Tumors of the renal pelvis and ureter - Treatment

Surgical treatment of tumors of the renal pelvis and ureter

An alternative to open surgery may be laparoscopic nephroureterectomy with bladder resection. Laparoscopic interventions use transperitoneal, retroperitoneal access, as well as a manual technique. The surgical technique is no different from the open one. Bladder resection may be performed endoscopically before laparoscopy or laparotomic before removal of the endoscopically mobilized kidney and ureter. Laparoscopic nephroureterectomy is associated with a decrease in the volume of operative blood loss, the need for pain relief, a shortened hospitalization and rehabilitation period, and a good cosmetic effect. With short observation periods, the oncological results of laparoscopic surgeries correspond to those using the open approach.

In recent years, there has been a tendency to increase the proportion of organ-preserving surgeries in patients with upper urinary tract tumors. Kidney preservation may be recommended for patients with small, highly differentiated superficial tumors, as well as for patients with bilateral lesions, a single kidney, and a high risk of end-stage renal failure after nephroureterectomy.

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

Ureteroscopic intervention is considered the method of choice for small, highly differentiated superficial tumors of all parts of the upper urinary tract. The scope of the surgery may include laser vaporization, transurethral resection, coagulation, and tumor ablation. General requirements for ureteroscopic interventions: mandatory collection of tumor tissue for histological examination, careful treatment of the intact mucous membrane of the urinary tract to avoid the development of strictures (it is preferable to use a laser rather than electrosurgical instruments), drainage of the bladder and, if indicated, the upper urinary tract on the side of the operation to ensure adequate urine outflow.

An alternative to nephroureterectomy for tumors of the renal pelvis and proximal ureter can be percutaneous nefroscopic surgeries. Percutaneous access allows the use of endoscopes of significant diameter, which improves visualization. This allows the removal of larger tumors, as well as a deeper resection than with ureteropyeloscopy. To implement percutaneous access, a puncture of the renal pelvis and calyces is performed, followed by dilation of the tract. A nephroscope is inserted through the formed fistula, pyeloureteroscopy is performed, biopsy and / or resection / ablation of the tumor under vision. The disadvantage of the method is the risk of tumor seeding of the nefroscopic tract and the development of a relapse. The relapse rate depends on the degree of tumor anaplasia and is 18% at G1, 33% - at G2, 50% - at G3.

Contraindications to surgical treatment of tumors of the renal pelvis and ureter are active infectious disease, uncorrected hemorrhagic shock, terminal renal failure, severe concomitant diseases, as well as dissemination of the tumor process.

Conservative treatment of tumors of the renal pelvis and ureter

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

After endoscopic operations for multiple, bilateral and/or poorly differentiated superficial tumors (Ta, T1) and carcinoma in situ of the upper urinary tract, adjuvant therapy can be performed, consisting of local instillations of cytostatics (mitomycin C, doxorubicin) or Mycobacterium tuberculosis vaccine (BCG). These drugs can be administered through a nephrostomy, a ureteral catheter or a urethral catheter (in patients with vesicoureteral reflux). Usually, instillations require hospitalization to monitor the volume and rate 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 the 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 relapses after adjuvant retrograde BCG instillations is 12.5-28.5% with observation periods of 4-59 months.

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

Randomized studies are needed to evaluate the results and identify optimal adjuvant therapy regimens for superficial urothelial tumors.

Patients with locally advanced high-risk (T3-4, N+) upper urinary tract tumors can receive adjuvant chemotherapy in the regimen of gemcitabine (1000 mg/m2 ^on days 1 and 8), cisplatin (70 mg/m2 on day 2) (GC) or chemoradiation therapy (chemotherapy in the GC regimen and irradiation of the resected tumor bed).

In cases of massive tumors, the probability of radical removal of which is low, an attempt at neoadjuvant chemotherapy in the same regimen is possible. The effectiveness of neoadjuvant and adjuvant chemotherapy for tumors of the renal pelvis and ureter has not been proven.

Until recently, the standard treatment for inoperable locally advanced and disseminated upper urinary tract tumors was MVAC (methotrexate, vinblastine, doxorubicin, cisplatin) chemotherapy, which moderately increased survival with significant toxicity. The efficacy of the GC combination in terms of remission rate, time to progression, and survival is comparable to that of MVAC with less toxicity. In this regard, GC is currently considered the standard of first-line chemotherapy for common urothelial tumors of the upper urinary tract. Studies are being conducted to study the efficacy of sorafenib (targeted agent, multikinase inhibitor) for the treatment of renal pelvis and ureter tumors.

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Complications of treatment of tumors of the renal pelvis and ureter

Complications of surgical treatment of renal pelvis and ureter tumors in the volume of nephroureterectomy are bleeding, infectious complications, postoperative hernia. Ureteroscopic operations are associated with the risk of such specific complications as perforation and stricture of the ureter. Percutaneous nefroscopic interventions can be complicated by pneumothorax, bleeding, and tumor seeding of the nephroscopic channel. Complications of intracavitary instillation of cytostatics can be local inflammatory reactions, granulocytopenia and sepsis as a result of excess perfusion pressure and drug absorption. Systemic chemotherapy is associated with hematological (neutropenia, thrombocytopenia, anemia) and non-hematological (increased concentration of nitrogenous wastes, nausea, vomiting, alopecia) toxicity.

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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 for renal pelvis and ureter tumors. More careful monitoring is necessary in cases of undifferentiated neoplasms at late stages, as well as after organ-preserving treatment for renal pelvis and ureter tumors.

Standard observation mode includes cystoscopy, urine cytology, excretory urography, ultrasound of the abdominal cavity and retroperitoneal space, and chest X-ray. Due to the low diagnostic efficiency of urine cytology in case of recurrent tumors of the upper urinary tract, new markers of urothelial cancer can be used, such as FDP (fibrinogen degradation products), BTA (bladder tumor antigen). The sensitivity of the methods for detecting recurrent tumors of the renal pelvis and ureter is 29.100 and 50%, specificity is 59.83 and 62%, respectively.

Patients who have undergone organ-preserving interventions also undergo ureteropyeloscopy on the affected side. If endoscopic examination is not possible, retrograde ureteropyelography can be performed. The sensitivity and specificity of the methods for detecting relapses are 93.4 and 71.7%. 65.2 and 84.7%, respectively.

Control examinations are carried out every 3 months during the first year, every 6 months during 2-5 years, and then annually.