Search

Isolated brain metastasis from cancers of urothelial origin are rare, especially after a long recurrence-free interval with few reports in the literature. We herein present the case of a 62 year old male with history of recurrent bladder cancers treated in 2004 and 2005 and a left distal ureteral high grade pT3aN1M0 urothelial cancer treated with distal ureterectomy and reimplant followed by adjuvant chemotherapy in 2014 who presented after a 5 year recurrence-free interval with tonic-clonic seizure. Further workup revealed an isolated 12.0 mm x 18.0 mm x 8.0 mm mass overlying the left parietal lobe with no other metastatic sites. The patient was treated with resection of the mass and adjuvant radiation therapy with pathology confirming metastatic carcinoma of urothelial origin. Though prognosis for patients with such a presentation remains poor, we provide a review of the current literature with respect to incidence, presentation and therapeutic considerations for such patients.

Nephrogenic adenoma is a rare, benign lesion that can be encountered anywhere along the urinary tract. It is associated with genitourinary trauma, chronic inflammation, genitourinary surgery, renal transplant, urolithiasis, and radiation. In children, these lesions are almost exclusively found in the bladder. However, we report an unusual case of a 15-year-old boy with no prior urologic history who presented with an obstructing right ureteral nephrogenic adenoma that required an ileal ureter interposition and right ureterectomy.

Duplicated collecting systems with minimal-to-no function of the upper moiety are often treated surgically with upper pole heminephrectomy and ureterectomy. Complications associated with the ureteral stump can occur and are collectively known as ureteral stump syndrome. We present a case of ureteral stump syndrome treated with percutaneous transgluteal access into the stump which aided in identification of an ectopic ureteral opening that could not be identified by surgical means alone.

We present an unusual pediatric case of invasive upper tract urothelial carcinoma with an associated genetic predisposition. A 14-year-old female presented with intermittent right flank pain, and was found to have a poorly functioning hydronephrotic right kidney. Laparoscopic nephrectomy was performed. Pathology demonstrated upper tract urothelial carcinoma, and she subsequently underwent completion ureterectomy. Genetic studies demonstrated a double-hit constitutional deletion of a DNA mismatch repair protein, revealing a rare Lynch syndrome variant known as Constitutional Mismatch Repair Deficiency Syndrome. This disease places her at high risk for multiple malignancies, including upper tract urothelial carcinoma.

OBJECTIVES To study the feasibility, safety, and effect of transperitoneal laparoscopic heminephrectomy in the duplex kidney. METHODS From December 2003 to January 2008, 18 patients with urinary tract duplex anomalies underwent laparoscopic heminephrectomy using a transperitoneal approach. The sites of surgery consisted of 6 right upper, 2 right lower, 9 left upper, and 1 left lower heminephrectomy. Follow-up studies were performed using renal ultrasonography in all patients. RESULTS All patients underwent laparoscopic surgery successfully without conversion to open surgery or intraoperative complications. The mean operative time was 142.8 minutes (range 90-195). The mean estimated blood loss was 196.1 mL (range 20-600), and the mean hospital stay was 6.1 days (range 4-10). In 1 patient, a minor postoperative urine leak resolved spontaneously with prolonged catheter drainage. The radiologic assessment showed normal ipsilateral renal growth in 18 patients at a mean follow-up of 25.8 months. CONCLUSIONS Our initial clinical experience suggests that laparoscopic heminephrectomy using a transperitoneal approach for the duplex kidney is feasible, safe, and effective. Therefore, the transperitoneal approach for moiety excision, which offers a technically simple approach for complete ureterectomy, is recommended.

OBJECTIVES To determine the pathologic features of bladder tumors after nephroureterectomy or segmental ureterectomy for upper urinary tract transitional cell carcinoma (UUT-TCC). METHODS From 1993 to 2003, 82 patients without a history of bladder cancer underwent nephroureterectomy or segmental distal ureterectomy for UUT-TCC. We reviewed the pathologic features of the subsequent bladder tumors, including stage, grade, and progression to cystectomy in these patients at a median follow-up of 44.1 months. RESULTS A total of 36 (44%) of 82 patients developed bladder tumors after definitive therapy for UUT-TCC at a mean interval of 13.9 months. The mean number of bladder tumors diagnosed per patient in the follow-up interval was 2.1 (range 1 to 6), for a total of 74 bladder tumors. Of the 74 bladder tumors, 71 (96%) were superficial (Stage Ta, Tis, T1), 49 of these superficial tumors (69%) being low grade (grade 1 and 2) and 22 (31%) high grade (grade 3). Three patients had high-grade, muscle-invasive disease, and all progressed to cystectomy during follow-up. A greater than 75% concordance was found in pathologic grade between the UUT lesion and subsequent bladder tumors. The stage of the UUT malignancy, however, did not correlate with subsequent bladder tumor pathologic findings. CONCLUSIONS Bladder tumors developed in 44% of patients after treatment of UUT-TCC. Of these bladder tumors, over 60% were superficial, low-grade lesions, yielding a similar pathologic distribution to that of bladder cancer de novo. The grade, but not the stage, of the UUT tumors correlated with the pathologic findings of subsequent bladder tumor recurrence. Aggressive surveillance with cystoscopy and urinary cytology after surgical management of UUT-TCC is imperative.

Objective To report our initial experience on robot-assisted radical nephroureterectomy, using the da Vinci Xi robotic system without patient or port repositioning. Materials and Methods The patients were in a modified flank position. A Bugbee electrode was used to cauterize and mark the ureteral orifice, aiding in the final robotic excision of the distal ureter. For the first step of the procedure, the second robotic arm holds the scope, the fourth robotic arm holds Port #1 (monopolar curved scissors), the first robotic arm holds Port #2 (Fenestrated bipolar forceps), and the third robotic arm holds Port #4 (Prograsp forceps). After completion of nephrectomy, all robotic arms were released and reconfigured. In the new setting, the third robotic arm and second robotic arm were switched between the camera port and the fourth port. The first port remained working with the monopolar curved scissors whereas Prograsp forceps was moved to the second port and fenestrated bipolar forceps was moved to the third port. Results Two patients underwent 2 successful radical nephroureterectomies with the above-mentioned technique. The console time for the first patient was 150 minutes whereas the estimated blood loss was 200 mL. The console time and blood loss for the second patient were 140 minutes and 300 mL, respectively. The hospitalization time and catheter removal time were 3 days for both patients and no complications were observed. Conclusion The use of the da Vinci Xi robotic system enabled us to perform both nephrectomy and distal ureterectomy and/or bladder cuff excision without any repositioning of the patient or trocars.

Objectives To evaluate the clinical outcome of nephroureterectomy with endoscopically assisted transurethral ureteral stripping for transitional cell carcinoma of the renal pelvis in a comparative study. Methods Sixty patients with localized renal pelvic cancer were enrolled in a prospective comparative nonrandomized study. Of these, 28 patients underwent nephroureterectomy with endoscopically assisted transurethral ureteral stripping and 32 underwent conventional nephroureterectomy with a bladder cuff. Both short-term and long-term results were analyzed in this series. Results The operating time for patients with ureteral stripping was significantly shorter than for those with a standard two-incision nephroureterectomy (median 183 versus 250 minutes, P = 0.0231), and the amount of blood loss was significantly less (median 150 versus 390 mL, P = 0.0002). Intravesical recurrence was detected in 10 (35.7%) of the 28 patients with ureteral stripping, and the 1-year and 3-year recurrence-free rate was 68.0% and 57.7%, respectively. Seven patients treated by the standard two-incision nephroureterectomy (21.9%) experienced intravesical recurrence, with a 1-year and 3-year recurrence-free rate of 96.8% and 75.0%, respectively. The recurrence rate was significantly greater in the group with ureteral stripping (P = 0.0287). Conclusions Compared with conventional nephroureterectomy with a bladder cuff, nephroureterectomy with transurethral stripping is a minimally invasive procedure with a shorter operating time and less blood loss, but a statistically significantly greater intravesical recurrence rate. Greater consideration should be taken before selecting this procedure.

Objectives To apply retroperitoneoscopy-assisted nephroureterectomy (RTN) and examine its benefit compared with traditional open nephroureterectomy. The reference standard of treatment for upper urinary tract transitional cell carcinoma is standard total nephroureterectomy (STN) with excision of a bladder cuff. Methods Retroperitoneoscopic radical nephrectomy was performed, followed by open distal ureterectomy with excision of a bladder cuff. The specimen was removed en bloc from the lower pararectal incision that was used during distal ureterectomy. From January 1999, 17 patients with upper urinary tract transitional cell carcinoma underwent this procedure at our institution. For comparison, the most recent 17 STNs were also reviewed. Results The operative time was longer in the RTN group than in the STN group but not to a significant extent (239.5 versus 286.8 minutes; P = 0.2663). On the other hand, the estimated blood loss, duration to potential discharge, and recovery to normal activities were significantly reduced in the RTN group (151.1 versus 299.6 minutes, 2.7 versus 4.2 days, and 15.9 versus 19.3 days; P = 0.0262, 0.0479, and 0.0363, respectively). From an oncologic standpoint, local recurrence occurred in 1 patient of the RTN group and 4 patients of the STN group (median follow-up of 8.8 and 23.0 months, respectively). No significant difference was detected in the disease-free survival rate between the two groups ( P = 0.6775). Conclusions RTN can make total nephroureterectomy less invasive. From an oncologic standpoint, although it revealed a disease-free survival rate comparable with the standard open procedure with limited follow-up, further follow-up of additional cases with simultaneous extended lymphadenectomy is necessary to evaluate the effectiveness of this procedure.

Objectives. To report a modified approach for hand-assisted laparoscopic nephroureterectomy (HALNU).Methods. Seven patients with localized transitional cell carcinoma of the upper urinary tract underwent unilateral HALNU. Patients were placed in a 60 degrees oblique position during the entire procedure. Via a 7-cm Gibson incision on the lesion side, the distal ureterectomy and bladder cuff excision were done by an open method without opening the bladder. Then, with the surgeon's hand inserted into the peritoneal cavity by way of the same wound, HALNU was performed with two to three additional laparoscopic ports. The perioperative parameters were compared with those of 15 cases of conventional open nephroureterectomy.Results. Patients in the HALNU group had significantly less mean blood loss (140 versus 455 mL) and earlier resumption of oral intake (33 versus 61 hours), required fewer narcotics (38 versus 70 mg of morphine sulfate equivalent), and were discharged earlier (7.33 versus 9.1 days), with a faster convalescence to normal activity (3.7 versus 5.6 weeks; all P < 0.05). The total mean surgical time was 3.7 hours for the HALNU group.Conclusions. Our approach used the same incision to both excise the distal ureter and apply the hand-assist device. It also preserved the benefits of the minimal invasiveness of laparoscopic surgery compared with its open counterpart.

Objectives To review the surgical management of upper tract urothelial carcinoma (UTUC) on a population level. UTUC accounts for 5% of urothelial malignancies, making it less amenable to single-center reporting. Complete nephroureterectomy is the standard of care, and increasing evidence has shown that a suboptimal surgical technique is associated with an adverse prognosis. Methods We obtained information for all patients diagnosed with UTUC (n = 830) and those treated surgically (n = 680) in the province of Ontario, Canada from the Ontario Cancer Registry from 1995 to 2004. Demographic, treatment, and vital status information was obtained for all patients, and pathology reports were available for 422 patients. The primary outcome was overall survival. The secondary outcomes included measures of surgical quality (ie, number of lymph nodes sampled, ureteral length excised, surgical margin status, and 30-day mortality) and disease-specific survival. Results The unadjusted 5-year overall survival rate was 57.2%, with a median survival of 72.5 months. For those treated surgically, the 30-day mortality rate was 1.8%, and the positive surgical margin rate was 8.5%. Lymph nodes were identified in only 27% of the specimens, with a median yield of 1 (range 1-15). An estimated 25.8% of patients might have undergone incomplete ureteral resection at the time of nephroureterectomy. Conclusions UTUC is a lethal malignancy, with nearly one half the patients dying within 5 years. Furthermore, lymphadenectomy was rarely performed and approximately one fourth of patients might have undergone incomplete ureterectomy. The published outcomes from “centers of excellence” do not appear to reflect the surgical quality seen on a population level for this rare, but significant, malignancy.

OBJECTIVES To present the first experience with a 3-port technique for retroperitoneoscopic (HARP) radical nephrectomy, radical nephroureterectomy, and total and live donor nephrectomy. We believe that the retroperitoneoscopic (RP) approach to nephrectomy is advantageous, as it avoids mobilization of intraperitoneal organs and provides direct access to the renal artery. Nonetheless, this approach is not as popular as the transperitoneal approach, likely because of the steeper learning curve. We believe that hand-assistance reduces the learning curve because of the tactile feedback and similarity to open surgery. METHODS Over a 4-year period, 133 HARP nephrectomies were performed, including 92 radical nephrectomies, 19 radical nephroureterectomies, 12 total nephrectomies, and 10 live donor nephrectomies. Mean patient age was 62 years and mean body mass index was 30; 42% of patients had abdominal scars. Our technique uses a 7-cm muscle-sparing Gibson incision for the hand-port with 2 endoscopic ports. RESULTS Mean operative time, including ureterectomy, was 109 minutes, with a mean operative blood loss of 167 mL. Average hospitalization was 3.8 days. Two cases (1.5%) required open conversion. The complication rate was limited to 3.8% for blood transfusion, 3.8% for cardiac issues, 1.5% for pulmonary embolism, 2.3% for wound infection, and 1.5% for urinary retention. CONCLUSIONS Based on our results, we conclude that HARP nephrectomy is safe and effective and can be expeditiously performed. It is a versatile approach that is applicable for both neoplastic and non-neoplastic indications. In addition, HARP provides a minimally invasive alternative to open conversion in difficult cases of simple nephrectomy.

We report our initial experiences with gasless, hand-assisted retroperitoneoscopic nephroureterectomy for the treatment of urothelial cancer of the upper urinary tract. One hand was inserted by way of the small incision made in the lower abdomen. This method provides easy maneuverability and an acceptable operative time without opening the upper urinary tract.

OBJECTIVES To present our experience and outcomes of robot-assisted laparoscopic surgery (RALS) performed for different ureteral pathologies and to discuss the true utility of robotics in ureteral surgery. METHODS We reviewed a total of 44 procedures performed for diverse ureteral pathologies involving the proximal and distal ureter in 2 institutions from July 2006 to July 2009. Operative time, blood loss, length of stay, complications, and subjective and objective follow-up were evaluated. RESULTS The 44 cases included 18 distal ureteral procedures including 5 distal ureterectomy with ureteroneocystostomy; 1 ureteroneocystostomy with psoas hitch; 2 ureteroneocystostomy with vesicovaginal fistula repair; 9 megaureter repairs in 8 cases; there were 12 proximal ureteral procedures including 7 ureteroureterostomies and 4 retrocaval ureter repairs; 10 ablative procedures consisting of 5 nephroureterectomies with cuff of bladder and 5 nephroureterectomies and 4 miscellaneous procedures. The mean operative time was 137.9 minutes (range: 70-240). Mean blood loss was 98.2 mL (range

Objectives To review our experience with various techniques used to manage the distal ureter during hand-assisted laparoscopic nephroureterectomy and to evaluate the surgical outcomes, including pathologic margin status and the incidence of disease recurrence. Methods We retrospectively analyzed 55 hand-assisted laparoscopic nephroureterectomies performed to treat transitional cell carcinoma (TCC), with the distal ureter managed as follows: cystoscopic disarticulation in 16 patients, stapled division in 7, open distal ureterectomy in 3, and hand-assisted laparoscopic extravesical en bloc distal ureterectomy with bladder cuff in 29. The cystotomy was not closed in 7 patients. Results The coexistence of renal pelvic and ureteral tumors was common but in 27% of cases was not recognized preoperatively. One outer and four distal ureteral margins were positive for tumor (n = 2) or carcinoma in situ (n = 3). Two (29%) of the seven cystotomies that were not closed and only 1 (2%) of the 42 that were closed demonstrated extravasation. The operative time was 60 to 90 minutes longer and the estimated blood loss, open conversion rate, and indwelling catheterization time were two to three times greater for the cystoscopic ureteral disarticulation cohort. The stapled division cohort had a greater positive margin rate (29%) than the other cohorts (10% or less). With a mean follow-up of 24 months, 19 patients had developed bladder cancer, 1 prostate cancer, 1 an extravesical malignancy with synchronous liver metastasis, and 4 distant recurrence (lung in 2 and the retroperitoneum and spine in 1 each). Conclusions The results of our study have shown that distal ureteral tumors have the greatest likelihood for a positive margin. Cystoscopic ureteral disarticulation increased the operative time and estimated blood loss. Cystotomy closure reduced the extravasation rate. We favor hand-assisted laparoscopic en bloc distal ureterectomy followed by cystotomy closure to minimize the risk of distal ureteral or extravesical recurrence.

Laparoscopic nephroureterectomy has faced technical criticism secondary to the unknown effects of urine-exposed intravesical or intraureteral staples. Although not reported, staples exposed to urine theoretically create a nidus for encrustation and stone formation. We present a case of a 66-year-old man after left laparoscopic ureterectomy for ureteral malignancy. Surveillance cystoscopy at 6 months revealed a nearly complete intravesical titanium staple line without encrustation. Successful transurethral removal of all staples with standard cystoscopic graspers revealed no immediate, or delayed, sequelae.

Objectives To evaluate the efficacy of our new retroperitoneoscopic nephroureterectomy for patients with transitional cell carcinoma of the renal pelvis and ureter, we present the operative procedure and analysis of the clinical outcome of retroperitoneoscopy in 23 patients. Methods Twenty-three patients with transitional cell carcinoma of the upper urinary tract underwent retroperitoneal laparoscopic nephroureterectomy between February 2000 and February 2002. Patient age ranged from 44 to 83 years (mean 66.7). Each kidney was retroperitoneoscopically dissected en bloc, together with the perirenal fatty tissue, lymph nodes, and/or adrenal gland, without transecting the ureter. The lower ureter was resected with the bladder cuff transected using an ultrasonic scalpel and an endoscopic gastrointestinal automatic stapler. The dissected specimen was removed intact through a 6-cm-long original incision. Results The mean operating time was 4.8 hours, including 0.7 hours for complete removal of the ureteral end with the bladder cuff. The mean estimated blood loss was 304 mL. The mean time to recovery to normal activity was 18 days. In the mean follow-up period of 15 months, 2 patients died of cancer progression in the sixth postoperative month, 2 died of other causes, and 4 had recurrent transitional cell carcinoma of the bladder after surgery. Conclusions Our retroperitoneal laparoscopic nephroureterectomy using an endoscopic gastrointestinal automatic stapler is a fast, low-risk, and minimally invasive procedure and might be an alternative to other laparoscopic techniques and open nephroureterectomy. However, long-term follow-up is necessary to confirm the efficacy for patients with transitional cell carcinoma of the renal pelvis and ureter.

Objectives. Ureteral endoscopic surgery has been proposed as the first step of nephroureterectomy, either open or laparoscopic, to obviate the low abdominal incision. We present our experience with a technique of one-incision nephroureterectomy endoscopically assisted by transurethral ureteral stripping. Methods. Standard nephrectomy is performed after placement of a Chevassu ureteral catheter. The lumbar ureter is sectioned and the catheter tip tied to the top of the distal portion of the ureter, which is later intussuscepted when the catheter is pulled out. Transurethral resection through the muscular wall and into the perivesical fat is performed around the everted ureteral orifice, and the bladder spontaneously closes with an indwelling Foley catheter. Since 1989, we have used this technique in 21 patients with urothelial malignancies of the renal pelvis or calyces (15 patients), renal cell carcinoma (2 patients), renal cholesteatoma (1 patient), or reflux nephropathy (3 patients). Results. Two patients required a low abdominal incision for removal of retained ureter after unsuccessful stripping. The rest underwent this procedure without complications or adverse effects. Mean follow-up was 44.6 ± 11.4 months (range 4 to 76). Three patients presented with bladder tumor but no recurrences were detected in the resected area of the bladder or the retroperitoneum. Conclusions. Endoscopically assisted nephroureterectomy allows removal of an adequate cuff of bladder with the distal ureter and generally obviates extending the incision or performing a second one. It can be an attractive option in selected cases, without apparent risk of neoplastic urine contamination in the retroperitoneum.

Objectives To report a technique for excision of bilateral ureteral transitional cell carcinoma which preserves renal function and provides ready access for endoscopic follow-up and therapy of the renal pelvis. Methods The operative procedure of bilateral ureterectomy with construction of a separated pyelocolocutaneous diversion utilizing transverse colon is described and the clinical course of 4 patients is reported. Results All 4 patients maintained excellent renal function and normal electrolytes. Conduit urine cytologic studies and renal pelvis endoscopic examinations have remained normal. Parastomal herniation was the most frequently observed postoperative complication. Conclusions This approach is well suited for the treatment of bilateral ureteral transitional cell carcinoma. Long-term complications are minimal and renal function is preserved. Periodic endoscopic visualization of each renal pelvis with resection and fulguration and/or instillation of immunotherapeutic or chemotherapeutic agents for recurrent renal pelvic lesions is readily accomplished.

Objectives To report the initial experience with retroperitoneoscopic nephroureterectomy for symptomatic, end-stage vesicoureteral reflux. Methods Two patients underwent a nephroureterectomy by a four-port retroperitoneal laparoscopic approach. In 1 patient, a double-balloon technique was used to dissect the pelvic extraperitoneal space and gain access to the juxtavesical ureter. In the second patient, the distal ureter was mobilized with routine laparoscopic dissection techniques. Results Operative time was 6 and 5.5 hours, respectively, and mean hospital stay was 4 days. Mean patient follow-up is 17.5 months. Conclusions The technique of retroperitoneoscopic nephroureterectomy is in evolution; until now, a major concern has been the inadequate access to the distal ureter through a completely retroperitoneoscopic approach. Described herein is a double-balloon technique that significantly facilitates dissection of the juxtavesical ureter during a retroperitoneal laparoscopic nephroureterectomy.

We report a case of transitional cell carcinoma occurring within an ectopically located upper pole ureter of a completely duplicated collecting system in an 81-year-old man. Presentation, evaluation, and management issues are discussed.

Endoscopic removal of the lower ureteral stump by transurethral resection of the mucosal cuff and intussusception of the ureter is safe, effective, and relatively easy. Although the technique has been used primarily for malignant disease, the cases described herein illustrate that it also is useful for benign disease.

Many cases of histologically distinct renal tumors occurring coincidentally in the same patient have been reported. We report the first case of a benign oncocytoma and a urothelial carcinoma occurring synchronously in the same kidney in a man who underwent radical nephrectomy for a suspicious renal mass. The patient subsequently underwent distal ureterectomy.

The case of a thirty-seven-year-old man with eosinophilic granuloma of the ureter is disucussed. Preoperative x-ray disclosed distal ureteric regional stenosis and moderate hydronephrosis with small stone shadows. A segmental ureterectomy and vesicoureteral neostomy wre performed. Pathologic examination of the removed specimen revealed markedly infiltrated eosinophils of the ureteric wall. The literature is reviewed and the causation of eosinophilic granuloma discussed.

Tuberculosis of the ureter is almost always secondary to renal tuberculosis. Nephrectomy has been advocated for advanced renal tuberculosis with severe renal parenchymal damage; however, failure to perform ureterectomy at the time of nephrectomy may cause ureterocutaneous fistula and a nonhealing wound. A case of ureterocutaneous fistula and delayed wound healing four months postnephrectomy and pertinent review of the literature is reported.

Intussusception ureterectomy has been used to excise prophylactically the distal ureter in 10 patients with carcinoma of the renal pelvis. The procedure has proved safe and expeditious, as well as permitting more precise excision of the surrounding vesical mucosa.

Sixty-eight patients with transitional cell carcinoma of the renal pelvis were studied with respect to clinical presentation, tumor grade, stage and location, subsequent development of other urothelial tumors, and patient survival. Of the 66 patients with adjacent mucosa available for evaluation, 63 (95 per cent) had abnormal findings with severe dysplasia and CIS common in the high-grade, high-stage tumors. Twenty-eight patients (41 per cent) had transitional cell carcinoma previously, concomitantly, and/or subsequently, and in 14 patients (21 per cent) subsequent bladder tumors developed. Because of the relatively high tumor recurrence rate in the ureter (16 per cent) in patients who underwent subtotal ureterectomies, nephrectomy and complete ureterectomy including a bladder cuff should be the operation of choice in patients with carcinoma of the renal pelvis.

A case of ureteral intussusception caused by a low-grade papillary transitional cell carcinoma of the ureter is described. This is the first case of ureteral intussusception resulting from a malignant tumor of the ureter. The patient presented with weight loss and vague pain in the right lower abdominal quadrant. Right ureterovesical junction obstruction was seen in the retrograde pyeloureterogram. Right nephroureterectomy including a cuff of adjacent bladder wall was performed.

Distal ureterectomy with direct ureteroneocystostomy facilitated by the psoas bladder hitch procedure has been used in 6 patients for management of low-grade, noninvasive primary ureteral carcinoma. All patients are alive, two to ninety-six months postoperatively. Recurrent ipsilateral urothelial malignant disease has occurred in only 1 patient, twenty-six months postoperatively, necessitating a secondary nephroureterectomy. Renal function has been preserved in the remaining 5 patients. The continued practice of conservative surgery in these cases appears warranted.