title: Ureteropyeloscopic diagnosis and treatment of upper urinary tract urothelial malignancies.
abstract: OBJECTIVE
  To study the application of endoscopic techniques in treating upper urinary tract urothelial malignancies and to define subgroups that may benefit from these therapies.
  
  
  METHODS
  During a 3-year period, 20 patients with upper urinary tract transitional cell carcinoma were referred specifically for endoscopic therapy. Indications for treatment included a solitary kidney, bilateral disease, modest renal insufficiency, and/or other significant comorbidities. All patients underwent retrograde ureteropyeloscopy. Lesions were biopsied, and lower grade tumors were treated with electrocautery or laser energy. High-grade lesions not amenable to minimally invasive techniques were palliated or treated with standard open surgery. Surveillance was performed at 3 to 4-month intervals by urine cytology and repeat panendoscopy on a similar schedule to lesions of the bladder treated endoscopically.
  
  
  RESULTS
  Eleven patients (55%) were found to have low-grade, papillary transitional cell carcinoma of the upper urinary tract. Tumors ranged in size from less than 1 cm to filling the entire ureter. All papillary lesions were treated successfully using ureteroscopic techniques without any disease progression. Five small, low-grade recurrences (45%) were defined and treated endoscopically, with a mean follow-up of 17.3 months. Three patients were found at the time of initial diagnostic ureteroscopy to have higher grade lesions and endoscopic treatment was chosen in light of their severe comorbidities. On subsequent imaging, 2 of the 3 patients were suspected of having progression and underwent open surgery, both had carcinoma-in-situ only in the specimen. No tumor progression has been defined in this group to date, with mean follow-up of 16.3 months. A final third group of 6 patients were found to have nonpapillary, high-grade lesions at diagnostic endoscopy and underwent standard surgical resection. The disease of 4 of these 6 patients has progressed with metastases.
  
  
  CONCLUSIONS
  Papillary, low-grade, low-stage tumors of the upper urinary tract are amenable to endoscopic resection irrespective of size and location. Patients with high-grade lesions defined endoscopically should be offered radical surgery in light of the high rate of disease progression.
authors.affiliation: Department of Urology, New York University School of Medicine, New York, USA.
authors.forename: M
authors.initials: M
authors.lastname: Grasso
authors.forename: M
authors.initials: M
authors.lastname: Fraiman
authors.forename: M
authors.initials: M
authors.lastname: Levine
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D002295:Carcinoma, Transitional Cell / Q000175:diagnosis* / Q000628:therapy*; D005260:Female; D006801:Humans; D007680:Kidney Neoplasms / Q000175:diagnosis* / Q000628:therapy*; D007682:Kidney Pelvis; D008297:Male; D008875:Middle Aged; D014516:Ureteral Neoplasms / Q000175:diagnosis* / Q000628:therapy*; D018666:Ureteroscopy; D019459:Urothelium