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Unifocal tumor
Treatment recommendations (all grade C) for these low-risk tumors are as follows[1]:
A percutaneous approach can be used in small low-grade caliceal tumors unsuitable for
ureteroscopic treatment
Nephroureterectomy with excision of the bladder cuff is considered the standard therapy
in patients with high-volume renal pelvis transitional cell carcinoma (TCC), regionally
extensive disease, and high-grade or high-stage lesions.
Segmental ureterectomy coupled with ureteral reimplantation is indicated in patients with
ureteral tumors located in the distal ureter, generally of lower grade and stage.
Unfortunately, because of the multifocal nature of TCC, the ipsilateral recurrence rate is
25% or greater after segmental ureterectomy.
Renal-sparing surgery, including segmental ureterectomy and endoscopic therapy,
maintains a vital role in the management of upper tract urothelial tumors. Typically,
patients with small, low-grade superficial lesions are the best candidates for this
approach. Some investigators use this approach more frequently in patients with a solitary
kidney, bilateral disease, compromised renal function, synchronous tumors, or greater
baseline operative risk.
Open radical nephroureterectomy
Nephroureterectomy is the standard for large, high-grade tumors of the renal pelvis and
proximal ureter that are organ-confined or locally advanced. Nephroureterectomy is also
recommended for multifocal, recurrent, low-grade tumors, which are found to be less
amenable to ureteroscopic management.
Classically, this procedure involves removal of the kidney, ureter, and bladder cuff via a
thoracoabdominal or flank approach, with a separate lower-quadrant Gibson incision.
Laparoscopic approaches to the radical nephroureterectomy are now commonplace and
offer some postoperative benefits.
In both open and laparoscopic surgeries, care is taken to excise the entire distal ureter and
bladder cuff to prevent local recurrence.
Excision of the cuff has a survival benefit.[34]
There are multiple effective approaches,[35]as follows:
Intussusception technique
Obtain adequate tissue during initial biopsy for accurate diagnosis and grade
Minimize the risk of stricture with the use of laser rather than the more deeply penetrating
electrosurgical devices when ablating ureteral tumors
Drain the bladder with a small catheter or use a ureteral access sheath to improve flow
and visibility, which can be limited by bleeding
Facilitate resection by slowing the patients respiratory rate, which decreases movement
and stabilizes the operative field during resection and ablation
Percutaneous treatment
Percutaneous therapy allows the use of larger scopes with improved maneuverability and
visibility to ablate larger tumors in the renal pelvis and upper ureter. Percutaneous access
may be used to administer topical therapeutic agents such as BCG or mitomycin. This
approach is an acceptable alternative to nephroureterectomy in patients with lowgrade
disease. However, as with all organ-preserving strategies, vigilant follow-up surveillance
is required.
Percutaneous techniques allow a renal-sparing approach and are well suited for largevolume disease of the renal pelvis and proximal ureter.
Percutaneous access to the diseased renal unit is established, followed by tract dilation.
This allows the passage of nephroscopes, laser fibers, biopsy forceps, and electrosurgical
resection devices to completely resect and ablate tumors under direct vision.
Percutaneous access also allows for a deeper resection and more accurate staging than
ureteroscopy for tumors of the renal pelvis and kidney.
Tumor seeding of the nephrostomy tract, although rare, has been reported and is
associated with high-grade lesions.
Radical nephroureterectomy versus conservative, endoscopic management
No randomized studies have been performed, and no studies have had good long-term
follow-up. Selection bias confounds nonstandardized studies. Tumors treated with
endoscopic management are generally smaller, of low grade, and of low stage.
The 5-year disease-specific survival rate in patients with low-grade disease is statistically
similar for conservative treatment and immediate nephroureterectomy, at 86.2-100% vs
87.4-89%, respectively.[44, 45]
Silberstein et al, in a 2012 study, showed that although oncologic outcomes were similar,
a significantly larger decrease in glomerular filtration rate was noted in patients
undergoing nephroureterectomy compared with endoscopic treatment.[46]
Lymph node dissection
One study demonstrated a significant survival advantage in patients undergoing extensive
regional lymphadenectomy at the time of open nephroureterectomy.[47]
Menurut pedoman Asosiasi Urologi Eropa (EAU), manajemen konservatif sesuai untuk
UTUC yang berisiko rendah [1] adapun indikasi EAU untuk UTUC risiko rendah adalah
sebagai berikut.
Tumor Unifokal
Ukuran tumor <1 cm
Tumor grade rendah (sitologi atau biopsi)
Tidak ada bukti lesi infiltratif pada CT urografi
Rekomendasi pengobatan (semua kelas C) untuk UTUC risiko rendah tersebut adalah
sebagai berikut [1]:
Laser harus digunakan dalam perawatan endoskopik
Ureteroscopy fleksibel lebih baik daripada ureteroscopy kaku
Manajemen perkutan dapat digunakan pada caliceal tumor yang berisiko kecil namun
tidak cocok untuk pengobatan Ureteroscopic
Ureteroureterostomy diindikasikan untuk low grade tumor noninvasif dari ureter
proksimal atau midureter yang tidak dapat dihilangkan sepenuhnya melalui
endoskopi
Ureterectomy distal lengkap dan neocystostomy diindikasikan untuk noninvasif,
tumor kelas rendah di ureter distal yang tidak dapat dihapus sepenuhnya melalui
endoskopi, dan untuk bermutu tinggi, tumor invasif lokal
Nephroureterectomy dengan eksisi manset kandung kemih dianggap terapi standar
pada pasien dengan high-volume pelvis ginjal karsinoma sel transisional (TCC), penyakit
regional yang luas, dan tumor dengan stage atau tahap lesi yang tinggi.
Ureterectomy segmental ditambah dengan ureter reimplantation diindikasikan pada
pasien dengan tumor ureter yang terletak di ureter distal, umumnya dari kelas yang lebih
rendah. Sayangnya, karena sifat multifokal dari TCC, tingkat kekambuhan ipsilateral
adalah 25% atau lebih besar setelah ureterectomy segmental.
Operasi Renal-Sparing, termasuk segmental ureterectomy dan terapi endoskopik,
mempertahankan peran penting dalam pengelolaan UTUC. Biasanya, pasien dengan lesi
superfisial kecil dan low grade merupakan yang terbaik untuk pendekatan ini. Beberapa
peneliti menggunakan pendekatan ini lebih sering pada pasien dengan ginjal soliter,
penyakit bilateral, compromised renal function, tumor sinkron, atau risiko operasi dasar
yang lebih besar.