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Upper tract urothelial carcinoma is a rare malignancy for which surgery provides definitive management. Open radical nephroureterectomy was the gold standard treatment, but laparoscopic and robot-assisted approaches are alternative options. Kidney-sparing approaches are feasible for carefully selected patients with ureteral cancer. This article discusses the evaluation of patients with upper tract urothelial carcinoma and definitive management using robot-assisted surgical approaches. Patients with urothelial carcinoma of the upper tract can be treated with robot-assisted nephroureterectomy, distal ureterectomy, and segmental ureterectomy.

Highlights • Primary papilloma of the ureteral proximal end is extremely rare. • Benign tumors of the ureter are much less frequent than malignant ones. • The main clinical signs of benign ureteral tumor are hematuria, pain and hydronephrosis. • The exact diagnosis can be established with histologic study. • The best noninvasive treatment of benign ureteral mass lesion is a segmental resection of ureter., Introduction Approximately 1 percent of the tumors observed in the upper urinary tract are primary tumors of the ureter. The exact diagnosis is done by a histologic study. Most cases need surgery, which is done by complete resection of the tumoral segment of the ureter. Presentation of case This study presents a 13-year-old boy who referred to Ali Asghar pediatric hospital with complaints of right flank pain and hematuria for four months. The ultrasonography revealed moderate-grade hydronephrosis. The retrograde urography confirmed a 1.5 cm lesion with filling defects in the proximal segment of the right ureter. The abdominal CT-scan confirmed a 1.5 cm filling defect lesion with a smooth margin in the right proximal ureter adjacent to the ureteropelvic orifice. On cystoscopy, a sessile mass developed in the proximal portion of right ureter and providing pronounced dilation of the ureter and ipsilateral hydronephrosis. Histopathology examination revealed a benign neoplasm composed of a delicate fibrovascular core covered by normal-appearing urothelium. The patient underwent a successful proximal segment resection of the ureter by surgery. Discussion Benign tumors of the ureter are much less frequent than malignant ones. Mostly, they involve the lower third of the ureter. Pain, hematuria, and hydronephrosis are the most clinical signs. The final diagnosis can be established with the histologic examination. The choice treatment in is segmental ureterectomy. Conclusion Primary ureteral papilloma is extremely rare in the child. The histopathology study is essential for ruling out malignancy. The recurrence and progression of ureteral papilloma are controversial.

Radical nephro-ureterectomy and bladder cuff excision (RNUBCE) is the gold standard treatment for upper tract urothelial carcinoma (UTUC). RNUBCE can be performed via an open, laparoscopic or robot-assisted approach. The primary objective of this narrative mini-review is to report the techniques and outcomes for robot-assisted RNUBCE in the published literature. Relevant articles were selected utilizing the following search categories: "robot nephro-ureterectomy", "robot-assisted nephro-ureterectomy", and "robot upper tract urothelial carcinoma". Different techniques in terms of patient positioning, port placement, lymph node dissection, and bladder cuff excision have been reported in the literature. Despite these varied techniques, perioperative outcomes of robot-assisted laparoscopic RNUBCE are favorable. In all, a total of 204 patients underwent RNUBCE, with a mean operating room time of 229.7min, mean blood loss of 189ml, and mean length of stay of 3.65 d. Further studies are needed to validate oncologic outcomes. PATIENT SUMMARY: Patients with high-risk upper tract urothelial carcinoma require complete removal of the kidney, ureter, and bladder cuff, along with a lymph node dissection. Although the procedure can be performed via an open approach, minimally-invasive surgery represents an alternative. Herein, we describe the techniques and outcomes of robot-assisted radical nephro-ureterectomy and bladder cuff excision.

Primary carcinoma of the ureteral stump following a radical nephrectomy is rare, and it is even rarer that the cause of the nephrectomy is renal cell carcinoma (RCC). Treatment by complete ureterectomy with a bladder cuff is considered as the standard treatment. We report a case of a 70-year-old female with urothelial carcinoma with glandular differentiation that occurred in the ureteral stump after nephrectomy for left RCC. We performed a novel technique of pure laparoscopic resection of the ureteral stump with a bladder cuff.

A duplicated collecting system is a common congenital anomaly of the urinary tract. However, late symptomatic presentation in adulthood is uncommon. We report the first case of left heminephrectomy, ureterectomy and radical prostatectomy using the da Vinci SP (single port) surgical system in a 64-year-old patient with localized prostate cancer and duplicated system with ectopic ureteral insertion into the prostatic urethra. The procedure was completed without technical difficulties or intraoperative adverse events. We demonstrate that the da Vinci SP robot allows for efficient performance of concomitant surgeries on the kidney and prostate without the limitations reported with single site surgeries., Highlights • A duplicated collecting system is a common congenital anomaly of the urinary tract. • Late symptomatic presentation of duplicated system in adulthood is uncommon. • We report single port robotic heminephrectomy, ureterectomy and radical prostatectomy. • The procedure was completed without technical difficulties or intraoperative events.

Context There is uncertainty regarding the oncologic effectiveness of kidney-sparing surgery (KSS) compared with radical nephroureterectomy (RNU) for upper tract urothelial carcinoma (UTUC). Objective To systematically review the current literature comparing oncologic outcomes of KSS versus RNU for UTUC. Evidence acquisition A computerised bibliographic search of the Medline, Embase, and Cochrane databases was performed for all studies reporting comparative oncologic outcomes of KSS versus RNU. Approaches considered for KSS were segmental ureterectomy (SU) and ureteroscopic (URS) or percutaneous (PC) management. Using the methodology recommended by the Preferred Reporting Items for Systematic Reviews and Meta-analysis guidelines, we identified 22 nonrandomised comparative retrospective studies published between 1999 and 2015 that were eligible for inclusion in this systematic review. A narrative review and risk-of-bias (RoB) assessment were performed using cancer-specific survival (CSS) as the primary end point. Evidence synthesis Seven studies compared KSS overall ( n =547) versus RNU ( n =1376). Information on the comparison of SU ( n =586) versus RNU ( n =3692), URS ( n =162) versus RNU ( n =367), and PC ( n =66) versus RNU ( n =114) was available in 10, 5, and 2 studies, respectively. No significant difference was found between SU and RNU in terms of CSS or any other oncologic outcomes. Only patients with low-grade and noninvasive tumours experienced similar CSS after URS or PC when compared with RNU, despite an increased risk of local recurrence following endoscopic management of UTUC. The RoB assessment revealed, however, that the analyses were subject to a selection bias favouring KSS. Conclusions Our systematic review suggests similar survival after KSS versus RNU only for low-grade and noninvasive UTUC when using URS or PC. However, selected patients with high-grade and invasive UTUC could safely benefit from SU when feasible. These results should be interpreted with caution due to the risk of selection bias. Patient summary We reviewed the studies that compared kidney-sparing surgery versus radical nephroureterectomy for upper tract urothelial carcinoma. We found similar oncologic outcomes for favourable tumours when using ureteroscopic or percutaneous management, whereas indications for segmental ureterectomy could be extended to selected cases of aggressive tumours.

Renal fusion abnormalities are rare. Even more rare is pancake kidney. We present a case of a 28-year-old male with symptomatic obstruction of a non-functioning moiety of a pancake kidney. He underwent ureterectomy with a finding of only atretic renal parenchyma at exploration. He recovered well and had resolution of his pain at 3-month follow-up.

Nephroureterectomy (NU) remains the gold-standard for upper-tract urothelial carcinoma (UTUC). However, nephron-sparing management (NSM), specifically segmental ureterectomy (SU) for urothelial tumors distal to the renal pelvis may offer decreased risk of renal insufficiency and equivalent cancer control.To identify patient-specific and facility-related factors that are associated with the selection of SU vs. NU for patients with clinically localized, high-grade, ureteral UTUC.We searched the National Cancer Database between 2004 and 2015 for patients with high-grade, clinically localized, primary ureteral UTUC managed by either NU or SU.Univariate and multivariate analysis was performed to assess patient, disease-specific, facility and treatment-related factors associated with SU vs. NU. Since surgical approach was only indexed after 2010, separate multivariable logistic regressions were performed including and excluding surgical approach in order to capture patients treated between 2004 and 2009. Survival analysis utilized Kaplan-Meier methods and Cox proportional hazards regression.Multivariate analysis including surgical approach demonstrated that among other factors, higher clinical stage (P = 0.034), larger tumor size (P0.001), the addition of neoadjuvant chemotherapy (P = 0.002), and the utilization of minimally invasive surgery (P0.05) decreased the likelihood of patients receiving SU. In this same cohort, institutions with larger facility volumes (P = 0.038) and performing intraoperative lymph node dissection (P0.001) were associated with a higher probability of SU. Excluding surgical approach, once again more advanced clinical stage (P = 0.005), larger tumor size (P0.001), and neoadjuvant chemotherapy (P = 0.003) decreased the probability of patients receiving SU, while increasing age (P = 0.049) and intraoperative lymph node dissection (P0.001) were more closely associated with SU compared to NU. No differences were noted in pathological T stage (P0.05), 30-day readmission (P = 0.7), 30-day mortality (P = 0.09), and 90-day mortality (P = 0.157) on multivariate analysis between SU and NU. Additionally, no significant differences were seen in median overall survival between patients receiving SU or NU (53 vs. 50 months; P = 0.143).Comparable outcomes suggest segmental ureterectomy for high-grade ureteral UTUC is appropriate in well-selected patients. Practice patterns appear consistent with guideline recommendations (decreased tumor size and lower clinical stage favor SU), but treatment disparities may exist based on a multitude of patient, pathologic- and facility-related factors. Improved dissemination of knowledge regarding practice patterns and outcomes of SU for UTUC of the ureter has the potential to improve delivery of NSM in appropriate patients.In this study, we examined factors associated with different surgical procedures for cancer of the ureter. We found that smaller tumor sizes, a less advanced clinical stage, intraoperative lymph dissection higher facility volumes tended to favor kidney-sparing treatment, while survival outcomes appear comparable to renal extirpation.

Objective The aim was to assess the feasibility and outcomes of pediatric urological laparoendoscopic single site (LESS) surgery. Materials and methods A retrospective review was performed of all children who underwent LESS surgery at a single pediatric institution from September 2010 to July 2013. Patient demographics, intraoperative details, narcotic usage, and complications were reviewed. The umbilicus was used as the surgical site in all cases. All procedures were performed with a flexible tip laparoscope, a multichannel port, standard 3- or 5-mm laparoscopic instrumentation, and articulating instruments. Results Sixty-one patients (50 male, 11 female) were identified. Procedures included 18 orchidopexies, 15 nephrectomies, 11 varicocelectomies, nine nephroureterectomies, four partial nephrectomies, one ureterectomy, one ureterolithotomy, one orchiectomy, and one utricle excision. The ureterolithotomy was converted to open surgery for failure to progress. The utricle excision was converted to conventional laparoscopy by adding one accessory port and one skin puncture because of the close proximity of the vas deferens to the utricle. Intraoperative complications included one vas deferens injury during orchidopexy in a postpubertal male. Postoperative complications occurred in six patients: five grade II and one grade IIIb. Conclusions Pediatric urological LESS procedures are technically feasible, safe, and effective. Further evaluation is warranted to better define its role in pediatric urological surgery.

Objective To evaluate risk factors for bladder cancer recurrence in a cohort of patients treated with radical nephroureterectomy (RNU). Patients and methods At 10 Canadian University Centers, we retrospectively evaluated data, between 1990 and 2010, from 743 patients who were free from bladder cancer and were previously treated with RNU for upper tract urothelial cancer. Results Of 743 patients, 167 (22.5%) developed bladder tumors after a median time of 17.2 months after RNU. Multivariable analysis detected age (hazard ratio [HR] = 1.028; 95% CI: 1.010–1.046; P = 0.0018), tumor location in both the renal pelvis and the ureter (HR = 2.205; 95% CI: 1.355–3.589; P = 0.0015), the use of adjuvant systemic chemotherapy (HR = 2.309; 95% CI: 1.439–3.705; P = 0.0005), and laparoscopic surgery (HR = 1.876; 95% CI: 1.226–2.87; P = 0.0037) as risk factors for bladder cancer recurrence. Open excision of a bladder cuff (HR = 0.661; 95% CI: 0.453–0.965; P = 0.0319) and transurethral resection of the intramural ureter (HR = 0.548; 95% CI: 0.306–0.981; P = 0.0429) on comparison with extravesical resection decreased the risk of bladder cancer recurrence significantly. Major limitations were the retrospective design and partially missing data, although the significance of variables did not change in the imputation analysis. Conclusion Older patients, those with tumor location in both the renal pelvis and the ureter, and those treated with adjuvant systemic chemotherapy were found at higher risk for intravesical recurrence, as were those having undergone extravesical ureterectomy or laparoscopic RNU.

The presence of hydronephrosis (HN) has been implicated as a predictor of poor outcomes for patients diagnosed with bladder cancer. Small, single institution preliminary reports suggest a similar negative relationship may exist for upper-tract urothelial carcinoma (UTUC). Herein, we attempt to validate the prognostic value of preoperative HN in a large, multi-institutional cohort of UTUC patients.Data on 469 patients with localized UTUC from 5 tertiary referral centers who underwent a radical nephroureterectomy (91%) or distal ureterectomy (9%) without neoadjuvant chemotherapy were integrated into a relational database. Preoperative HN data, including presence vs. absence and high vs. low grade, were available in 408 patients. The association of HN with pathologic features was evaluated.A total of 254 men and 154 women with a median age of 69 years (IQR 15) were analyzed. Overall, 192 patients (47%) had ≥pT2 disease, 145 (36%) had non-organ-confined (NOC) cancers (≥pT3 and/or positive lymph nodes), and 298 (73%) had high grade UTUC on final pathology. Forty-six percent of patients had tumors in the renal pelvis, 27% in the ureter, and 27% in both locations. Preoperatively, 223 patients (55%) were noted to have ipsilateral HN (39% low grade and 61% high grade). Hydronephrosis was associated with ≥pT2 stage (P0.001), NOC disease (P0.001), and high grade cancers (P = 0.04). On multivariate analysis adjusting for gender, age, and tumor location, HN was an independent predictor of muscle invasive (HR 7.4, P0.001), NOC (HR 5.5, P0.001), and high pathologic grade (HR 1.6, P = 0.03) UTUC disease.The presence of preoperative HN was associated with advanced stage UTUC. This readily available imaging modality may improve preoperative risk stratification for UTUC patients thereby guiding use of endoscopic versus extirpative surgery as well as the need for neoadjuvant chemotherapy regimens.

Resumen Introduccion La ureterectomia segmentaria con preservacion del rinon es una opcion de tratamiento para el carcinoma urotelial de bajo grado (CUBG) en el ureter distal no susceptible de reseccion endoscopica. La ureterectomia distal laparoscopica (UDL) con reimplantacion ureteral es habitual en un proceso patologico benigno (estenosis, lesion iatrogenica, endometriosis), pero se ha descrito escasamente en enfermedad ureteral maligna. Se revisa la literatura al respecto y se describe la tecnica quirurgica. Material y metodos Se expone la experiencia relativa a 2 casos de UDL por carcinoma urotelial de bajo grado en el ureter distal. En ambos se llevo a cabo RTU vesical previa, la citologia urinaria fue negativa y los estudios de imagen identificaron obstruccion urinaria y defecto de llenado en el ureter distal. Uno de los pacientes tenia antecedentes de neoplasia vesical T1G3 y padecia insuficiencia renal. En ambos el ureter se ligo precozmente. La ureterectomia segmentaria se practico mediante procedimiento combinado endoscopico y laparoscopico con desinsercion ureteral en un caso, y en el otro de forma exclusivamente laparoscopica; ambos con 4 trocares. La reimplantacion ureteral se llevo a cabo con sutura continua hermetica y sin tension. En un caso con antecedente de tumor vesical de alto grado se practico tambien linfadenectomia pelvica. Resultados El tiempo operatorio fue 180 y 240 min, respectivamente; el sangrado estimado 100 y 250 ml y el tiempo de ingreso 6 y 4 dias. La unica complicacion postoperatoria fue ileo paralitico (Clavien I) en el primer caso. Con un seguimiento de 20 y 12 meses no hay evidencia de recidiva ni de dilatacion. En el paciente con insuficiencia renal el aclaramiento de creatinina mejoro. Conclusiones La UDL con reimplantacion ureteral es una tecnica compleja, pero representa una alternativa factible y efectiva para el tratamiento del CUBG en el ureter distal, siempre que se respeten los principios oncologicos y reconstructivos.

Introduction Segmental ureterectomy with preservation of the kidney is a treatment option for the low grade urothelial carcinoma (LG-UC) in distal ureter that is not a candidate for endoscopic resection. Laparoscopic distal ureterectomy (LDU) with ureteral reimplantation is common in benign conditions (stenosis, iatrogenic lesion, endometriosis). However, it has been hardly described in malignant ureteral condition. The literature is reviewed in this regard and the surgical technique is described.

Patients diagnosed with upper tract urothelial carcinoma (UTUC) sometimes experience a delay from diagnosis to extirpative surgery (nephroureterectomy or ureterectomy) as a result of attempted endoscopic management and/or neoadjuvant chemotherapy. The purpose of this analysis is to examine the impact of such delay on survival outcomes.An IRB-approved retrospective review identified consecutive patients undergoing extirpative surgery for UTUC treated at a single institution between 1990 and 2007. 240 patients with non-metastatic disease represented both primarily-presenting and referred patients. Patients in the "early" surgery group underwent extirpative surgery3 months after diagnosis and patients in the "delayed" surgery group underwent surgery ≥ 3 months after diagnosis. Timing to surgery was at the discretion of individual patient-surgeon decision-making. Analyses and measurements were univariate and multivariate models correlating death from disease with clinico-pathologic parameters, recurrence-free survival (RFS), cancer-specific survival (CSS), and overall survival (OS) in the "early" and "delayed" surgery groups.186 patients underwent early surgery and 54 patients underwent delayed surgery. Median follow-up for all patients was 29 months. The 5-year CSS were 72% and 71% for the early versus late groups, respectively (P = 0.39) and corresponding 5-year OS rates were 60% and 69%, respectively (P = 0.69). Delay in surgery was not associated with a worse outcome, even following adjustment for potential confounders. The most common factor contributing to delayed surgery in our cohort was administration of neoadjuvant chemotherapy (50%), which did not impact survival. Limitations included a median follow-up of 19 months in the neoadjuvant group; and the requirement to analytically group pathologic high-stage and low-stage disease, which reflects challenges inherent to current clinical staging.Our results show no difference in survival between patients undergoing early versus delayed extirpative surgery for UTUC, suggesting the feasibility of delayed surgery in appropriately selected patients. Only prospective validation of delayed surgery can guarantee its safety.

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 describe a purely laparoscopic nephroureterectomy approach that avoids the disadvantages of transurethral bladder cuff excision and open/laparoscopic distal ureterectomy using the EndoGIA. Methods A standard transperitoneal laparoscopic nephrectomy is carried out through three or four ports in the flank. The ureter is dissected caudally into the pelvis. Two additional ( 5- and 10-mm) trocars are placed in the ipsilateral lower abdomen. Caudal ureteral dissection continues until the detrusor muscle fibers at the ureterovesical junction are identified. A 1-cm area of bladder adventitia around the ureterovesical junction is cleared. The ureter is retracted upward and laterally, tenting up the bladder wall. The bladder cuff is excised using a 10-mm LigaSure Atlas and detached from the bladder. A 6-cm lower-quadrant incision is used to remove the specimen in an Endocatch bag. An indwelling 16F Foley catheter is then placed. Results Thirteen adult patients with suspected upper-tract transitional cell carcinoma underwent this surgical technique (operative time: 170–270min): none had local recurrence, and two had recurrence remote from the bladder cuff scar (follow-up: 1–23 months). Conclusions The described procedure adheres strictly to oncologic principles (removal of the affected renal unit without opening the urinary tract), and circumvents the need for transurethral/intraureteral instrumentation and patient repositioning.

A late consequence of ureteral endometriosis is the silent loss of renal function caused by progressive "enclosure" of the lower part of the ureter by the endometriosis. In our experience, in cases of severe loss of renal function with cortical atrophy and residual kidney function (evaluated by Tc99 DMSA scintigraphy) of less than 15%, removal of the endometriosis combined with ureterolysis does not allow recovery of renal function. A nonfunctioning kidney associated with hydronephrosis is a risk factor for vascular hypertension, recurrent pyelonephritis, or kidney stones and therefore an indication for nephrectomy. By means of a case report, this paper describes the combination of laparoscopic nephrectomy, ureterectomy, removal of the rectovaginal endometriotic nodule, and extraction of the kidney through the vagina.

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.

s / Urological Science 26 (2015) S50eS81 S58 NDP032: IS THERE NECESSARY TO PERFORM URETERECTOMY IN RENAL CELL CARCINOMA TREATMENT Hueih-Shing Hsu, Heng-Chang Chuang, Shyh-Chyi Chang, Hsu-Hsiang Wang, I-Hung Shao. Division of Urology, Department of Surgery, Lotung Pohai Hospital Yilan, Taiwan Purpose: Radical nephrectomy is the standard surgical treatment of localized renal cell carcinoma. Is there necessary to perform ureterectomy at the same time? We challenge this question, because we have tow cases of renal cell carcinoma received radical nephrectomy but recurrent tumor was found in the ureter several years later. Materials and Methods: This is a 79 years old man who received left radical nephrectomy for renal cell carcinoma stage (T2N0M0) 4 years ago. And he underwent hemodialysis for end stage renal disease for 5 years. Gross hematuria was noted recently and CT scan showed left ureter tumor in the remaining stump. Ureterectomy with bladder cuff was done and pathology shoed transitional cell carcinoma stage T3NoMo. Results: This is a 90 years old man who received left radical nephrectomy for renal cell carcinoma (stage T3N0M0) 14 years ago. He suffered from gross hematuria and CT showed left ureter tumor in the stump. Ureterectomy with bladder cuff was done and pathology shoed renal cell carcinoma stage T4N1Mo. Conclusion: Renal cell carcinoma is not only existed in renal parenchyma but also in collecting system. Transitional cell carcinomamay occured in the remaining stump of ureter in uremia patient. So it is better to perform ureterectomy in uremia patient or the larger renal tumor closed to renal pelvis. NDP033: ACUTE URINARY RETENTION IN A MAN WITH PROSTATE CANCER STILL ELIGIBLE FOR TRANSURETHRAL RESECTION OF PROSTATE Chih-Te Lin, Chen-Pang Hou, Yu-Hsiang Lin, Ke-Hung Tsui, Phei-Lang Chang, Chien-Lun Chen. Division of Urology, Department of Surgery, Chang Gung Memorial Hospital at Linkou, Chang Gung University, College of Medicine, Taoyuan, Taiwan Purpose: To interrogate the outcome of transurethral resection of prostate (TURP) in men with prostate cancer (PCa). Materials and Methods: A total of 160 patients with prostate cancer undergoing TURP for acute urinary retention (AUR) between 2001 and 2010 were retrospectively reviewed. Thirty-eight patients undergoing palliative TURP (pTURP group) and the other 122 patients with newly diagnosed prostate cancer received TURP (iTURP group) were compared. We also included 9 patients with prostate cancer undergoing palliative cystostomy without TURP (cystostomy group). The data, including preoperative characteristics, perioperative morbidities and mortality were analyzed. Results: Therewere no significant differences between the 2 groups in age, initial PSA (iPSA), operative time, incontinence rate, hospital stay or Foley catheter duration. However, the prostate volume was higher in iTURP group (49.31± 25.57gm) than in pTURP group (39.29 ± 18.36 gm) (p 1⁄4 0.006). The mean resected weight was higher in iTURP group (14 gm) than in pTURP group (10 gm). The pTURP group was more likely to recatheterization and the Foley home rate (FHR) was higher. The re-operation rate was not significant over two groups. There was no complication such as transurethral resection (TUR) syndrome or perioperative death in either group. There was no significant difference of mortality over two groups. Conclusion: TURP can be performed safely for relief of AUR in patients with prostate cancer, no matter if the cancer was diagnosed before or after surgery. The recatherization rate and FHR were higher in pTURP group, which may be due to the palliative intent. NDP034: TWO RARE CASES OF PRIMARY MALIGNANAT SMALL CELL CARCINOMA COMBINED WITH UROTHELIAL CELL CARCINOMA IN THE URETER AND METAANALYSIS Jhih-Cheng Wang , Li-Jing Ye , Zi-Ru Chen , Yu-Hsuan Kuo . Divisions of Urology, Department of Surgery, Chi-Mei Medical Center, Tainan, Taiwan; 2 Institution of Biomedical Engineering, National Cheng Kung University, Tainan, Taiwan; Department of Pathology, Chi-Mei Medical Center, Tainan, Taiwan; Division of hemato-oncology, Department of Medicine, Chi Mei Medical Center, Tainan, Taiwan Background: Extrapulmonary small cell carcinomas have been reported in a variety of organs, and their incidence in the genitourinary tract is second only to that in the gastrointestinal tract. To date, however, only a few cases of small cell carcinoma of the ureter have been reported. Because the extreme rarity of this combined type of carcinoma, its clinical behavior, and effective treatment modalities have not yet been studies well. Cases Presentation: A 73-year-old man has a past history of prostate adenocarcinoma, cT3aN0M0, s/p hormone therapy and radiotherapy and regular followup at OPD. He presented with a two-month history of painless gross hematuria. He had a smoking history of one pack (Cigarettes, 20/pack) per day for over 30 years, but without having any respiratory symptoms. After intravenous pyelography survey, left UPJ tumor was suspected and diagnostic ureteronephroscopic biopsy revealed urothelial carcinoma. Laparoscopic Nephroureterectomy done and pathologic examination showed an SCC combined with a urothelial carcinoma in the ureter. Another patient is a 67 year-old female with a diabetes history, present with intermittent painless gross hematuria. She also received diagnostic ureteronephroscopic biopsy then laparoscopic nephroureterectomy with bladder cuff done. The small cell carcinoma was diffusely positive for neuron-specific enolase, and exhibited focal positivity for CD 56, synaptophysin, chromogranin and cytokeratin 20. They were treated with adjuvant chemotherapy, consistingof cisplatin and etopside, and has being well, without evidence of tumor recurrence or metastasis in the 6 months after surgery. Conclusion: Small cell carcinoma of the ureter is rare. Combined urothelial carcinoma with SCC is rarer. Although its clinical behavior and diagnostic modalities have not been determined and it has yet to be diagnosed immunohistopathologically, multimodality treatment including surgery, chemotherapy and radiotherapy may improve patient survival.

Objectives To present and discuss clinical and surgical management of urologic endometriosis. Methods Retrospective review of a database on surgical patients with endometriosis. Results Thirty-one patients (incidence, 2.6%; mean age, 33.1 yr) were affected by urologic endometriosis (bladder, 12; ureter, 15; both, 4). Bladder endometriosis was revealed by symptoms related to menses and showed a typical endoscopic picture, whereas ureteral involvement had a nonspecific or silent symptomatology. All patients affected by bladder endometriosis and undergoing transurethral resection (2 cases) developed a bladder recurrence; a ureteral recurrence was observed in two of six patients submitted to laparoscopic ureterolysis and in one of two patients submitted to ureterectomy with ureteroureterostomy. Conversely, no relapses were observed among the 14 patients who had partial cystectomy or the 9 who had ureterectomy and ureterocystoneostomy. Finally, two patients underwent nephrectomy due to end-stage renal atrophy. Conclusions Cystoscopy is advisable in women with pelvic endometriosis with lower urinary tract symptoms; the upper urinary tract should be evaluated in all patients with pelvic endometriosis to exclude asymptomatic ureteral involvement. Partial cystectomy gives the best results when used to treat bladder endometriosis. Ureterolysis can be successful only in case of limited ureteral involvement with no urinary obstruction, whereas terminal ureterectomy and ureterocystoneostomy should be preferred in case of obstructive ureteral endometriosis.

Objectives: We retrospectively compared two techniques of transurethral management of the lower ureter in nephroureterectomy. Patients and Methods: From August 1992 to December 2003, 34 patients underwent either transurethral detachment of the intramural ureter and cephalad extraction ("pluck"; Group 1, N = 18) or transection of the ureter with subsequent transurethral extraction (Group 2, N = 16). Choice of technique was left to the operating surgeon. All patients with upper tract urothelial carcinoma (TCC) were regularly followed by cystoscopy and abdominal ultrasound. Results: Of the 34 patients, 29 had upper tract TCC. Mean follow-up in these was 44 months (range: 1–129), with 24 (83.8%) over 24 months. On follow-up, 14 bladder tumors (all superficial) occurred in 7 patients (24.1%), but in no case on the scar of the excised ureteral orifice. No extravesical recurrences in the former ureteral bed were found. Of the 29 with upper tract TCC, 19 (65.5%) are alive without disease (median 45 months, range: 6–129), 5 (17.2%) have died with no evidence of disease (median 34 months, range: 20–58), and 4 (13.8%) have died from progressive disease (median 18 months, range: 1–33); 1 patient was lost to follow-up at 34 months with no evidence of disease. Differences between techniques with regard to blood loss, operative time, complications, and oncologic outcome were not significant. Conclusion: Both techniques proved technically and oncologically safe. Bladder tumor recurrence rate was in the range reported for classic nephroureterectomy. No extravesical tumor recurrence in the former ureteral bed or on the scar of the resected ureteral orifice occurred.

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.

Objective: Nephroureterectomy is the treatment of choice for tumors of the upper urinary tract (UUTT). In 1952, a modified version of this technique was described, involving endoscopic detachment of the ureter followed by nephroureterectomy with a single lumbar incision. We reviewed a retrospective survey to assess whether UUTT patients treated with nephroureterectomy with no prior history of bladder tumor had different rates of incidence or different sites of bladder recurrence according to the specific technique employed. Methods: Patients were divided into group A, 87 patients who underwent a double incision nephroureterectomy and group B with 58 patients with prior detachment of the ureter. In both groups, incidence was calculated for two variables (bladder tumor recurrences and homolaterality of such recurrences) and chi-square tested. Results: Bladder tumor was diagnosed at follow-up in 39% of patients in group A and 34.5% in group B, with no statistically significant difference (N.S.). Bladder tumor recurrences were homolateral to UUTT in 50% of group A cases and 55% of group B cases (N.S.). Conclusions: Although this is a retrospective survey of two asynchronous groups, given the similar nature of the UUTT cases in both groups and the fact that no statistically significant differences have been found, it is reasonable to conclude that nephroureterectomy with prior endoscopic detachment of the ureter is a safe and radical procedure.

Primary squamous cell carcinoma (SCC) of the pelvic retroperitoneum is very rare. We present a primary SCC of the pelvic retroperitoneum, which to our knowledge is the second case described. In this case, a heterogenous mass with irregular cystic echoes located at the left pelvic cavity was examined in a 44-year-old female patient. Final pathological studies proved it to be a SCC. The patient received radical abdominal hysterectomy and left distal ureterectomy. Concurrent chemo-radiation therapy was given after surgery. The patient was followed up for 4 years without any recurrence. In conclusion, it is difficult to find an optimum therapeutic modality for such rare cases. Our report suggests that surgical excision combined with concurrent chemo-radiotherapy is an effective option for the treatment of this tumor.

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.

We present a case of a 57-year-old woman who sustained bladder erosion with extension to the left ureter after a mesh-augmented recurrent cystocele repair. The persistence of the eroding mesh eventually necessitated a partial cystectomy and distal left ureterectomy, using a Boari flap technique.

To assess the prognostic factors in patients with transitional-cell carcinoma of the renal pelvis and/or ureter, a series of 138 patients with transitional-cell carcinoma of the renal pelvis and/or ureter was collected in a retrospective multicentre study. 12 patients with distant metastases were excluded from the statistical evaluation. All but 3 patients underwent radical surgery: nephroureterectomy (n = 71), nephroureterectomy and lymphadenectomy (n = 20), nephroureterectomy and partial bladder resection or transurethral resection (n = 20), nephrectomy (n = 10), and ureterectomy (n = 5). Sixty-one per cent (n = 77) of the tumours were located in the renal pelvis, and 21% (n = 27) in the ureter (both in 22 [17%]). Following surgery, residual tumour was still present in 33 patients (16 microscopic and 17 macroscopic). Postoperative radiotherapy was given to 45 (36%) patients. The median follow-up period was 39 months. In a median period of 9 months, 66% of the patients relapsed (34 local, 7 locoregional, 16 regional, and 24 distant). The 5- and 10-year survival were 29% and 19%, respectively, in all patients. In univariate analyses, statistically significant factors influencing the outcome were Karnofsky index, pT-classification, pN-classification, tumour localisation, grade, and residual tumour after surgery. Multivariate analysis revealed that independent prognostic factors influencing outcome were pT-classification, the existence of residual tumour, and tumour localisation. In patients with urothelial renal pelvis and/or ureter tumours, a radical surgical attitude is mandatory; and the presence of tumour in the ureter is associated with a poorer prognosis.

To compare the oncological outcomes of radical nephroureterectomy (RNU), distal ureterectomy (DU), and endoscopic surgery (ENDO) for elective treatment of clinically organ-confined upper tract urothelial carcinoma (UTUC) of the distal ureter. From a multi-institutional collaborative database, we identified 304 patients with unifocal clinically organ-confined UTUC of the distal ureter and bilateral functional kidneys. Overall survival (OS), cancer-specific survival (CSS), local recurrence-free survival (LRFS), and intravesical recurrence-free survival (IVRFS), according to the surgery type, were compared using Kaplan-Meier statistics. Univariable and multivariable Cox regression analyses were performed to assess the adjusted outcomes of RNU, DU, and ENDO. Overall, 128 (42.1%), 134 (44.1%), and 42 (13.8%) patients were treated with RNU, DU, and ENDO, respectively. Although OS, CSS, and IVRFS were equivalent between the three surgical procedures, the 5-year LRFS rate was lower in the ENDO group (35.7%) when compared to RNU (95.0%; p

1.022 JCR (2014) Q4, 60/76 Urology & nephrology UEM

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.

Purpose To compare renal function outcomes in patients undergoing radical nephroureterectomy (RNU) or partial (distal) ureterectomy (PU) for upper tract urothelial carcinoma (UTUC). Methods Clinicopathologic data of patients undergoing RNU or PU for UTUC from 1998 to 2012 were compiled. Glomerular filtration rate was calculated preoperatively and postoperatively using the Modification of Diet in Renal Disease equation. We defined “event” as new-onset stage III chronic kidney disease (CKD) or worsening of CKD stage with preexisting CKD. Event-free survival was assessed with Kaplan-Meier methods. Cox regression analyses were performed to identify predictors of events. Results In total, 193 patients underwent RNU ( n = 143) or PU ( n = 50) over a median follow-up of 25.9 months. Overall, 15% of patients died of UTUC. High tumor grade (85.9% vs. 66.0%, P = 0.003) and locally advanced stage (>pT2, 37.8% vs. 18.0%, P = 0.014) were significantly more frequent in the RNU cohort. Stage III or higher CKD was present in 61% of RNU patients vs. 48% of PU patients ( P = 0.135) at baseline. Although total event rate was higher in the PU cohort (66% vs. 43.4%, P = 0.008), event rates within the first 3 months of surgery were similar between the groups ( P = 0.572). Adjuvant chemotherapy was the only predictor of events on Cox regression. Conclusions Rates of new-onset CKD or worsening of CKD stage were similar in patients treated with RNU and PU. Adjuvant chemotherapy may have a more significant effect on renal outcomes than surgical approach, warranting further investigation. Consideration should be given to preoperative chemotherapy, as adjuvant chemotherapy is limited by decreased renal function following surgery.

Objectives We evaluated cancer-specific survival (CSS) and recurrence-free survival (RFS) rates of open distal ureterectomy (DU) compared with radical nephroureterectomy (RNU) for urothelial carcinoma of the distal ureter. Methods and materials We retrospectively considered patients with urothelial carcinoma of the distal ureter who underwent DU or RNU at our department. Survival analysis and Cox regression models compared CSS and RNU after DU and RNU. RFS was evaluated separately for bladder and upper tract. Covariates were age, gender, symptoms at diagnosis, pathologic stage and grade, associated carcinoma in situ, surgical margins, lympho-vascular invasion, multifocality, necrosis, and previous or concomitant bladder cancer. Results Forty-nine and 42 patients underwent DU and RNU, respectively. Median patients' follow-up was 51.5 months (range 4–290 mo). Two patients (4%) in the DU group were diagnosed with a recurrence in the ipsilateral upper tract after 63 and 45 months, respectively. Both patients underwent nephroureterectomy and are still alive in strict follow-up for non–muscle invasive bladder recurrence. Contralateral upper tract recurrence was observed in 1 and 3 patients in the RNU and DU group, respectively. At 5 years, CSS and RFS (upper tract) rates were 77% and 91% for DU and 78% and 96% for RNU, respectively. On univariable and multivariable analyses the type of surgery did not influence CSS and RFS ( P = 0.92 and P = 0.94). Conclusions DU is a safe surgical option in patients with urothelial carcinoma of the distal ureter and does not compromise oncologic outcomes compared with RNU.

Introduction: Radical nephroureterectomy with resection of a bladder cuff remains the “gold standard” in the treatment of upper urinary tract transitional cell tumors. McDonald is the first to describe a ureteral stripping technique with subsequent endoscopic resection of the bladder cuff around the ureteral orifice during nephroureterectomy, which is called transurethral endoscopic ureterectomy and is a less invasive alternative of open surgical ureterectomy in patients with transitional cell renal pelvic carcinoma. Objective: To evaluate the clinical outcome of transurethral endoscopic ureterectomy during nephroureterectomy for transitional cell carcinoma of the renal pelvis and calyces.