Tumors of the renal pelvis and ureter: treatment

Operative treatment of tumors of the renal pelvis and ureter

An alternative to open surgical intervention can serve as a laparoscopic nephrureterectomy with a resection of the bladder. When performing laparoscopic interventions, transperitoneal, retroperitoneal approaches are used, as well as a manual technique. The technique of operation is not different from open. Resection of the bladder can be performed endoscopically before laparoscopy or laparotomy access until removal of endoscopically mobilized kidney and ureter. Laparoscopic nephrureterectomy is associated with a decrease in the volume of operational blood loss. The need for anesthesia, the shortening of the period of hospitalization and rehabilitation and a good cosmetic effect. With short observation periods, the oncological results of laparoscopic operations correspond to those with open access.

In recent years, there has been a trend towards an increase in the proportion of organ-preserving surgeries in patients with tumors of the upper urinary tract. Kidney preservation can be recommended for patients with small highly differentiated surface tumors, as well as patients with bilateral lesions, a single kidney and a high risk of terminal renal failure after nephrenorelectomy.

Resection of the ureter with ureterocystoanastomosis is indicated for patients with tumors of the distal ureter. The frequency of local recurrences after organ-preserving treatment of tumors of the renal pelvis and ureter reaches 25%.

Ureteroscopic intervention is considered a method of choice for small, highly differentiated surface tumors of all parts of the upper urinary tract. The volume of the operation can be in the laser vaporization, transureteral resection, coagulation and ablation of the tumor. General requirements for ureteroscopic interventions: mandatory production of tumor tissue for histological examination, careful treatment of intact mucosa of the urinary tract to avoid the development of strictures (preferably using a laser, rather than electrosurgical instruments), drainage of the bladder and, according to indications, the upper urinary tract from the side operations to ensure adequate outflow of urine.

An alternative to nephrureterectomy for tumors of the renal pelvis and proximal ureter can be percutaneous nephroscopic surgery. Percutaneous access allows the use of endoscopes of considerable diameter, which makes it possible to improve visualization. This allows to remove tumors of a larger size, as well as to perform a deeper resection than with ureteropyeloscopy. To perform percutaneous access, a puncture of the cup-and-pelvic system is performed followed by a dilatation of the stroke. On a formed fistula, a nephroscope is performed, performing pyeloureteroscopy. Biopsy and / or tumor resection / ablation under vision control. The disadvantage of the method is the risk of tumor seeding of the nephroscope and the development of relapse. The frequency of recurrence depends on the degree of tumor anaplasia and is 18% at G1.33% - at G2.50% - with G3.

Contraindications to the surgical treatment of tumors of the renal and ureteric pelvis are an active infectious disease, uncorrected hemorrhagic shock, terminal renal failure, severe co-morbidities, and dissemination of the tumor process.

Conservative treatment of tumors of the renal and renal pelvis

In randomized trials in patients with localized and locally advanced tumors of the upper urinary tract, the effectiveness of drug treatment in neoadjuvant and adjuvant regimens with respect to time to progression and survival has not been proven.

After endoscopic operations, adjuvant therapy consisting of local instillations of cytotoxic agents (mitomycin C, doxorubicin) or the vaccine Mycobacterium tuberculosis (BCG) can be performed with multiple, bilateral and / or low-grade surface tumors (Ta, T1) and carcinoma in situ in the upper urinary tract. Possible administration of these drugs through the nephrostomy, the ureteral or urethral catheter (in patients with vesicoureteral reflux). Typically, installations require hospitalization to control the volume and pace of perfusion in order to prevent systemic absorption of drugs.

BCG contains a weakened strain of Mycobacterium tuberculosis. In a small proportion of observations, the use of BCG vaccine is associated with the risk of developing BCG-sepsis. To prevent systemic complications, vaccine therapy is not prescribed for hematuria. The frequency of local recurrences after adjuvant retrograde installations of BCG is 12.5-28.5% with a follow-up period of 4-59 months.

Adjuvant intracavitary mitomycin C therapy (retrograde installations after endoscopic resection) is associated with a risk of local recurrence, reaching 54% with a median of 30 months. When using doxorubicin, this indicator is 50% with a follow-up period of 4-53 months.

To evaluate the results and identify the optimal regimens of adjuvant therapy for superficial urothelial tumors, randomized trials are necessary.

Patients with locally advanced tumors of the upper urinary tract of the high-risk group (T3-4, N +) can undergo adjuvant chemotherapy in the gemcitabine regimen (1000 mg / m ² on days 1, 8), cisplatin (70 mg / (GC) or chemoradiotherapy (chemotherapy in GC mode and irradiation of the bed of a distant tumor).

In cases of massive tumors, the probability of radical removal of which is low, an attempt may be made to carry out neoadjuvant chemotherapy in the same regime. The efficacy of neoadjuvant and adjuvant chemotherapy for tumors of the pelvis and ureter has not been proven.

Until recently, MVAC chemotherapy (methotrexate, vinblastine, doxorubicin, cisplatin), moderately increasing survival with a pronounced toxic effect, was the standard treatment for inoperable locally advanced and disseminated upper urinary tract tumors. The effectiveness of the combination of GC on the frequency of remissions, time to progression and survival is comparable to that of MVAC with less toxicity. In this regard, at present GC is considered the standard of chemotherapy for the 1st line in the prevalent urothelial tumors of the upper urinary tract. Studies are being conducted to study the efficacy of sorafenib (targeting agent, multi-kinase inhibitor) for the treatment of tumors of the renal and ureteral pelvis.

[1], [2], [3], [4], [5], [6], [7], [8], [9], [10]

Complications of treatment of tumors of the renal pelvis and ureter

Complications of surgical treatment of tumors of the kidney and ureter in the volume of nephrureterectomy - bleeding, infectious complications, postoperative hernia. Ureteroscopic operations are associated with a risk of such specific complications as perforation and stricture of the ureter. Percutaneous nephroscopic interventions can be complicated by pneumothorax, bleeding, as well as tumor seeding of the nephroscope canal. Complications of intracavitary cytotoxic installation may include local inflammatory reactions, granulocytopenia and sepsis as a consequence of exceeding perfusion pressure and absorption of the drug. Systemic chemotherapy is associated with hematologic (neutropenia, thrombocytopenia, anemia) and non-hematological (increasing the concentration of nitrogenous slags, nausea, vomiting, alopecia) toxicity.

[11], [12], [13], [14], [15], [16], [17]

Further management

The frequency of follow-up examinations may vary depending on the stage of the disease, the degree of tumor anaplasia and the type of treatment of tumors of the kidney and ureter. A more thorough control is necessary in cases of undifferentiated neoplasms in the late stages, and also after organ-preserving treatment of the tumor of the renal and ureteric pelvis.

The standard mode of observation includes cystoscopy, cytological examination of urine, excretory urography. Ultrasound of the abdominal cavity and retroperitoneal space, as well as radiography of the lungs. Due to the low diagnostic efficiency of urinary cytology, new markers of urothelial cancer, such as FDP (fibrinogen degradation products), BTA (vesicovirus tumor antigen), can be used in recurrences of tumors of the upper urinary tract. Sensitivity of methods for detecting relapses of tumors of the pelvis and ureter is 29.100 and 50%, specificity is 59.83 and 62%, respectively.

Patients who have sustained organ-preserving interventions also perform ureteropyeloscopy on the side of the lesion. If it is not possible to carry out an endoscopic examination, retrograde ureteropyelography can be performed. Sensitivity and specificity of methods for detecting relapses are 93.4% and 71.7%. 65.2 and 84.7% respectively.

Follow-up examinations are performed every 3 months during the first year, every 6 months for 2-5 years. Further annually.