Define upper urothelial tract tumors?
Any neoplastic growth that affects the lining of the urinary tract from the calyces to the distal ureter
Upper Urinary Tract Tumors after Known Bladder Cancer?
The incidence of upper tract recurrence has been shown to be higher in patients with carcinoma in situ than in patients with noninvasive papillary TCCs and in patients treated with cystectomy for carcinoma in situ rather than for invasive cancer.
Upper urinary tract recurrence is also more likely to occur with high-grade bladder cancer (hazard ratio [HR] 2.16), in T1 versus Ta disease (HR 1.16), and in patients with trigonal or periureteral presentation (HR 1.76)
Etiology of upper urinary tract TCC?
- Balkan Nephropathy
- Occupation - chemical, petroleum, and plastic industries
- Chronic Inflammation, Infection, or Exposure to Chemotherapeutic Agents.
What is Balkan Nephropathy?
- Also called as Chinese herb nephropathy.
- Aristolochic acid, which is found in plants Aristolochia fangchi and Aristolochia clematitis, has a mutagenic action on codon 139 of p53 gene
Location of upper urinary tract TCC?
- 70% - Distal ureter
- 25% - Midureter
- 5% - Proximal ureter
Incidence of bladder cancer in Upper tract TCC?
Estimated incidence that varies in multiple reports from 15% to 75% within 5 years of the development of the upper tract cancer.
Why are upper tract cancers followed by bladder cancers more often than bladder cancers are followed by upper tract cancers?
- - downstream seeding
- - longer exposure time to carcinogens in the bladder, and
- - greater number of urothelial cells in the bladder that are subject to random carcinogenic events.
Progression to Muscle Invasion and Metastases in upper tract TCC?
The thin muscle layer of the renal pelvis and ureter probably allows earlier penetration of invasive upper tract tumors through the thinned muscle layer than is seen in bladder cancers
Normal Upper Tract Urothelium?
The urothelial lining of the upper urinary tract closely approximates that of the bladder except for the markedly reduced thickness of the muscle layer and the abutting of the urothelium to the renal parenchyma proximally.
Signs and symptoms of Upper tract TCC?
Most common presenting symptom - hematuria, either gross or microscopic
Diagnosis of UTUC?
- Ureteroscopy and biopsy - only if the additional information obtained will change the management.
Radiological features of upper tract TCC?
–Sessile filling defect
–Range of 10 to 70 HU (average 46 HU)
–Early enhancement on arterial phase.
–Pelvicaliceal irregularity, focal or diffuse mural thickening, oncocalyx, and focally obstructed calyces
–Advanced TCC extends into the renal parenchyma - distorts normal architecture. However, reniform shape is typically preserved (unlike in renal cell carcinoma)
–enhances poorly after IV contrast (Less than RCC)
Same as Bladder carcinoma
Treatment of upper tract TCC?
Open Nephron-Sparing Surgery for Renal Pelvis Tumors: Pyelotomy and Tumor Ablation and Partial Nephrectomy - in selected cases when nephron sparing for preservation of renal function is required
Radical nephroureterectomy with removal of a bladder cuff - treatment of large, invasive tumors of the renal pelvis and proximal ureter
Management of Distal Ureter and Bladder Cuff?
The entire distal ureter, including the intramural portion and the ureteral orifice, is removed. Failure to completely remove the entire distal ureter and ureteral orifice is associated with a high rate of tumor recurrence.
- Traditional Open Distal Ureterectomy
- Transurethral Resection of the Ureteral Orifice (Pluck technique) - reserved for proximal, low-grade tumors
- Intussusception (Stripping) Technique
- Transvesical Ligation and Detachment Technique
- Total Laparoscopic Technique
Flowchart for management of UTUC? [EAU 18]