Carcinoma in situ is significantly underdetected by prenephroureterectomy ureteroscopy in the management of upper tract urothelial cancers.

Objective. Diagnostic reliability of prenephroureterectomy ureteroscopy (PNU) for the detection of upper tract carcinoma in situ (CIS) remains unproven in particular and underreported in general. Methods. Patients who underwent radical nephroureterectomy (RNU) in a large multicentre retrospective study for upper tract transitional cell carcinoma (UT-TCC) between January 2002 and December 2013 were identified from our hospitals databases. PNU appearances, stage, and grade of ureteroscopic biopsy were compared with final histology results of RNU to assess the diagnostic reliability of PNU for carcinoma in situ (CIS). Results. Three hundred patients underwent RNU for UT-TCC. 106 (106/300; 35.3%) of the cohort had PNU using white light with biopsies taken in most (92/106; 86.7%). Postnephroureterectomy histology of the cohort showed CIS in 65 (65/300; 21.6%) patients. Thirty nine of patients with CIS (39/65; 60%) had prenephroureterectomy ureteroscopy biopsies. Out of ten patients with CIS on ureteroscopic biopsies, six did not show CIS on final histopathology (6/10; 60%). Moreover, grading and staging on PNU biopsies of obvious tumours showed a significant nonconcordance with final histopathology of RNU specimen (P = 0.02). Overall survival was also shorter in patients with CIS compared with those without; this showed strong statistical significance (P = 0.004). Conclusions. There is a high incidence of CIS in upper tract with significant underdetection and discordance rate between the histopathology of biopsy samples obtained by white light PNU and resected specimen of radical nephroureterectomy. The presence of concomitant CIS and high stage disease in the upper tract TCC carried a poor prognosis following radical nephroureterectomy.

Laparoscopic en bloc resection of ureter with a cuff of bladder during radical nephroureterectomy for lower ureteric tumors: a matched-paired analysis.

BACKGROUND: Surgical management of the lower end of the ureter during laparoscopic nephroureterectomy remains a matter of debate. The commonest method during laparoscopic nephroureterectomy-endoscopic incision-has been shown to have a higher recurrence rate compared with open surgical excision with a cuff of bladder. In addition, the literature still lacks comparative studies between different approaches to support and guide the current clinical practice. PATIENTS AND METHODS: Three consecutive series of patients undergoing laparoscopic radical nephrectomy for transitional cell carcinoma located in the lower one-third of the ureter with different methods (laparoscopic en bloc resection of ureter with a cuff of bladder, open surgical excision, and endoscopic incision) of dealing with the lower end were compared in their short-term surgical and oncological outcomes. The primary outcome was recurrence at 12 months of follow-up. The secondary outcomes were hospital stay, positive surgical margins, and duration of catheterization. RESULTS: Analysis of perioperative and postoperative outcomes revealed laparoscopic en bloc resection of the lower end of the ureter with a cuff of bladder is a safe and feasible approach with the advantages of the laparoscopic approach such as less hospital stay compared with the open approach. The analysis of oncological outcomes in this feasibility study showed a higher rate of recurrences in the endoscopic approach. CONCLUSIONS: Laparoscopic en bloc resection of the lower end of the ureter with a cuff of bladder during nephroureterectomy for tumors located in the lower one-third of ureters is safe and feasible in terms of perioperative outcomes and early oncological results. We acknowledge that the small sample size and the nonrandomized design are a limit of the study. Thus, prospective randomized controlled trials are recommended to prove the superiority of one approach over the others.