Endourological Management of Urogenital Carcinoma
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However, no consensus has been reached regarding its indications. In addition, it is accompanied by several limitations and potential adverse events such as dissemination of malignant cells, adhesion of the ureter to the surrounding tissue, ureteral stricture, and ureteral perforation.
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- Endoscopic Management of Upper Urinary Tract Urothelial Carcinoma | Journal of Endourology.
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In order to determine when and what circumstances dictate the need for ureteropyeloscopy to detect upper urinary tract tumors, we investigated the indications for ureteropyeloscopy based on voided urine cytology and preoperative radiographic findings. Patients and Methods: In this retrospective study, we evaluated 92 patients 62 men and 30 women with a mean age of Ureteropyeloscopic findings including histology were compared with urine cytology and radiographic findings.
Results: Voided urine cytology exhibited Carcinomas were detected in all patients in Subgroups A1 and A2. Carcinomas were also detected in 9 patients The remaining 10 patients all had a history of bladder cancer. In Subgroups C1, C2, and D, carcinomas were detected in 14 patients These results suggested that ureteropyeloscopy should be recommended for patients with negative cytology.
Three complications pyelonephritis, renal failure, and urinary retention were noted, but none of these was severe and all were cured within a few days.
Management of Priapism After the initial resection, a re-entry nephrostomy catheter with an cm extension allows for easy access to the ureter with safety guidewire during the second look Fig. Thulium:YAG laser vaporesection versus bipolar transurethral resection of the prostate for the treatment of benign prostatic hyperplasia: comparative study. After induction of anesthesia in the supine position, the patient is repositioned to dorsal lithotomy for a thorough cystoscopy if the bladder has not been inspected recently. Thulium:YAG laser vaporesection versus bipolar transurethral resection of the prostate for the treatment of benign prostatic hyperplasia: comparative study.
No malignant findings were obtained in any of the patients during follow-up after negative findings in ureteropyeloscopy. Conclusions: Ureteropyeloscopy is essential for detecting upper urinary tract carcinoma in patients with negative voided urine cytology and positive radiographic findings. In addition, ureteropyeloscopy seems to be used commonly among patients with positive urine cytology and negative radiographic findings, or those with bleeding from the ureteral orifice.
However, unless conservative nephron-sparing treatment is considered, ureteropyeloscopy may be unnecessary for patients with positive urine cytology and positive radiographic findings. Advanced Search. Users Online: Flanigan RC. Urothelial tumors of the upper urinary tract.
The role and efficacy of adjuvant intrarenal topical agents are examined as well as the protocol for administering these agents. Follow-up protocols are also reviewed. T raditionally, radical nephroureterectomy has been the gold standard treatment for high-grade, large-volume upper urinary tract urothelial tumors with a normal contralateral kidney.
Over the past few decades, the role of ureteroscopic and percutaneous management of upper tract urothelial carcinoma gained popularity. The goal of the endoscopic approach is to preserve kidney function while attempting to achieve oncologic control similar to radical surgery. Ureteroscopy is used not just for diagnosis but also as a therapeutic means in the treatment of low-grade, low-volume, noninvasive disease. Percutaneous resection is preferred over ureteroscopy in cases of larger tumors or tumors in unfavorable locations via retrograde ureteroscopic approach i.
Staging is also more feasible through the percutaneous approach where ureteroscopy often falls short. The imperative indications for endoscopic management of upper tract urothelial carcinoma are the presence of low-grade tumor s in a solitary kidney, bilateral tumors, or chronic renal insufficiency. Tract seeding is another potential disadvantage of the percutaneous approach, although this is limited to a small number of case reports. With the development of better equipment and improved techniques, the endoscopic approach has been used in patients outside of the abovementioned imperative indications.
Although there have not been any randomized control studies comparing endoscopic vs radical surgery, many case series have been published supporting the practice of endoscopic resection of upper tract urothelial tumors in patients with a normal contralateral kidney. To assess candidates for the endoscopic approach, a full medical and surgical history, as well as physical examination, is essential. In patients at low risk for perioperative cardiovascular events, aspirin can be held 7—10 days before surgery, although there is evidence that continuing low-dose aspirin does not significantly increase the risk of bleeding in percutaneous nephrolithtomy.
A complete blood count, basic metabolic panel, and coagulation studies should be obtained to assess for anemia, renal function, and bleeding disorders. A preoperative urine culture is required, and any infection should be treated before surgery. In cases with sterile preoperative urine culture, the American Urologic Association Best Practice Statement recommends 24 hours or less of a first- or second-generation cephalosporin as first-line antimicrobial perioperative prophylaxis.
Preoperative imaging is used to assess tumor burden, identify the optimal calix of entry, and ensure extrarenal organs are away from the intended percutaneous tract. Recent imaging can also dictate which treatment modality a patient requires—that is, if there is progression of disease or invasion into parenchyma, the patient would no longer be a candidate for endoscopic management. After induction of anesthesia in the supine position, the patient is repositioned to dorsal lithotomy for a thorough cystoscopy if the bladder has not been inspected recently.
An open-ended 5F or 6F ureteral catheter is inserted at this time into the ureter of interest to enable opacification of the collecting system. The patient will remain in this position if a ureteroscopic approach is performed.
Smith's Textbook of Endourology
The patient is then turned to the prone position if percutaneous resection is deemed appropriate. Gel rolls are placed underneath the torso to prevent hyperextension of the neck. The arms are abducted with the elbows below degree angles on armrests on each side. All pressure points should be padded. Alternatively, if leg extenders are available, the entire procedure can be performed in the prone split-leg position. With the hips abducted, the urethra is easily accessible, allowing for cystoscopic surveillance as well as retrograde flexible ureteroscopy possible through this position.
When performing ureteroscopy for diagnosis and treatment of upper tract urothelial tumors, one should minimize trauma to the upper urinary tract. A 5F or 6F open-ended ureteral catheter inserted cystoscopically can be used to obtain ureteral washing with physiologic saline if selective cytology is warranted. Provided the ureteral orifice is patent enough, a flexible ureteroscope can be advanced into the ureter without the use of guidewires, to prevent any trauma or dislodgement of tumor and for better detection of carcinoma in situ.
If available, using a smaller 7. If a ureteroscope is not easily passed, retrograde pyelography should be performed through an open-ended ureteral catheter to obtain a roadmap of the collecting system and identify any filling defects. Then, a sensor-tipped guidewire can be passed into the ureter up to the level of the renal pelvis under fluoroscopic guidance, and the flexible ureteroscope may be able to be passed over the wire more easily.
Balloon dilation of the ureteral orifice may be necessary if the ureteroscope is still unable to be passed at this point. Once the ureteroscope is advanced into the ureter, the entire upper tract should be visualized, and physiologic saline washing of any suspicious areas should be performed. Narrow band imaging, if available, may help detect subtle abnormalities in the urothelium Figs. The specimen is best sent to the cytopathology laboratory as it is usually too small to be sent for conventional pathologic review.
The holmium laser has a 0. Commonly used settings are an energy of 0. The thulium laser has a shallower depth of penetration at 0.
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After all tumors are ablated, a ureteral stent is typically left in place to aid in the healing process. White light ureteroscopic image of urothelial tumor. Ureteroscopic image of urothelial tumor with narrow band imaging. Ureteroscopic biopsy of renal pelvis tumor permission for use granted by Cook Medical.
In the 6 years since the publication of the first volume of Recent Advances in Endourology by the Japanese Society of Endourology and ESWL, data on. Endourological Management of Urogenital Carcinoma (Recent Advances in Endourology) [S. Naito, Y. Hirao, T. Terachi] on giuliettasprint.konfer.eu *FREE* shipping on.
Proper selection of the calix of entry is critical in optimizing the amount of tumor able to be resected. Tumors in posterior calices are best accessed by direct puncture into the affected calix.
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Anterior caliceal tumors may be difficult to access directly and may require flexible nephroscopy through a posterior calix. Renal pelvis and upper ureteral tumors should be approached through an upper or middle calix to allow the nephroscope to be maneuvered in the renal pelvis and upper ureter with minimal torquing of the kidney. However, caution should be used when obtaining access into the upper pole to minimize the risk of pleural injury, especially if it requires a supracostal puncture. Radiopaque contrast is injected through the open-ended ureteral catheter that was previously placed in the ureter to opacify the collecting system.
A diamond-tipped gauge needle is used to access the desired calix either by the bull's eye or triangulation technique with fluoroscopic guidance. Once a wire is secured in the collecting system, the tract is dilated to 30F using either sequential renal dilators or a balloon dilator. Once the 30F Amplatz sheath is positioned in the proper calix, the rigid nephroscope is passed into the collecting system to visualize the tumor directly Figs.
Secure placement of the sheath should be ensured to minimize the risk of tract seeding. Using the cold cup biopsy forceps, the tumor is removed piecemeal without creating thermal artifact that loop electrocautery may create Fig.