Treatment Option Overview
The rarity of synchronous bilateral renal pelvic neoplasia, the low incidence
of asynchronous development of contralateral upper tract tumors, and the
increased risk of tumor recurrence in the ipsilateral ureter distal to the
original pelvic tumor are the rationale for total nephroureterectomy with
bladder cuff for most patients with renal pelvic transitional cell cancers and
ureteral cancers.
Contemplation of anything less than total excision must take into account the
potential risk for tumor recurrence anywhere in the upper tract unit. In other
than unifocal, low-grade, low-stage renal pelvic tumors, the probable extensive
involvement of both contiguous and noncontiguous sites would appear to make
segmental excision an unnecessary option with a potentially serious risk.
However, an operative possibility includes segmental excision of a particular
lesion. If the extent of a tumor can be determined by intraoperative
assessment, and frozen section histologic diagnosis confirms low-grade,
unifocal tumor of limited size, then segmental excision is possible. However,
this approach should be reserved for highly selected patients. This includes
those patients who have a solitary kidney or those with decreased renal
function and who require maximal preservation of renal tissue. The likelihood
of tumor recurrence in this setting, and of extension of disease outside the
renal pelvis once the pelvis has been violated, is a serious risk that must be
heavily weighed in offering a patient this therapeutic option.
Ureteral transitional cell cancer may more readily offer the possibility of
segmental excision if the absence of proximal disease can be documented. In
this setting, attention is focused on the ease of reconstruction of the ureter
and restoration of ureterovesical continuity. This is most feasible if the
cancer is in the distal ureter. If partial ureterectomy is possible and
proximal disease has been excluded, then segmental excision and ureteral
reimplantation can be performed.
Systematic regional lymph node dissection in conjunction with
nephroureterectomy or segmental excision has not been found to enhance the
effectiveness of surgery if tumors are of high grade or high stage, since in
these instances the overall results are so poor. Correspondingly, lymph node
involvement is uncommon in low-stage disease, and lymphadenectomy is therefore
unlikely to remove additional tumor. Thus, lymph node dissection at the time
of nephrectomy may offer prognostic information, but little, if any,
therapeutic benefit.
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