M.D. M.D.

From the Department of Urology, The University System Cancer Center, M. D. Anderson Hospital Tumor Institute, Houston, Texas

of Texas and

ABSTRACT - Distal ureterectomy with direct ureteroneocystostomy facilitated by the psoas bladder hitch procedure has been used in 6 patients for management of low-grade, noninvasive primary ureteral carcinoma. All patients are alive, two to ninety-six months postoperatively. Recurrent ipsilateral urothelial malignant disease has occurred in only 1 patient, twenty-six months postoperatively, necessitating a secondary nephroureterectomy. Renal function has been preserved in the remaining 5 patients. The continued practice of conservative surgery in these cases appears warranted.

The standard treatment for carcinoma of the ureter is total nephroureterectomy, which requires an excision of a bladder cuff around the ureteral orifice. While Skinner’ has suggested a more aggressive surgical approach to include a regional lymphadenectomy, there has been a plea by many investigators in recent years for more conservatism in the surgical management of this uncommon neoplasm.2-5 It appears that the prognosis in these cases closely parallels the grade and stage of the malignant disease.5 However, there is a paucity of data from this country regarding the risk for subsequent development of ipsilateral upper tract urothelial malignant disease when local resection is performed. Previous reports6-8 recommending conservative therapy have heretofore included either cases of benign papillomas or tumors endemic to the Balkans, conditions that may have entirely different biological behaviors relative to distal ureteral carcinoma diagnosed most frequently in this country. In view of these factors, we are reporting our experience with 6 cases of primary ureteral carcinoma treated by distal ureterectomy with direct ureteroneocystostomy facilitated by the psoas bladder hitch procedure. Material

and Methods

Over the past eight years, 26 patients with primary carcinoma of the ureter have been





evaluated at M. D. Anderson Hospital and Tumor Institute, with 14 patients having tumors localized to the distal one third of the ureter. In 6 patients in whom the tumor appeared radiographically to be noninvasive and confined to the lower ureter, a distal ureterectomy with wide excision of the adjacent vesical mucosa was performed. At least a 2.5-cm. length of normal proximal ureter was included with the specimen. Frozen section examination was done immediately to substantiate a diagnosis of noninvasive, low-grade transitional cell carcinoma. To facilitate the ureteroneocystostomy, a psoas bladder hitch procedure, as described by Turner-Warwick and Worth’ and Harrow,” was performed, tacking the bladder to the psoas muscle cephalad to the common iliac artery (Fig. 1). A site was then carefully selected that would allow for a direct ureteroneocystostomy without placing tension on the ureter. No attempt was made to perform an antireflux procedure. The bladder was closed in three layers without a suprapubic tube, and a Foley catheter was left indwelling in the urethra for approximately two weeks. The patients were 6 men ranging in age from fifty-four to seventy-three years at the time of diagnosis, with a mean age of 63.7 years. The malignant disease was confined to the right ureter in 4 patients and in the left ureter in 2 patients. The tumors were all either grade I or II


FIGURE 1. (A) Usual anatomic pelvic I -elationships showing segment of ureter to be resecteud. (B) Bladder sutured to psoas muscle allowing ureteroneocystostomy without (C) Direct uretension. teroneocystostomy without submucosal tunnel.


and limited to the mucosa or lamina propria (stage O/A). Th ree patients gave a prior history of superficial bladder carcinoma, and 3 patients had concomitant vesical malignant disease, treated by transurethral resection prior to their open surgical procedure. Results All patients remain alive without current evidence of urothelial malignant disease, two, sixteen, thirty-one, thirty-eight, eighty-seven, and ninety-two months, respectively, following distal ureterectomy. The mean follow-up time is 3.7 years. In only 1 patient has recurrent ipsilateral upper urinary tract urothelial malignant disease developed, and in that case, disease recurred in the proximal ureter twenty-six months after the distal ureterectomy. Nephroureterectomy was performed, and he remains free of subsequent urothelial malignant disease. Satisfactory renal function has been maintained in the remaining 5 patients without evidence of symptomatic reflux or recurrent pyelonephritis (Fig. 2).

Comment The incidence of primary ureteral carcinoma, while still uncommon, is no longer a rare entity. The number of reported cases has exploded from the 68 cases recorded in the literature in 193411 to approximately 1,500 cases reported as of 1975.12 Although there has been a definite increase in the incidence of the disease, these larger numbers are probably more a reflection of the precise methods currently available for diagnosis and the improved survival rates for patients with bladder carcinoma, which may place more patients at risk for development of ureteral cancer. The variable natural history of urothelial tumors and a well-documented multicentric origin for their malignant expression warrants conservative surgery, when applicable. The fact that ureteral tumors tend to occur in older patients who now have a longer life expectancy, coupled with the finding that with aging there are increased risks for renal deterioration resulting from nephrosclerosis, atherosclerosis, diabetes mellitus, etc., only strengthens the need





FIGURE 2. Intravenous pyelograms (A) preoperative showing distal ureteral tumor, and (B) postoperative showing prompt drainage into urinary bladder, which has typical elongated “horn” appearance.

for preservation of renal function by conservative, local resection. Malignant disease rarely develops subsequently in the upper urinary tract above the level of ureteral resection. The only instance we have been able to find occurred in one of our patients herein reported. However, previous experience would suggest a high incidence of tumors developing below the line of resection. If one extrapolates from the experience gained from performing simple nephrectomies for renal recurrences in the ureteral pelvic tumors, stump may be expected in at least one third of the cases. Mazeman l3 has shown a recurrence rate of 50 per cent at three years for ureteral cancer in which a portion of the ureter distal to the original lesion was left in situ. Consequently, local resection would appear to be most applicable for treatment of lower ureteral carcinoma, since distal ureterectomy eliminates the likelihood of recurrent disease. Distal ureterectomy with reimplantation should be considered only in patients who on radiographic assessment have: (1) papillary tumor(s) confined to the lower one third of the ureter; (2) no evidence of invasive disease (as suggested by the findings of a pliable, distensible, and unconstricted ureter); and (3) absence of tumors occurring above the level of the distal ureter. Histologic confirmation of low-grade, noninvasive (stage O/A) disease by frozen section technique is mandatory prior to performing the ureteroneocystostomy. Although a variety of techniques may be employed, reimplantation without ureteral tension has been greatly facilitated by the use of psoas bladder hitch procedure. This technique allows for removal of the



APRIL 1979




longest ureteral segment without compromising the results from ureteroneocystostomy. The need for close, regularly scheduled longterm follow-up consisting of endoscopy, urinary cytology, and excretory urography is obvious. However, in properly selected cases, recurrent disease developing in the upper urinary tract should be rare. Houston, Texas 77030 (DR. JOHNSON) References 1. Skinner DC: Technique of nephroureterectomy with regional lymph node dissection, Ural. Clin. North Am. 5: 253 (1978). 2. Getson TE: Treatment of transitional cell carcinoma of the upper urinary tract by local resection, in Scott R, Ed: Current Controversies in Urologic Management, Philadelphia, W. B. Saunders Co., 1972, pp. 73-76. 3. McIntyre D, Pyrah LN, and Raper FP: Primary ureteric neoplasms with a report of forty cases, Br. J. Ural. 37: 160 (1965). 4. Vest SA: Conservative surgery in cetain benign tumors of the ureter, J. Urol. 53: 97 (1945). 5. Kretkowski RC, and Derrick FC: Primary ureteral tumors. Reconsideration of management, Urology I: 36 (1973). 6. Bloom NA, Vidone RA, and Lytton B: Primary carcinoma of the ureter: a report of 102 new cases, J. Urol. 103: 590 (1970). 7. Petkovic SD: A plea for conservative oneration for ureteral tumors, ibid. 107: 226(1972). 8. IDEM: Epidemiology and treatment of renal pelvic and ureteral tumors, ibid. 114: 858 (1975). 9. Turner-Warwick RT, and Worth PHL: The psoas bladderhitch procedure for the replacement of the lower third of the ureter, Br. J. Urol. 41: 701 (1969). 10. Harrow BR: A neglected maneuver for ureterovesical reimplantation following injury at gynecologic operations, J. Ural. 100: 280 (1968). 11. Scott WW: Primary carcinoma of ureter, Surg. Gynecol. Obstet. 58; 215 (1934). 12. Bat&a MA, et al: Primary carcinoma of the ureter: a prognostic study, Cancer 35: 1626 (1975). 13. Mazeman E: Tumours of the upper urinary tract calyces, renal pelvis, and ureter, Eur. Urol. 2: 120 (1976).


Conservative surgical management for noninvasive distal ureteral carcinoma.

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