czerniak B, Chaturvedi V, Li L, Hodges S, Johnston D, Roy JY, et al. Superimposed histologic and genetic mapping of chromosome 9 in progression of human urinary bladder neoplasia: implications for a genetic model of multistep urothelial carcinogenesis and early detection of urinary bladder cancer. Oncogene. Feb 4 1999;18(5):1185-96. [Medline].

  34. Czito B, Zietman A, Kaufman D, Skowronski U, Shipley W. Adjuvant radiotherapy with and without concurrent chemotherapy for locally advanced transitional cell carcinoma of the renal pelvis and ureter. J Urol. Oct 2004;172(4 Pt 1):1271-5. [Medline].

  35. Eastham JA, Huffman JL. Technique of mitomycin C instillation in the treatment of upper urinary tract urothelial tumors. J Urol. Aug 1993;150(2 Pt 1):324-5. [Medline].

  36. Grace DA, Taylor WN, Taylor JN. Carcinoma of the renal pelvis: a 15-year review. J Urol. Nov 1967;98(5):566-9. [Medline].

  37. Greenland JE, Weston PM, Wallace DM. Familial transitional cell carcinoma and the Lynch syndrome II. Br J Urol. Aug 1993;72(2):177-80. [Medline].

  38. Grossman HB, Schwartz SL, Konnak JW. Ureteroscopic treatment of urothelial carcinoma of the ureter and renal pelvis. J Urol. Aug 1992;148(2 Pt 1):275-7. [Medline].

  39. Harris CC, Hollstein M. Clinical implications of the p53 tumor-suppressor gene. N Engl J Med. Oct 28 1993;329(18):1318-27. [Medline].

  40. Huang A, Low RK, deVere White R. Nephrostomy tract tumor seeding following percutaneous manipulation of a ureteral carcinoma. J Urol. Mar 1995;153(3 Pt 2):1041-2. [Medline].

  41. Jarrett TW, Sweetser PM, Weiss GH. Percutaneous management of transitional cell carcinoma of the renal collecting system: 9-year experience. J Urol. Nov 1995;154(5):1629-35. [Medline].

  42. Jensen OM, Knudsen JB, McLaughlin JK. The Copenhagen case-control study of renal pelvis and ureter cancer: role of smoking and occupational exposures. Int J Cancer. Apr 15 1988;41(4):557-61. [Medline].

  43. Johansson S, Wahlqvist L. A prognostic study of urothelial renal pelvic tumors: comparison between the prognosis of patients treated with intrafascial nephrectomy and perifascial nephroureterectomy. Cancer. Jun 1979;43(6):2525-31. [Medline].

  44. Johnson DE, Babaian RJ. Conservative surgical management for noninvasive distal ureteral carcinoma. Urology. Apr 1979;13(4):365-7. [Medline].

  45. Keeley FX Jr, Bibbo M, Bagley DH. Ureteroscopic treatment and surveillance of upper urinary tract transitional cell carcinoma. J Urol. May 1997;157(5):1560-5. [Medline].

  46. Lantz EJ, Hattery RR. Diagnostic imaging of urothelial cancer. Urol Clin North Am. Nov 1984;11(4):567-83. [Medline].

  47. Lee BR, Jabbour ME, Marshall FF. 13-year survival comparison of percutaneous and open nephroureterectomy approaches for management of transitional cell carcinoma of renal collecting system: equivalent outcomes. J Endourol. May 1999;13(4):289-94. [Medline].

  48. Lee D, Trabulsi E, McGinnis D, et al. Totally endoscopic management of upper tract transitional-cell carcinoma. J Endourol. Feb 2002;16(1):37-41. [Medline].

  49. Mazeman E, Biserte J. Renal-sparing treatment of upper tract urothelial tumors. Curr Opin Urol. 1994;4:168-73.

  50. McCoy JG, Honda H, Reznicek M. Computerized tomography for detection and staging of localized and pathologically defined upper tract urothelial tumors. J Urol. Dec 1991;146(6):1500-3. [Medline].

  51. Messing EM, Catalona W. Urothelial tumors of the urinary tract. In: Walsh PC, Retik AB, Vaughan ED Jr et al, eds. Campbell's Urology. 7th ed. Philadelphia, Pa: WB Saunders; 1998:2327-410.

  52. Murphy DM, Zincke H, Furlow WL. Management of high grade transitional cell cancer of the upper urinary tract. J Urol. Jan 1981;125(1):25-9. [Medline].

  53. Murphy DM, Zincke H, Furlow WL. Primary grade 1 transitional cell carcinoma of the renal pelvis and ureter. J Urol. May 1980;123(5):629-31. [Medline].

  54. Nonomura N, Ono Y, Nozawa M, Fukui T, Harada Y, Nishimura K. Bacillus Calmette-Guérin perfusion therapy for the treatment of transitional cell carcinoma in situ of the upper urinary tract. Eur Urol. Dec 2000;38(6):701-4;discussion 705. [Medline].

  55. O'Donoghue JP, Crew JP. Adjuvant topical treatment of upper urinary tract urothelial tumours. BJU Int. Sep 2004;94(4):483-5. [Medline].

  56. Patel A, Fuchs GJ. New techniques for the administration of topical adjuvant therapy after endoscopic ablation of upper urinary tract transitional cell carcinoma. J Urol. Jan 1998;159(1):71-5. [Medline].

  57. Petkovic SD. Epidemiology and treatment of renal pelvic and ureteral tumors. J Urol. Dec 1975;114(6):858-65. [Medline].

  58. Radovanovic Z, Krajinovic S, Jankovic S. Family history of cancer among cases of upper urothelial tumours in a Balkan nephropathy area. J Cancer Res Clin Oncol. 1985;110(2):181-3. [Medline].

  59. Ramsey JC, Soloway MS. Instillation of bacillus Calmette-Guerin into the renal pelvis of a solitary kidney for the treatment of transitional cell carcinoma. J Urol. Jun 1990;143(6):1220-2. [Medline].

  60. Razdan S, Johannes J, Cox M, Bagley DH. Current practice patterns in urologic management of upper-tract transitional-cell carcinoma. J Endourol. Apr 2005;19(3):366-71. [Medline].

  61. Resseguie LJ, Nobrega FT, Farrow GM. Epidemiology of renal and ureteral cancer in Rochester, Minnesota, 1950- 1974, with special reference to clinical and pathologic features. Mayo Clin Proc. Aug 1978;53(8):503-10. [Medline].

  62. Schlegel PN. What's new in urology. J Am Coll Surg. Aug 2001;193(2):179-201. [Medline].

  63. Seaman EK, Slawin KM, Benson MC. Treatment options for upper tract transitional-cell carcinoma. Urol Clin North Am. May 1993;20(2):349-54. [Medline].

  64. Shalhav AL, Dunn MD, Portis AJ. Laparoscopic nephroureterectomy for upper tract transitional cell cancer: the Washington University experience. J Urol. 2000;163 (4):1100-1104. [Medline].

  65. Sharpe JR, Duffy G, Chin JL. Intrarenal bacillus Calmette-Guerin therapy for upper urinary tract carcinoma in situ. J Urol. Mar 1993;149(3):457-9; discussion 459-60. [Medline].

  66. Simoneau M, Aboulkassim TO, LaRue H, Rousseau F, Fradet Y. Four tumor suppressor loci on chromosome 9q in bladder cancer: evidence for two novel candidate regions at 9q22.3 and 9q31. Oncogene. Jan 7 1999;18(1):157-63. [Medline].

  67. Spires SE, Banks ER, Cibull ML. Adenocarcinoma of renal pelvis [published erratum appears in Arch Pathol Lab Med 1994 Sep;118(9):872]. Arch Pathol Lab Med. Nov 1993;117(11):1156-60. [Medline].

  68. Stein A, Sova Y, Lurie M. Adenocarcinoma of the renal pelvis. Report of two cases, one with simultaneous transitional cell carcinoma of the bladder. Urol Int. 1988;43(5):299-301. [Medline].

  69. Stower MJ, MacIver AG, Gingell JC. Inverted papilloma of the ureter with malignant change. Br J Urol. Jan 1990;65(1):13-6. [Medline].

  70. Tanagho EA. Anatomy of the Genitourinary Tract. In: Tanagho EA, McAninch JW, eds. Smith's General Urology. 15th ed. New York, NY: McGraw-Hill; 2000:4-7.

  71. Tawfiek ER, Bagley DH. Upper-tract transitional cell carcinoma. Urology. Sep 1997;50(3):321-9. [Medline].

  72. Tomera KM, Leary FJ, Zincke H. Pyeloscopy in urothelial tumors. J Urol. Jun 1982;127(6):1088-9. [Medline].

  73. Vasavada SP, Streem SB, Novick AC. Definitive tumor resection and percutaneous bacille Calmette-Guerin for management of renal pelvic transitional cell carcinoma in solitary kidneys. Urology. Mar 1995;45(3):381-6. [Medline].

  74. von der Maase H, Hansen SW, Roberts JT, et al. Gemcitabine and cisplatin versus methotrexate, vinblastine, doxorubicin, and cisplatin in advanced or metastatic bladder cancer: results of a large, randomized, multinational, multicenter, phase III study. J Clin Oncol. Sep 2000;18(17):3068-77. [Medline].

 
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Intravenous pyelogram (IVP) demonstrating an upper calyx filling defect characteristic of transitional cell carcinoma (TCC). Blunting of the involved calyx is noted. Courtesy of Andrew J. Taylor, MD, University of Wisconsin Medical School.
CT scan demonstrating right renal pelvis transitional cell carcinoma (TCC). Contrast in the renal pelvis is displaced by the tumor. Courtesy of Andrew J. Taylor, MD, University of Wisconsin Medical School.
CT scan demonstrating left distal ureteral transitional cell carcinoma (TCC). The left ureter is dilated and a medial filling defect is noted. Courtesy of Andrew J. Taylor, MD, University of Wisconsin Medical School.
Left retrograde ureterogram demonstrating the classic "goblet" sign of ureteral transitional cell carcinoma (TCC). Ureteral dilation distally and proximally to the tumor is present. The narrowed wall of the ureter is irregular. Courtesy of Andrew J. Taylor, MD, University of Wisconsin Medical School.
CT scan demonstrating bulky right renal pelvis transitional cell carcinoma (TCC) replacing the majority of the renal parenchyma. A pericaval lymph node metastasis is noted. Courtesy of Andrew J. Taylor, MD, University of Wisconsin Medical School.
CT scan demonstrating metastatic transitional cell carcinoma (TCC) of the right adrenal gland. A heterogeneous adrenal mass is noted adjacent to the spine. The superior portion of the right kidney is observed. Courtesy of Andrew J. Taylor, MD, University of Wisconsin Medical School.
Treatment algorithm for managing upper-tract transitional cell carcinoma (TCC).
 
 
 
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