PRIMARY CARCINOMA OF URETER Report of 27 New Cases
MOHAMAD
R. GHAZI,
PABLO A. MORALES, SALAH AL-ASKARI,
M.D. M.D.
M.D.
From the Department of Urology, New York University Medical Center, New York, New York
ABSTRACT - A retrospective analysis of 27 cases of primary carcinoma of the ureter is presented. The ages of the patients ranged from forty-two to eighty-three years, with the highest incidence between the fifth and seventh decades. Males were more frequently affected than females, and the tumors were usually found in the lower third of the ureter. Hematuria and flank pain were the presenting symptoms in the majority of cases. Poorly differentiated invasive tumors had poor prognosis when compared to well-diff erentiated noninvasive lesions. Total nephroureterectomy with excision of bladder cuff is the preferred treatment fm ureteral carcinoma in view of the high rate of ipsilateral tumor recurrence.
Primary carcinoma of the ureter is a rare disease. It accounts for 1 per cent of all cancers of the upper urinary tract and is found in 1 of every 3,600 admissions for urologic disease.lm4 Herein, we report a retrospective analysis of our experience with primary ureteral carcinoma at New York University Medical Center. Major emphasis is placed on histopathology, tumor invasion, prognosis, and treatment. Material
and Methods
Twenty-seven cases of primary carcinoma of the ureter were seen at our Center between 1965 and 1976. Patients with associated renal pelvis tumors were excluded from the study. The majority of these cases were followed until the patient died or to the conclusion of the study. A major focus of this evaluation was to determine the influence of tumor invasion and histopathologic grade on patient survival. In addition, the records of these patients were analyzed with respect to incidence, location, clinical presentation, and surgical management.
18
Results Age, sex, and location Patients ranged in age from forty-two to of eighty-three years, with peak incidence tumors between the fifth and seventh decades. Twenty-one of 27 cases were males, resulting in a 3 to 1 male to female ratio. The tumors were more common on the left side where 63 per cent were found, and the lower third of the ureter was the site of cancer in 70 per cent of the cases. These observations are in accord with previous reports by others. 4-6 Clinical presentation Hematuria and flank pain were the most common complaints. Eleven patients (44 per cent) had hematuria, 8 (30 per cent) had flank pain, and 1 (3 per cent) had an abdominal mass. Of the 7 patients in the asymptomatic group, 3 of the tumors (11 per cent) were discovered during routine follow-up examination of patients with bladder carcinoma, and only 4 (15 per cent) of ureteral tumors were silent.
UROLOGY
/ JULY 1979 / VOLUME
XIV, NUMBER
1
I.
TABLE
Stage
Survival according to treatment and stage
Nephroureterectomy and Excision of Bladder Cuff Alive Dead
Invasive Noninvasive
2 4
6 2
TOTALS
6
-i
Nephroureterectomy Dead Alive 1
2 3
1
0 1
*In 2 patients in this group, 1 with invasive tumor and 1 with noninvasive their tumor developed, and they were treated with nephroureterectomy.
Diagnosis
In general, ureteral tumors were diagnosed on the basis of excretory urograms. A filling defect in the ureter was found in 9 cases (33 per cent), hydronephrosis in 7 (25 per cent), and nonfunctioning kidney in another 7 cases (25 per cent). Filling defect and hydronephrosis were present in 4 cases (14 per cent). Poorly differentiated invasive tumors were found in 5 of 7 cases with nonfunctioning kidneys on excretory urograms. Likewise, 5 of 7 cases with hydronephrosis had invasive tumors. Retrograde ureterograms were used to confirm the diagnosis of ureter-al tumor in 45 per cent of the cases, while in 2 instances the diagnosis was made following surgical exploration of the ureter. Histopathology
There were 25 cases of transitional cell carcinoma, 1 case of fibrosarcoma, and 1 squamous cell carcinoma. Transitional cell carcinomas were divided into two groups according to cellular differentiation. Low-grade tumors consisted of well-differentiated lesions of Broder’s classification 1 and 2, while the poorly differentiated Broder’s classification 3 and 4 were regarded as high-grade lesions. The epithelial tumors were also staged according to the degree of tumor invasion. Tumors limited to the mucosa and lamina propria were considered noninvasive, whereas tumors involving any portion of the muscularis or periureteral tissue were considered invasive. There were 16 patients with high-grade tumors and 13 of them were invasive (81 per cent). In contrast, 2 of 9 low-grade tumors were invasive (22 per cent). Bladder
tumors
In 9 patients (33 per cent) with transitional cell carcinoma of the ureter, bladder tumors also developed. In 3 patients (11 per cent), carcinoma of the ureter was diagnosed during
UROLOGY
/ JULY1979 / VOLUMEXIV,
NUMBER
1
Partial Ureterectomy Dead Alive 2 -1 3* tumor,
1 1 2 recurrence
of
follow-up evaluation of patients with known bladder tumors. In the remaining 6 patients (22 per cent), the bladder tumor appeared following resection of the ureteral carcinoma. Treatment
Twenty patients had nephroureterectomy, and 14 of them had excision of a periureteral cuff of bladder mucosa. Five patients were treated with partial lower ureterectomy and ureteroneocystostomy. Advanced metastasis at the time of diagnosis precluded surgery in the remaining 2 patients. Of the 5 patients who were treated with partial ureterectomy, ipsilateral ureteral recurrence developed in 2, after one year in 1 case and after seven years in the other, following surgery. These patients underwent nephroureterectomy with excision of the bladder cuff. There was no operative or immediate postoperative mortality in our series. Survival
rate
Stage and grade. Twenty-five of the 27 patients were available for follow-up at the conclusion of the study. There were 10 patients with noninvasive tumors. Of these, 3 died and 7 survived, a survival rate of 70 per cent. The deaths in this group occurred two, six, and eight years after diagnosis. Fifteen patients had invasive tumors, and 10 of them died between one month and eleven years after diagnosis. The remaining 5 patients with invasive tumors survived for up to ten years. Tumor grade also influenced survival. Nine patients had lowgrade tumors (Broder’s classification 1 and 2) and 6 of them survived, a survival rate of 66 per cent. On the other hand, 6 of 15 patients with high-grade tumors (Broder’s classification 3 and 4) survived, a survival rate of 44 per cent. Treatment. There were 6 survivors among the 14 patients who had nephroureterectomy with excision of bladder cuff. Four of those who survived had noninvasive lesions (Table I). Three of
19
4 patients who had nephroureterectomy without bladder cuff excision survived. Five patients had partial ureterectomy and 3 of them survived. However, 2 of the survivors in this group later had recurrence of their tumor and were treated by nephroureterectomy and excision of bladder cuff. The over-all survival of patients who had excision of the kidney and the entire ureter, including the 2 who were initially treated by partial ureterectomy, was 50 per cent. Comment Carcinoma of the ureter is rarely considered in patients presenting with hematuria or flank pain, yet over 70 per cent of our patients presented with such complaints. Similar observations were made in other series, emphasizing the symptomatic nature of this disease.4s7*8 The majority of ureteral tumors are diagnosed on the basis of an excretory urogram. 8 However, in our series, retrograde urograms were needed in almost half of the cases to confirm the diagnosis. Hydronephrosis or nonvisualization was associated with invasive ureteral tumors in 70 per cent of our cases. This is in accord with the observation of Bloom, Vidone, and Lytton3 who found a high incidence of invasive lesions in patients with nonvisualizing kidneys on excretory urograms. The majority of ureteral tumors are transitional cell carcinomas. Tumor invasion appears to be the most important factor affecting the survival of patients with ureteral carcinoma. In our series, 10 of 13 patients who died of ureteral carcinoma had invasive lesions. Eight of the deaths due to invasive tumors occurred within three years of diagnosis, whereas only 1 patient with noninvasive tumor died during a similar period. The over-all survival of patients with invasive ureteral tumors was 33 per cent as compared with 70 per cent in the noninvasive group. It is apparent from these results and the observation of others that patients with noninvasive tumors fared much better than those with invasive lesions.3-5~7~8Our results also indicate that tumor grade aff_ects the survival of patients with ureteral carcinoma. Patients with well-differentiated ureteral tumors, Broder’s classification 1 and 2, had a better survival rate, 66 per cent, than those with poorly differentiated lesions where the survival rate was 40 per cent. Nine of the 10 patients who died of invasive ureteral tumors had high-grade tumors. Similar observations were made in other reported series. 3.4*7
20
There is a significant incidence of bladder tumors in patients with transitional cell carcinoma of the ureter. Williams and Mitchell9 reported 37 per cent, Beck and associates’ had 28 per cent, and McIntyre, Pyrah, and Raper’O found 20 per cent; the incidence in our series was 33 per cent, and in two thirds of our cases the bladder tumor developed following excision of the ureteral neoplasm. In other series, the appearance of bladder tumor after excision of ureteral carcinoma ranged from 15 to 37 per cent.4*‘0,‘1 This relatively high incidence of bladder tumors after excision of ureteral tumors emphasizes the importance of periodic postoperative cystoscopic examinations. It is generally recognized that transitional cell carcinoma of the upper urinary tract is multicentric in a significant percentage of cases. The incidence of reported multiple ureteral tumors ranges from 20 to 44 per cent2a4 Also, unsuspected renal pelvis tumors have been found in patients with ureteral tumors.4 These observations emphasize the multicentric potential of transitional cell tumors and the need for accurate evaluation of the entire urinary tract when such a lesion is discovered. There is a high incidence, 10 to 40 per cent, of ipsilateral recurrence following partial ureterectomy for transitional cell tumors. 3n4*12 In our series, 40 per cent of patients treated with partial ureterectomy had recurrence and required additional surgery. Nephroureterectomy with excision of bladder cuff appears to be the treatment of choice for ureteral carcinoma. This approach is supported by the high incidence of multiple ipsilateral tumors and the high recurrence rate after conservative surgery. The advocates of conservative surgery for noninvasive, low-grade tumors are motivated by the desire to conserve renal tissue, the risk of tumors developing in the opposite side, and the high mortality rate associated with total nephroureterectomy. 3~13-16 However, the risk of tumor developing in the opposite ureter is small in view of the few reported cases of bilateral asynchronous ureteral tumors3 We have had no mortality in our series of 22 nephroureterectomies and believe that the risk from surgery can be minimized by careful patient selection and diligent postoperative care. It is our view that conservative surgery for ureteral carcinoma should be reserved for patients with: (1) solitary kidney, (2) renal insufficiency, (3) bilateral tumors, or (4) poor-risk patients.
UROLOGY
/ JULY 1979 / VOLUME
XIV, NUMBER
1
New York, New York 10016 (DR. GHAZI) References 1. Foord AC, and Ferrier PA: Primary carcinoma of the ureter, with report of 7 cases, J.A.M.A. 112: 596 (1939). 2. Abeshouse BS: Primary benign and malignant tumors of the ureter; review of literature and report of one benign and 12 malignant tumors, Am. J. Surg. 91: 237 (1956). 3. Bloom NA, Vidone RA, and Lytton B: Primary carcinoma of the ureter: a report of 102 new cases, J. Urol. 103: 590 (1970). 4. Newman, DM, et al: Transitional cell carcinoma of the upper urinary tract, ibid. 98: 322 (1967). 5. Hawtrey C: Fifty-two cases of primary ureteral carcinoma: a clinico-pathologic study, ibid. 105: 188 (1971). 6. Jewett HJ: Tumors of the ureter, in Campbell ME, and Harrison JH, Eds: Umlogy, Philadelphia, W. B. Saunders Co., 1970, vol. 2, p. 981. 7. Ochsner MG, Brannan W, Pond HS III, and Collins HT: Transitional cell carcinoma of renal pelvis and ureter, Urology 4: 392 (1974).
UROLOGY
/
JULY 1979
/
VOLUME
XIV, NUMBER
1
8. Beck AD, He&n JE, Mimer WA, and Garlick WB: Primary tumors of the ureter: diagnosis and management, J. Uml. 192: 683 (1969). 9. Williams CB, and Mitchell JP: Carcinoma of the ureter: a review of 54 cases, Br. J. Urol. 49: 377 (1973). 10. McIntyre D, Pyrah LN, and Raper FP: Primary ureteric neoplasms: with a report of forty cases, ibid. 37: 160 (1965). 11. Whitlock GF, McDonald JR, and Cook NE: Primary carcinoma of the ureter: a pathologic and prognostic study, J. Urol. 73: 245 (1955). 12. Holtz F: Papillomas and primary carcinoma of the ureter: report of 20 cases, ibid. 88: 380 (1962). 13. Gibson TE: Focal excision in transitional cell tumor of the upper urinary tract, ibid. 97: 619 (1967). 14. Vest SA: Conservative surgery in certain benign tumors of the ureter, ibid. 53: 97 (1945). 15. Brown HE, and Rouman GK: Conservative management of transitional cell carcinoma of upper urinary tract, ibid. 112: 184 (1974). 16. Famarier G, Sommer D, and Jouve P: Primary tumor of ureter. Conservative surgical treatment. Three year result, J. Ural. Nephrol. 97: 619 (1967).
21
MOHAMAD
R. GHAZI,
PABLO A. MORALES, SALAH AL-ASKARI,
M.D. M.D.
M.D.
From the Department of Urology, New York University Medical Center, New York, New York
ABSTRACT - A retrospective analysis of 27 cases of primary carcinoma of the ureter is presented. The ages of the patients ranged from forty-two to eighty-three years, with the highest incidence between the fifth and seventh decades. Males were more frequently affected than females, and the tumors were usually found in the lower third of the ureter. Hematuria and flank pain were the presenting symptoms in the majority of cases. Poorly differentiated invasive tumors had poor prognosis when compared to well-diff erentiated noninvasive lesions. Total nephroureterectomy with excision of bladder cuff is the preferred treatment fm ureteral carcinoma in view of the high rate of ipsilateral tumor recurrence.
Primary carcinoma of the ureter is a rare disease. It accounts for 1 per cent of all cancers of the upper urinary tract and is found in 1 of every 3,600 admissions for urologic disease.lm4 Herein, we report a retrospective analysis of our experience with primary ureteral carcinoma at New York University Medical Center. Major emphasis is placed on histopathology, tumor invasion, prognosis, and treatment. Material
and Methods
Twenty-seven cases of primary carcinoma of the ureter were seen at our Center between 1965 and 1976. Patients with associated renal pelvis tumors were excluded from the study. The majority of these cases were followed until the patient died or to the conclusion of the study. A major focus of this evaluation was to determine the influence of tumor invasion and histopathologic grade on patient survival. In addition, the records of these patients were analyzed with respect to incidence, location, clinical presentation, and surgical management.
18
Results Age, sex, and location Patients ranged in age from forty-two to of eighty-three years, with peak incidence tumors between the fifth and seventh decades. Twenty-one of 27 cases were males, resulting in a 3 to 1 male to female ratio. The tumors were more common on the left side where 63 per cent were found, and the lower third of the ureter was the site of cancer in 70 per cent of the cases. These observations are in accord with previous reports by others. 4-6 Clinical presentation Hematuria and flank pain were the most common complaints. Eleven patients (44 per cent) had hematuria, 8 (30 per cent) had flank pain, and 1 (3 per cent) had an abdominal mass. Of the 7 patients in the asymptomatic group, 3 of the tumors (11 per cent) were discovered during routine follow-up examination of patients with bladder carcinoma, and only 4 (15 per cent) of ureteral tumors were silent.
UROLOGY
/ JULY 1979 / VOLUME
XIV, NUMBER
1
I.
TABLE
Stage
Survival according to treatment and stage
Nephroureterectomy and Excision of Bladder Cuff Alive Dead
Invasive Noninvasive
2 4
6 2
TOTALS
6
-i
Nephroureterectomy Dead Alive 1
2 3
1
0 1
*In 2 patients in this group, 1 with invasive tumor and 1 with noninvasive their tumor developed, and they were treated with nephroureterectomy.
Diagnosis
In general, ureteral tumors were diagnosed on the basis of excretory urograms. A filling defect in the ureter was found in 9 cases (33 per cent), hydronephrosis in 7 (25 per cent), and nonfunctioning kidney in another 7 cases (25 per cent). Filling defect and hydronephrosis were present in 4 cases (14 per cent). Poorly differentiated invasive tumors were found in 5 of 7 cases with nonfunctioning kidneys on excretory urograms. Likewise, 5 of 7 cases with hydronephrosis had invasive tumors. Retrograde ureterograms were used to confirm the diagnosis of ureter-al tumor in 45 per cent of the cases, while in 2 instances the diagnosis was made following surgical exploration of the ureter. Histopathology
There were 25 cases of transitional cell carcinoma, 1 case of fibrosarcoma, and 1 squamous cell carcinoma. Transitional cell carcinomas were divided into two groups according to cellular differentiation. Low-grade tumors consisted of well-differentiated lesions of Broder’s classification 1 and 2, while the poorly differentiated Broder’s classification 3 and 4 were regarded as high-grade lesions. The epithelial tumors were also staged according to the degree of tumor invasion. Tumors limited to the mucosa and lamina propria were considered noninvasive, whereas tumors involving any portion of the muscularis or periureteral tissue were considered invasive. There were 16 patients with high-grade tumors and 13 of them were invasive (81 per cent). In contrast, 2 of 9 low-grade tumors were invasive (22 per cent). Bladder
tumors
In 9 patients (33 per cent) with transitional cell carcinoma of the ureter, bladder tumors also developed. In 3 patients (11 per cent), carcinoma of the ureter was diagnosed during
UROLOGY
/ JULY1979 / VOLUMEXIV,
NUMBER
1
Partial Ureterectomy Dead Alive 2 -1 3* tumor,
1 1 2 recurrence
of
follow-up evaluation of patients with known bladder tumors. In the remaining 6 patients (22 per cent), the bladder tumor appeared following resection of the ureteral carcinoma. Treatment
Twenty patients had nephroureterectomy, and 14 of them had excision of a periureteral cuff of bladder mucosa. Five patients were treated with partial lower ureterectomy and ureteroneocystostomy. Advanced metastasis at the time of diagnosis precluded surgery in the remaining 2 patients. Of the 5 patients who were treated with partial ureterectomy, ipsilateral ureteral recurrence developed in 2, after one year in 1 case and after seven years in the other, following surgery. These patients underwent nephroureterectomy with excision of the bladder cuff. There was no operative or immediate postoperative mortality in our series. Survival
rate
Stage and grade. Twenty-five of the 27 patients were available for follow-up at the conclusion of the study. There were 10 patients with noninvasive tumors. Of these, 3 died and 7 survived, a survival rate of 70 per cent. The deaths in this group occurred two, six, and eight years after diagnosis. Fifteen patients had invasive tumors, and 10 of them died between one month and eleven years after diagnosis. The remaining 5 patients with invasive tumors survived for up to ten years. Tumor grade also influenced survival. Nine patients had lowgrade tumors (Broder’s classification 1 and 2) and 6 of them survived, a survival rate of 66 per cent. On the other hand, 6 of 15 patients with high-grade tumors (Broder’s classification 3 and 4) survived, a survival rate of 44 per cent. Treatment. There were 6 survivors among the 14 patients who had nephroureterectomy with excision of bladder cuff. Four of those who survived had noninvasive lesions (Table I). Three of
19
4 patients who had nephroureterectomy without bladder cuff excision survived. Five patients had partial ureterectomy and 3 of them survived. However, 2 of the survivors in this group later had recurrence of their tumor and were treated by nephroureterectomy and excision of bladder cuff. The over-all survival of patients who had excision of the kidney and the entire ureter, including the 2 who were initially treated by partial ureterectomy, was 50 per cent. Comment Carcinoma of the ureter is rarely considered in patients presenting with hematuria or flank pain, yet over 70 per cent of our patients presented with such complaints. Similar observations were made in other series, emphasizing the symptomatic nature of this disease.4s7*8 The majority of ureteral tumors are diagnosed on the basis of an excretory urogram. 8 However, in our series, retrograde urograms were needed in almost half of the cases to confirm the diagnosis. Hydronephrosis or nonvisualization was associated with invasive ureteral tumors in 70 per cent of our cases. This is in accord with the observation of Bloom, Vidone, and Lytton3 who found a high incidence of invasive lesions in patients with nonvisualizing kidneys on excretory urograms. The majority of ureteral tumors are transitional cell carcinomas. Tumor invasion appears to be the most important factor affecting the survival of patients with ureteral carcinoma. In our series, 10 of 13 patients who died of ureteral carcinoma had invasive lesions. Eight of the deaths due to invasive tumors occurred within three years of diagnosis, whereas only 1 patient with noninvasive tumor died during a similar period. The over-all survival of patients with invasive ureteral tumors was 33 per cent as compared with 70 per cent in the noninvasive group. It is apparent from these results and the observation of others that patients with noninvasive tumors fared much better than those with invasive lesions.3-5~7~8Our results also indicate that tumor grade aff_ects the survival of patients with ureteral carcinoma. Patients with well-differentiated ureteral tumors, Broder’s classification 1 and 2, had a better survival rate, 66 per cent, than those with poorly differentiated lesions where the survival rate was 40 per cent. Nine of the 10 patients who died of invasive ureteral tumors had high-grade tumors. Similar observations were made in other reported series. 3.4*7
20
There is a significant incidence of bladder tumors in patients with transitional cell carcinoma of the ureter. Williams and Mitchell9 reported 37 per cent, Beck and associates’ had 28 per cent, and McIntyre, Pyrah, and Raper’O found 20 per cent; the incidence in our series was 33 per cent, and in two thirds of our cases the bladder tumor developed following excision of the ureteral neoplasm. In other series, the appearance of bladder tumor after excision of ureteral carcinoma ranged from 15 to 37 per cent.4*‘0,‘1 This relatively high incidence of bladder tumors after excision of ureteral tumors emphasizes the importance of periodic postoperative cystoscopic examinations. It is generally recognized that transitional cell carcinoma of the upper urinary tract is multicentric in a significant percentage of cases. The incidence of reported multiple ureteral tumors ranges from 20 to 44 per cent2a4 Also, unsuspected renal pelvis tumors have been found in patients with ureteral tumors.4 These observations emphasize the multicentric potential of transitional cell tumors and the need for accurate evaluation of the entire urinary tract when such a lesion is discovered. There is a high incidence, 10 to 40 per cent, of ipsilateral recurrence following partial ureterectomy for transitional cell tumors. 3n4*12 In our series, 40 per cent of patients treated with partial ureterectomy had recurrence and required additional surgery. Nephroureterectomy with excision of bladder cuff appears to be the treatment of choice for ureteral carcinoma. This approach is supported by the high incidence of multiple ipsilateral tumors and the high recurrence rate after conservative surgery. The advocates of conservative surgery for noninvasive, low-grade tumors are motivated by the desire to conserve renal tissue, the risk of tumors developing in the opposite side, and the high mortality rate associated with total nephroureterectomy. 3~13-16 However, the risk of tumor developing in the opposite ureter is small in view of the few reported cases of bilateral asynchronous ureteral tumors3 We have had no mortality in our series of 22 nephroureterectomies and believe that the risk from surgery can be minimized by careful patient selection and diligent postoperative care. It is our view that conservative surgery for ureteral carcinoma should be reserved for patients with: (1) solitary kidney, (2) renal insufficiency, (3) bilateral tumors, or (4) poor-risk patients.
UROLOGY
/ JULY 1979 / VOLUME
XIV, NUMBER
1
New York, New York 10016 (DR. GHAZI) References 1. Foord AC, and Ferrier PA: Primary carcinoma of the ureter, with report of 7 cases, J.A.M.A. 112: 596 (1939). 2. Abeshouse BS: Primary benign and malignant tumors of the ureter; review of literature and report of one benign and 12 malignant tumors, Am. J. Surg. 91: 237 (1956). 3. Bloom NA, Vidone RA, and Lytton B: Primary carcinoma of the ureter: a report of 102 new cases, J. Urol. 103: 590 (1970). 4. Newman, DM, et al: Transitional cell carcinoma of the upper urinary tract, ibid. 98: 322 (1967). 5. Hawtrey C: Fifty-two cases of primary ureteral carcinoma: a clinico-pathologic study, ibid. 105: 188 (1971). 6. Jewett HJ: Tumors of the ureter, in Campbell ME, and Harrison JH, Eds: Umlogy, Philadelphia, W. B. Saunders Co., 1970, vol. 2, p. 981. 7. Ochsner MG, Brannan W, Pond HS III, and Collins HT: Transitional cell carcinoma of renal pelvis and ureter, Urology 4: 392 (1974).
UROLOGY
/
JULY 1979
/
VOLUME
XIV, NUMBER
1
8. Beck AD, He&n JE, Mimer WA, and Garlick WB: Primary tumors of the ureter: diagnosis and management, J. Uml. 192: 683 (1969). 9. Williams CB, and Mitchell JP: Carcinoma of the ureter: a review of 54 cases, Br. J. Urol. 49: 377 (1973). 10. McIntyre D, Pyrah LN, and Raper FP: Primary ureteric neoplasms: with a report of forty cases, ibid. 37: 160 (1965). 11. Whitlock GF, McDonald JR, and Cook NE: Primary carcinoma of the ureter: a pathologic and prognostic study, J. Urol. 73: 245 (1955). 12. Holtz F: Papillomas and primary carcinoma of the ureter: report of 20 cases, ibid. 88: 380 (1962). 13. Gibson TE: Focal excision in transitional cell tumor of the upper urinary tract, ibid. 97: 619 (1967). 14. Vest SA: Conservative surgery in certain benign tumors of the ureter, ibid. 53: 97 (1945). 15. Brown HE, and Rouman GK: Conservative management of transitional cell carcinoma of upper urinary tract, ibid. 112: 184 (1974). 16. Famarier G, Sommer D, and Jouve P: Primary tumor of ureter. Conservative surgical treatment. Three year result, J. Ural. Nephrol. 97: 619 (1967).
21
