Vol. 115, June

THE JOURNAL OF UROLOGY

Printed in U.S.A.

Copyright© 1976 by The Williams & Wilkins Co.

THE URETERAL STUMP AFTER NEPHROURETERECTOMY DAVID W. STRONG, HARPER D. PEARSE,* EDWARD S. TANK, JR.

AND

CLARENCE V. HODGES

From the Division of Urology, Department of Surgery, University of Oregon Health Sciences Center and Portland Veterans Hospital, Portland, Oregon

ABSTRACT

Herein we review 70 cases of transitional cell carcinoma of the upper urinary tract. When complete nephroureterectomy was not performed transitional cell carcinoma developed in 30 per cent of the remaining ureteral stumps. Single incision nephroureterectomy did not include the intramural ureter in 50 per cent of the cases in which it was performed. When nephroureterectomy is selected as treatment for carcinoma of the renal pelvis or ureter a cuff of bladder, which includes the ureteral orifice, should be removed. A second incision may be required for adequate exposure. Management of transitional cell carcinoma of the upper urinary tract has become controversial. Nephroureterectomy with removal of a periureteral cuff of bladder has been the accepted treatment.'· 2 However, there have been a number of reports advocating a more conservative approach in selected cases. 3·• Total nephroureterectomy has been the surgical procedure of choice in our teaching hospitals. Unfortunately, ureteral orifices and intramural ureters, as well as surprisingly long segments of ureteral stumps, have been seen in several patients who underwent this procedure. Recurrent carcinoma has developed in the ureteral remnants in some of these patients. These clinical observations prompted our review of 70 cases of transitional cell carcinoma of the renal pelvis and ureter. We have determined the incidence of subsequent ureteral stump tumors when incomplete nephroureterectomy is performed. MATERIAL AND METHODS

The records of all patients with primary transitional cell carcinoma of the renal pelvis or ureter treated during the last 30 years were reviewed. Operative reports were individually reviewed to determine the type of operation initially performed and the incidence of subsequent second operations. When nephroureterectomy was performed special attention was given to whether the intramural ureter was excised, how it was removed and whether a second incision was used. All records of subsequent cystoscopic examinations were reviewed for the presence or absence of the ureteral orifice, the length of remaining ureter and subsequent ureteral stump tumors. There were 20 primary ureteral carcinomas and 50 carcinomas of the renal pelvis. We found that 4 patients with renal pelvic tumors had concurrent carcinoma in the resected ureters (table 1). There was 1 instance of asynchronous bilateralism. RESULTS

The surgical treatment used for the neoplasms in our series is shown in table 2. Of the 19 patients who had nephrectomy only 7 had subsequent ureterectomy, including a bladder cuff for recurrent tumor in the ureteral stump. One patient with recurrent ureteral stump carcinoma refused an additional operation and was treated with radiation therapy. Another patient had secondary ureterectomy 3 years later for suspected stump tumor but pathologic examination revealed chronic ureteritis. Thus, ureteral stump tumors developed in 42 per cent of the patients who had nephrectomy only.

Of the 7 patients who had segmental ureterectomy for primary ureteral carcinoma 1 subsequently underwent a nephroureterectomy for carcinoma of the ipsilateral ureter and renal pelvis. In 21 patients incomplete or partial nephroureterectomy was performed. Of these patients 12 underwent nephrectomy and partial ureterectomy with no attempt made to remove the entire ureter. However, in the remaining 9 patients the surgeon described the procedure as a complete nephroureterectomy. All of these operations had been performed by tenting up the distal ureter, clamping and excising the ureter flush with the bladder. However, on subsequent cystoscopic and retrograde examinations all 9 patients still had their ureteral orifice and intramural ureter remaining. These patients were categorized as incomplete nephroureterectomy. Of these 21 patients 3 had subsequent transurethral resection of the ureteral orifice and intramural ureter for recurrent stump tumors. One patient had a segmental resection of the intramural ureter and a cuff of bladder for recurrent tumor. One patient was explored for recurrent ureteral stump tumor but it was unresectable. Thus, recurrent carcinoma developed in the ureteral stump in 24 per cent of the patients having partial or incomplete nephroureterectomy. Twenty-three patients had complete nephroureterectomy with excision of the entire ureter, including the intramural segment, ureter al orifice and cuff of bladder. Of these 15 were performed as a single stage operation, while 8 had a secondary distal ureterectomy with removal of a cuff of bladder within 3 months of the initial operation. Of the 15, 1-stage complete nephroureterectomies 9 were successfully accomplished using a single incision. The over-all stump recurrence rate in our series was 20 per cent. If one excludes the 23 patients who had complete 1 or 2-staged nephroureterectomy and who, thus, had no ureteral stump remaining, the rate of recurrence of carcinoma in ureteral stumps was 30 per cent (14 of 47). In 3 instances recurrent tumor in the ureteral remnant was of a higher grade than the primary tumor. Of these 14 patients 10 are dead, 5 of metastatic carcinoma.

Accepted for publication October 17, 1975. Read at annual meeting· of Western Section, American Urological Association, Portland, Oregon, April 13-17, 1975. * Requests for reprints: Division of Urology, Department of Surgery, University of Oregon Health Sciences Center, Portland, Oregon 97201.

654

DISCUSSION

The incidence of recurrent carcinoma in the ureteral stump after incomplete nephroureterectomy for transitional cell carcinoma of the upper urinary tract ranges from 20 to 58 per cent (table 3). 3 • 10• 12 Subsequent ureteral stump tumor was found in 42 per cent of our series of patients having nephrectomy alone but this decreased to 24 per cent if most of the ureter was removed. Primary transitional cell carcinoma of the ureter reportedly does not recur as often as those of the renal pelvis. However,

655

URETERAL STUMP TUMORS TABLE

1. Pathologic findings

Grade

Ureteral Tumors*

Renal Pelvic Tumors

I and II III and IV

20

32 18

* Includes

4

4 cases of renal pelvic tumors having concurrent ureteral carcino-

mas. TABLE

2. Surgical treatment and ureteral stump recurrences No. Cases

Ureteral Stump Recurrences No.

{%)

19

8

7 12

1* 3 2 0

(42) (14) (25) (22) (0)

Complete nephroureterectomy for primary tumors of the ureter or renal pelvis has been the most widely practiced method of treatment for this disease.' When such a procedure is not performed the incidence of recurrent tumor in the ureteral remnant is significant and appears to increase in proportion to the length of ureter left behind. Complete removal of the ureter and its intramural segment cannot be accomplished in all cases through a single incision and a second incision must be used. If one elects to perform a complete nephroureterectomy it is essential that the intramural portion, including the ureteral orifice, be removed. In our hands excision of the ureter by tenting up does not appear to be adequate. REFERENCES

Nephrectomy only Partial ureterectomy N ephrectomy and partial ureterectomy Incomplete nephroureterectomy Complete nephroureterectomy: 1 stage, 15 2 stages, 8

* Recurrent tumor in TABLE

9

23

1. Hewitt, C. B.: Nephroureterectomy with bladder cuff in the

2.

proximal ureter and renal pelvis.

3.

3. Recurrent carcinoma in the ureteral stump

Kimball and Ferris 10 Kinder and Wallace" Bloom and associates' Present study Newman and associates 12

No.

{%)

43/74

(58) (46)

21/46 4/10 14/47 2/10 84/187

(40) (30) (20) (45)

Bloom and associates noted ureteral stump tumors in 4 of 10 patients with primary ureteral carcinoma who had nephrectomy and partial ureterectomy. 3 Abeshouse reported a 12 per cent recurrence rate 2 and Newman and associates reported 20 per cent. 12 In the present series 5 of 13 patients who had primary ureteral carcinoma treated by segmental ureterectomy or incomplete nephroureterectomy had stump recurrences. Because of the multicentricity of urothelial tumors and the fear that tumors in the contralateral upper urinary tract may later develop, several reports have recommended a more conservative approach in this disease.•-• In a recent extensive review Latham and Kay noted that only 1.5 per cent of patients with transitional cell carcinoma of the renal pelvis had simultaneous or subsequent tumor in the opposite renal pelvis. 13 In the present series contralateral upper urinary tract carcinoma developed in only 1 patient.

4. 5. 6. 7.

8. 9. 10. 11. 12. 13.

treatment of transitional cell carcinoma of the upper urinary tract. In: Current Controversies in Urologic Management. Edited by R. Scott, Jr. Philadelphia: W. B. Saunders Co., p. 69, 1972. Abeshouse, B. S.: Primary benign and malignant tumors of the ureter. A review of the literature and report of one benign and twelve malignant tumors. Amer. J. Surg., 91: 237, 1956. Bloom, N. A., Vidone, R. A. and Lytton, B.: Primary carcinoma of the ureter: a report of 102 new cases. J. Urol., 103: 590, 1970. McIntyre, D., Pyrah, L. N. and Raper, F. P.: Primary ureteric neoplasms: with a report of forty cases. Brit. J. Urol., 37: 160, 1965. Brown, H. E. and Roumani, G. K.: Conservative surgical management of transitional cell carcinoma of the upper urinary tract. J. Urol., 112: 184, 1974. Burger, R. and Spjut, H.J.: Primary ureteral carcinoma. Urology, 4: 40, 1974. Gibson, T. E.: Treatment of transitional cell carcinoma of the upper urinary tract by local resection. In: Current Controversies in Urologic Management. Edited by R. Scott, Jr. Philadelphia: W. B. Saunders Co., p. 73, 1972. Vest, S. A.: Conservative surgery in certain benign tumors of the ureter. J. Urol., 53: 97, 1945. Kim, K. H., Leiter, E. and Brendler, H.: Primary tumors of the ureter. J. Urol., 107: 955, 1972. Kimball, F. N. and Ferris, H. W.: Papillomatous tumor of the renal pelvis associated with similar tumors of the ureter and bladder. J. Urol., 31: 257, 1934. Kinder, C. H. and Wallace, D. M.: Recurrent carcinoma in the ureteric stump. Brit. J. Surg., 50: 202, 1962. Newman, D. M., Allen, L. E., Wishard, W. N., Jr., Nourse, M. H. and Mertz, J. H. 0.: Transitional cell carcinoma of the upper urinary tract. J. Urol., 98: 322, 1967. Latham, H. S. and Kay, S.: Malignant tumors of the renal pelvis. Surg., Gynec. & Obst., 138: 613, 1974.

The ureteral stump after nephroureterectomy.

Vol. 115, June THE JOURNAL OF UROLOGY Printed in U.S.A. Copyright© 1976 by The Williams & Wilkins Co. THE URETERAL STUMP AFTER NEPHROURETERECTOMY...
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