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According to European Association of Urology (EAU) guidelines, conservative

management is appropriate for low-risk upper tract urothelial carcinomas.[1]EAU


indications of low risk are as follows:

Unifocal tumor

Tumor size < 1 cm

Low-grade tumor (cytology or biopsies)

No evidence of an infiltrative lesion on CT urography

Understanding of close follow-up

Treatment recommendations (all grade C) for these low-risk tumors are as follows[1]:

Laser should be used in endoscopic treatments

Flexible ureteroscopy is preferable to rigid ureteroscopy

A percutaneous approach can be used in small low-grade caliceal tumors unsuitable for
ureteroscopic treatment

Ureteroureterostomy is indicated for noninvasive low-grade tumors of the proximal ureter


or midureter that cannot be removed completely via endoscopy

Complete distal ureterectomy and neocystostomy is indicated for noninvasive, low-grade


tumors in the distal ureter that cannot be removed completely via endoscopy, and for
high-grade, locally invasive tumors

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:

Open excision and repair of cystotomy

Endoscopic pluck technique

Transurethral resection of the intramural ureter

Intussusception technique

Lymphadenectomy, which generally requires little additional operative time, is performed


for staging purposes and potentially offers a therapeutic benefit.
Laparoscopic nephroureterectomy
The indications and oncologic surgical principles for laparoscopic nephroureterectomy
are similar to those of the open approach.
Pure laparoscopic transperitoneal and retroperitoneal approaches, as well as hand-assisted
laparoscopic approaches, have been described. The optimal technique depends largely on
surgeon experience.
Management of the bladder cuff remains variable. Some investigators prefer handassisted laparoscopic en bloc excision of the distal ureter with closure of the cystotomy
defect.
Open versus laparoscopic nephroureterectomy
Operative time is comparable to that of the standard open procedure.

Laparoscopic nephroureterectomy offers the benefits of minimally invasive surgery,


including less blood loss, shorter hospitalization, and improved cosmetic result.[36]
Recent studies have shown comparable oncologic outcomes between open and
laparoscopic nephroureterectomy.[36, 37]
Simone et al conducted a randomized control trial that demonstrated significantly lower
blood loss (104 vs 430 mL, P < .001) and shorter hospital stay (2.30 vs 3.65 d, P < .001)
for laparoscopic nephroureterectomy compared with open surgery. Their group also
demonstrated a nonsignificant difference in 5-year cancer specific survival (89.9% vs
79.8%) and 5-year metastasis-free survival rates (77.4% vs 72.5%) favoring open surgery.
[36]
A 2012 meta-analysis of observational studies comparing open versus laparoscopic
nephroureterectomy showed significantly lower urinary recurrence and distant metastasis
favoring the laparoscopic approach. Local recurrence was found to be comparable.[38]
Many surgeons consider large and locally advanced (T3/T4) tumors to be
contraindications to laparoscopic surgery.
Distal ureterectomy
High-grade and/or large distal ureteral tumors are most commonly managed with distal
ureterectomy with ureterovesical reimplant. Jeldres et al showed equivalent 5-year
cancer-specific survival rates when compared with nephroureterectomy, regardless of
stage.[39]
Ureteroscopic treatment
Ureteroscopy offers a renal-preserving alternative to traditional nephroureterectomy and
is used in patients with compromised renal function, bilateral upper tract disease, or other
medical contraindications to nephroureterectomy. Ureteroscopic ablation is now the
preferred choice for low-grade upper tract TCC. However, management of upper tract
tumors with this approach is associated with the need for multiple additional procedures
versus more definitive surgical management.
Ureteroscopy allows biopsy and treatment of tumors along the entire upper urinary tract.
Cold-cup biopsy forceps or a flat-wire basket is used for tissue diagnosis and to
determine tumor grade to plan for future intervention.
The use of Nd:YAG and Ho:YAG lasers, as well as small 2F-3F electrosurgical devices,
enable ureteroscopic resection, coagulation, and ablation of upper tract tumors under
direct vision.
In 2012, a systematic review of ureteroscopic and percutaneous management was
conducted by Cutress et al,[21]involving 22 ureteroscopic studies with 736 patients and
11 percutaneous studies with 288 patients. No controlled trials compared radical
nephroureterectomy. Approximately 20% patients eventually required
nephroureterectomy. Upper tract recurrence was high, at 52% for endoscopy and 37%
percutaneous management. Overall survival in the pooled analysis was 72% for

ureteroscopic management and 79% for percutaneous approach. The disease-specific


survival rate was 91% for ureteroscopy and 89% for percutaneous resection.
Also in 2012, Cutress et al reported their 20-year experience with endoscopic
management.[40]Seventy-three patients had longer follow-up than most studies, at a
mean of 63 months. Nineteen percent of patients proceeded to nephroureterectomy. The
upper tract recurrence rate was 68%. The overall survival rate was 69.7% and the diseasespecific survival rate was 88.9% at 5 years.
Another study examined 90 patients with upper tract TCC managed endoscopically who
had a history of bladder cancer. They found that the recurrence-free survival rate at 5
years was only 29% in this group. The authors of this study recommended a low
threshold for more aggressive surgical intervention based up stage and grade migration.
[41]
Grasso et al published their 15-year experience of ureteroscopic and extirpative therapy
and concluded that uteroscopic management was an acceptable option for managing lowgrade disease.[42]
The following are technical considerations for ureteroscopic treatment of upper tract
tumors[43]:

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.

Open Radical Nephroureterectomy


Nephroureterectomy adalah pendekatan standar untuk tumor yang besar, tumor
pelvis ginjal yang high-grade dan tumor pada ureter proksimal yang terbatas pada organ
lokal. Nephroureterectomy juga dianjurkan untuk tumor multifokal, berulang, tumor
derajat rendah, yang didapati kurang sesuai untuk manajemen Ureteroscopic.Biasanya,
prosedur ini melibatkan pengangkatan ginjal, ureter, dan manset kandung kemih melalui
pendekatan thoracoabdominal atau flank, dengan sayatan pemisahan kuadran rendah
Gibson. Pendekatan laparoskopi ke nephroureterectomy radikal sekarang biasadilakukan
dan memberikan beberapa manfaat pasca operasi.
Dalam kedua operasi baik yang terbuka dan laparoskopi, dilakukan pengangkatan
untuk seluruh distal ureter dan kandung kemih manset untuk mencegah kekambuhan
lokal. Eksisi manset ini sendiri memiliki manfaat untuk kelangsungan hidup. [34] Ada
beberapa pendekatan yang efektif, [35] sebagai berikut:
Terbuka eksisi terbuka dan perbaikan cystotomy
Teknik Pluck Endoskopi
Reseksi transurethral dari ureter intramural
Teknik intususepsi
Nephroureterectomy laparoskopi
Indikasi dan prinsip-prinsip bedah onkologi untuk nephroureterectomy laparoskopi
mirip dengan pendekatan open nephroureterectomy. Waktu operasi sebanding dengan
prosedur standar open nephroureterectomy. Nephroureterectomy laparoskopi
menawarkan manfaat operasi minimal invasif, termasuk rendahnya resiko kehilangan
darah, waktu untuk rawat inap lebih pendek, dan peningkatan hasil kosmetik. [36]
Studi terbaru menunjukkan hasil onkologi sebanding antara open nephroureterectomy dan
laparoskopi. [36, 37]
Ureterectomy distal
Salah satu pendekatan bermutu tinggi untuk tumor besar pada ureter distal yang
paling sering dikelola dengan ureterectomy distal dengan ureterovesical reimplant.
Jeldres et al menunjukkan dengan pendekatan ini tingkat kelangsungan hidup kanker
tertentu 5 tahun setara bila dibandingkan dengan nephroureterectomy, terlepas dari
stagingnya.

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