1442 | Kidney Sparing Surgery for Urothelial Carcinoma of the Pyelocalyceal System: Is There a Role for Open Techniques? Re- sults from a Small Series Stefan Latz, Stefan Hauser, Stefan C. Müller, Guido Fechner Purpose: To‎evaluate‎ individually‎ tailored‎open‎nephron-sparing‎surgical‎ techniques‎for‎ urothelial‎carcinoma‎of‎the‎pyelocalyceal‎system‎(UCPCS).‎ Materials and Methods:‎Four‎patients‎underwent‎nephron-sparing‎surgery‎for‎UCPCS‎in- cluding,‎open‎partial‎resection‎of‎the‎pyelon‎with‎peritoneal‎reconstruction,‎partial‎nephrec- tomy,‎open‎partial‎resection‎of‎the‎pyelon‎with‎kidney‎autotransplantation,‎combined‎open‎ resection and calicoscopic laser coagulation. Results:‎Recurrence-free‎survival‎was‎24‎months‎without‎any‎impairment‎of‎kidney‎function‎ in all patients. Conclusion:‎Open‎nephron-sparing‎surgery‎for‎UCPCS‎should‎be‎taken‎into‎consideration‎ for‎selected‎cases. Keywords: carcinoma;‎transitional‎cell;‎urothelium;‎organ‎sparing‎treatments;‎treatment‎out- come;‎neoplasm‎recurrence;‎pelvic‎neoplasms. Corresponding Author: Stefan Latz, MD Department of Urology, Bonn University, Sigmund-Freud St. 25, 53127 Bonn, Germany. Tel: +49 228 287 14180 Fax: +49 228 287 19150 E-mail: stefan.latz@ukb.uni- bonn.de Received June 2013 Accepted January 2014 Department of Urology, Bonn University, Sigmund-Freud St. 25, 53127 Bonn, Germany. Urological Oncology UROLOGICAL ONCOLOGY 1443Vol. 11 | No. 02 | March- April 2014 |U R O LO G Y J O U R N A L INTRODUCTION Radical‎nephroureterectomy‎(RNU)‎with‎excision‎of‎a‎bladder‎cuff‎is‎considered‎as‎standard‎treat-ment‎ for‎ urothelial‎ carcinoma‎ of‎ the‎ pyelocal- yceal‎system‎for‎best‎survival.(1)‎According‎to‎the‎risk‎of‎ potential‎overtreatment‎especially‎in‎low‎grade‎tumors‎less‎ invasive‎ kidney-sparing‎ strategies‎ have‎ been‎ introduced‎ successfully‎ for‎ selected‎ cases.(2)‎ Both‎ percutaneous‎ and‎ ureteroscopic‎treatment‎could‎show‎efficient‎cancer‎control‎ but‎relevant‎risk‎of‎recurrence‎and‎progression.‎As‎a‎conse- quence,‎Cutress‎and‎colleagues‎concluded‎from‎a‎systemat- ic‎review‎that‎endoscopic‎kidney‎sparing‎treatment‎should‎ be‎limited‎to‎imperative‎indications‎in‎the‎context‎of‎the‎ patient's‎overall‎life‎expectancy‎and‎competing‎comorbid- ity.(3) In contrast, in patients with distal ureteric urothelial carcinoma‎RNU‎has‎been‎completely‎replaced‎by‎segmen- tal‎ ureteric‎ resection‎ followed‎ by‎ ureteroneocystostomy.‎ Here‎excellent‎results‎comparable‎to‎RNU‎are‎provided‎in- dependent‎of‎tumor‎stage‎and‎grade.(4)‎We‎report‎on‎a‎small‎ series‎of‎selected‎patients‎with‎urothelial‎carcinoma‎of‎the‎ pyelocalyceal‎system‎and‎imperative‎indications‎for‎kidney‎ sparing‎surgery‎who‎underwent‎open‎surgery‎with‎individu- ally‎adjusted‎techniques.‎ MATERIALS AND METHODS Case 1 A‎55‎years‎old‎female‎patient‎presented‎with‎a‎papillary‎le- sion‎of‎the‎right‎renal‎pelvis‎as‎metachronous‎manifestation‎of‎ UCPCS.‎Five‎years‎before,‎invasive‎urothelial‎carcinoma‎of‎ the‎left‎kidney‎was‎diagnosed‎and‎treated‎with‎RNU.‎Preop- erative‎serum‎creatinine‎was‎1.0‎mg/dL.‎For‎technical‎reasons‎ ureteroscopic‎laser‎coagulation‎was‎only‎partially‎feasible.‎We‎ performed‎an‎open‎resection‎of‎the‎tumor‎bearing‎renal‎pelvis‎ (classified‎as‎low‎grade‎urothelial‎carcinoma‎pTa‎in‎the‎final‎ specimen)‎including‎a‎right‎sided‎complete‎ureterectomy‎fol- lowed‎by‎an‎autotransplantation‎of‎the‎right‎kidney‎in‎the‎left‎ iliac‎fossa.‎Urinary‎drainage‎was‎achieved‎by‎direct‎pyelovesi- costomy.‎A‎14‎French‎(F)‎stent‎was‎placed‎in‎the‎pyelovesicos- tomy‎intraoperatively‎and‎could‎be‎removed‎on‎the‎12th day after‎surgery.‎Clinical‎course‎was‎uneventful.‎In‎2012‎there‎is‎ no‎evidence‎of‎recurrence.‎Routine‎follow-up‎is‎performed‎by‎ cystoscopy‎easily‎passing‎the‎pyelovesicostomy‎into‎each‎re- nal‎calyx‎with‎a‎flexible‎cystoscope‎(Figure‎1).‎ Case 2 After‎gross‎hematuria‎transitional‎cell‎carcinoma‎(TCC)‎of‎ the‎upper‎urinary‎tract‎was‎diagnosed‎in‎a‎60‎years‎old‎male‎ patient‎with‎a‎single‎kidney‎40‎years‎after‎left‎sided‎nephrec- tomy‎for‎nephrolithiasis.‎Ureteroscopy‎gave‎evidence‎of‎a‎ TCC‎with‎a‎diameter‎of‎3‎centimeters‎located‎in‎the‎renal‎pel- vis.‎In‎contrast‎to‎its‎large‎volume,‎the‎tumor‎was‎considered‎ most‎probably‎as‎superficial.‎Preoperative‎serum‎creatinine‎ was‎1.3‎mg/dL.‎Therefore‎we‎performed‎open‎partial‎pye- lonic‎resection‎followed‎by‎free‎peritoneal‎flap‎reconstruc- tion‎supported‎by‎greater‎omentum.‎A‎urinary‎leak‎demanded‎ percutaneous‎drainage‎combined‎with‎ureteric‎stenting‎for‎8‎ weeks‎postoperatively.‎Pathologists‎diagnosed‎a‎low‎grade‎ urothelial‎carcinoma‎pTa‎in‎the‎final‎specimen.‎In‎2012‎the‎ patient‎is‎recurrence-free‎without‎any‎functional‎impairment‎ of‎the‎kidney‎(Figure‎2). Case 3 The‎ main‎ reason‎ for‎ initial‎ clinical‎ presentation‎ in‎ a‎ 61‎ years‎old‎man‎was‎gross‎hematuria‎caused‎by‎bladder‎can- cer.‎Complete‎transurethral‎resection‎was‎carried‎out‎and‎as‎ a‎high‎grade‎pT1‎urothelial‎carcinoma‎was‎found,‎a‎second‎ resection‎was‎planned‎after‎6‎weeks.‎Surprisingly,‎multifocal‎ tumor‎recurrence‎was‎detected,‎including‎urethra‎and‎upper‎ urinary‎tract‎on‎both‎sides‎(Figure‎3).‎Preoperative‎creatinine‎ was‎1.1‎mg/dL.‎Thus‎radical‎cystectomy‎including‎urethrec- tomy‎was‎carried‎out.‎To‎prevent‎the‎patient‎from‎hemodi- alysis‎therapy‎(and‎on‎his‎strong‎demand),‎right-sided‎neph- roureterectomy‎combined‎with‎left‎sided‎urethrectomy‎was‎ performed.‎Multifocal‎urothelial‎carcinoma‎of‎the‎left‎pyelo- calyceal‎system‎was‎treated‎with‎combined‎open‎resection‎ and‎intraoperative‎open‎pyeloscopic‎laser‎coagulation.‎An‎il- eal‎conduit‎was‎sutured‎to‎the‎left‎renal‎pelvis‎for‎retrograde‎ pyeloscopic‎follow-up‎(Figure‎4).‎A‎14‎F‎stent‎placed‎in‎the‎ pyeloileal‎anastomosis‎intraoperatively‎which‎was‎removed‎ after‎12‎days.‎Postoperative‎course‎was‎uneventful.‎In‎the‎fi- nal‎specimen‎low‎grade‎pTa‎urothelial‎carcinoma‎of‎the‎renal‎ pelvis‎and‎urethra‎were‎diagnosed,‎respectively.‎In‎the‎blad- der‎pathologists‎found‎a‎low‎grade‎urothelial‎carcinoma‎pT1,‎ lymph‎node‎negative.‎After‎routine‎3-monthly‎retrograde‎py- eloscopy‎for‎2‎years‎a‎lesion‎of‎the‎lower‎calyx‎suspicious‎ for‎carcinoma‎in‎situ‎was‎detected.‎For‎technical‎reasons‎a‎ biopsy‎was‎not‎possible,‎but‎barbotage‎cytology‎gave‎evi- dence‎of‎high‎grade‎TCC.‎A‎weekly‎bacillus‎calmette-guerin‎ (BCG)‎installation‎via‎ureteric‎stent‎was‎started,‎followed‎by‎ Open Nephron-Sparing Surgery for UCPCS | Latz et al 1444 | BCG‎maintenance‎therapy‎which‎is‎now‎ongoing.‎ Case 4 In‎a‎60‎years‎old‎woman‎localized‎urothelial‎carcinoma‎in‎ the‎upper‎calyx‎of‎the‎right‎kidney‎was‎diagnosed‎(Figure‎5).‎ Due‎to‎a‎scheduled‎chemotherapy‎for‎metastatic‎breast‎can- cer,‎preservation‎of‎renal‎function‎was‎mandatory.‎Preopera- tive‎serum‎creatinine‎was‎1.3‎mg/dL.‎For‎technical‎reasons‎ ureteroscopic‎laser‎coagulation‎was‎impossible.‎Therefore,‎ an‎upper‎pole‎resection‎of‎the‎kidney‎was‎performed‎(patho- Figure 1. Cystoscope passing pyelovesicostomy (edge in foreground) facing the renal pelvis and calyxes after autotransplantation. Figure 2. Retrograde uretreopyelography after partial resection of the renal pelvis and reconstruction with a peritoneal flap. Figure 3. Intravenous urography with panurothelial transitional cell carcinoma. Figure 4. Retrograde contrast filling of ileal conduit connected to the left renal pelvis. Urological Oncology 1445Vol. 11 | No. 02 | March- April 2014 |U R O LO G Y J O U R N A L Open Nephron-Sparing Surgery for UCPCS | Latz et al logical‎diagnosis‎in‎the‎specimen‎was‎low‎grade‎urothelial‎ carcinoma‎pTa).‎Besides‎a‎prolonged‎urinary‎extravasation‎ treated‎with‎ureteric‎stenting‎for‎4‎weeks,‎clinical‎course‎was‎ uneventful.‎In‎2012‎there‎was‎no‎evidence‎of‎upper‎urinary‎ tract‎urothelial‎carcinoma‎recurrence‎but‎a‎low‎grade‎superfi- cial bladder cancer was diagnosed and treated with transure- thral resection. RESULTS In‎all‎patients‎kidney‎sparing‎surgery‎for‎upper‎urinary‎tract‎ TCC‎was‎technically‎feasible‎and‎could‎be‎carried‎out‎with- out‎severe‎complications.‎No‎patient‎received‎any‎applica- tion‎of‎intracavitary‎drugs‎like‎mitomycin‎in‎the‎early‎post- operative‎period.‎For‎kidney‎sparing‎strategy‎in‎all‎patients‎ intraoperative‎ frozen‎ section‎ with‎ evidence‎ of‎ superficial‎ low‎grade‎TCC‎was‎present.‎Low‎grade‎superficial‎TCC‎was‎ confirmed‎in‎all‎patients‎later‎in‎embedded‎specimen.‎Mean‎ recurrence-free‎follow-up‎was‎24‎months‎(range‎15-60).‎In‎3‎ single-kidney‎patients‎mean‎serum‎creatinine‎value‎was‎1.2‎ mg/dL‎(range‎0.9-1.4)‎one‎year‎postoperatively.‎No‎obstruc- tions‎of‎the‎upper‎urinary‎tract‎or‎symptomatic‎urinary‎tract‎ infections‎were‎reported. DISCUSSION Endoscopic‎treatment‎of‎upper‎urinary‎tract‎TCC‎has‎disad- vantages,‎especially‎in‎lower‎calyx‎tumors‎technical‎limita- tions‎(e.g.‎maximum‎endoscope‎bending‎with‎laser‎probe)‎ are‎met.‎Follow-up‎is‎difficult‎as‎sensitivity‎of‎both‎intrave- nous‎urography‎and‎computed‎tomography‎is‎low‎in‎small‎ lesions.(5)‎In‎case‎of‎suspicious‎results‎of‎imaging,‎ureteral‎ instrumentation‎like‎diagnostic‎pyeloscopy‎is‎necessary.‎Our‎ main‎aim‎in‎two‎patients‎with‎single‎kidney‎was‎to‎create‎ an‎easy‎access‎to‎the‎upper‎urinary‎tract‎both‎to‎follow-up‎ and‎for‎occasional‎endoscopic‎treatment‎in‎case‎of‎tumor‎re- currence.‎In‎these‎patients‎the‎aim‎has‎been‎reached‎by‎au- totransplantation‎with‎pyelovesicostomy‎or‎anastomosis‎of‎ an‎ileal‎conduit‎to‎the‎renal‎pelvis,‎respectively.‎As‎a‎major‎ advantage,‎during‎the‎follow-up‎period,‎easy‎endoscopic‎ac- cess‎to‎the‎renal‎pelvis‎or‎calyces‎was‎possible‎as‎an‎outpa- tient procedure without general anesthesia. Discussing onco- logical‎results‎of‎nephron-sparing‎surgery,‎the‎idea‎of‎tumor‎ cell‎seeding‎has‎to‎be‎taken‎into‎account.‎In‎transurethral‎re- section,‎this‎historical‎(and‎theoretical)‎hypothesis‎is‎accused‎ for‎tumor‎recurrence‎and‎may‎be‎transferred‎to‎endoscopic‎ ablation‎of‎UCPCS.(6)‎In‎open‎or‎laparoscopic‎surgery‎for‎ urothelial‎carcinoma‎tumor‎cell‎seeding‎is‎a‎frequently‎dis- cussed‎issue.‎Although‎worldwide‎surgeons‎are‎afraid‎of‎this‎ phenomenon,‎there‎is‎only‎little‎evidence.‎Available‎data‎are‎ restricted‎to‎case‎histories‎describing‎extravesical‎tumor‎im- plantation‎or‎port-site‎metastasis‎after‎surgery‎for‎urothelial‎ carcinoma.(7-9)‎Therefore‎the‎clinical‎relevance‎of‎the‎`seed- ing-theory`‎remains‎unclear.‎Although‎our‎study‎is‎limited‎ by‎the‎small‎number‎of‎patients‎we‎would‎like‎to‎encourage‎ urological‎surgeons‎considering‎open‎surgery‎for‎TCC‎of‎the‎ upper urinary tract in selected cases. CONCLUSION Transitional‎cell‎carcinoma‎of‎the‎upper‎urinary‎tract‎is‎a‎rare‎ entity,‎but‎if‎diagnosed,‎usually‎treated‎with‎nephroureterec- tomy.‎In‎selected‎cases‎nephron‎sparing‎surgery‎is‎possible.‎ All‎4‎patients‎reported,‎underwent‎various‎tailored‎open‎op- erations‎with‎excellent‎cancer‎control‎and‎functional‎results‎ keeping‎adequate‎renal‎function. CONFLICT OF INTEREST None declared. Figure 5. Transitional cell carcinoma of the right upper renal calyx in magnetic resonance imaging. 1446 | REFERENCES 1. Margulis V, Shariat SF, Matin SF, et al. Outcomes of radical nephro- ureterectomy: a series from the Upper Tract Urothelial Carcinoma Collaboration. Cancer. 2009;115:1224-33. 2. Bader MJ, Sroka R, Gratzke C, et al. Laser therapy for upper urinary tract transitional cell carcinoma: indications and management. Eur Urol. 2009;56:65-71. 3. Cutress ML, Stewart GD, Zakikhani P, Phipps S, Thomas BG, Tol- ley DA. Ureteroscopic and percutaneous management of up- per tract urothelial carcinoma (UTUC): systematic review. BJU Int. 2012;110:614-28. 4. Jeldres C, Lughezzani G, Sun M, et al. Segmental ureterectomy can safely be performed in patients with transitional cell carcinoma of the ureter. J Urol. 2010;183:1324-9. 5. Caoili EM, Cohan RH, Inampudi P, et al. MDCT urography of upper tract urothelial neoplasms. AJR Am J Roentgenol. 2005;184:1873- 81. 6. Weldon TE, Soloway MS. Susceptibility of urothelium to neoplastic cellular implantation. Urology. 1975;5:824-7. 7. Herawi M, Leppert JT, Thomas GV, De Kernion JB, Epstein JI. Im- plants of noninvasive papillary urothelial carcinoma in peritoneum and ileocolonic neobladder: support for "seed and soil" hypothesis of bladder recurrence. Urology. 2006;67:746-50. 8. Segawa N, Azuma H, Takahara K, et al. [Port-site metastasis after re- troperitoneoscopy-assisted nephroureterectomy and cystectomy for bladder cancer invading the ureter: a case report]. Hinyokika Kiyo. 2008;54:13-6. 9. Via KJ, Burns KM, Lamm DL. Tumor implantation: a rare but poten- tially preventable cause of death in cystectomy patients. Can J Urol. 2010;17:5216-8. Urological Oncology