13-year survival comparison of percutaneous and open nephroureterectomy approaches for management of Transitional cell carcinoma of renal collecting system : Equivalent outcomes

Transitional cell carcinoma (TCC) of the renal collecting system traditionally has been managed by open nephroureterectomy with en bloc resection of a bladder cuff. However, for a select patient population with a solitary kidney or bilateral disease, the morbidity and mortality associated with chronic renal insufficiency and dialysis is deterring. In these situations, a more conservative approach such as antegrade percutaneous resection should be considered. The long-term disease-free outcome of percutaneous management in comparison with open nephroureterectomy has not been previously reported. We evaluated our experience with two surgical approaches to treat upper tract TCC: percutaneous resection and nephroureterectomy/nephrectomy to assess the clinical efficacy of these surgical modalities. We retrospectively identified 162 patients who had clinically localized TCC of the upper urinary tract. Records were reviewed to identify those with 13-year follow-up (N = 110) in respect to tumor grade, stage, disease-free status, length of cancer-specific survival, and overall survival. Statistical analysis of the results of open nephroureterectomy/nephrectomy (N = 60) and percutaneous resection (N = 50) was performed using Kaplan-Meier survival curves and Student's t-test. All patients had disease in clinical stage Ta through T3. During a mean follow-up of 46.6 (range 6-150) months, grade 1 disease demonstrated little invasive potential. Of the disease-specific deaths, 60% (17/26) were of patients with grade 3 lesions, with a mean cancer survival period of 15.2 months after the initial procedure. Disease-specific survival rates after open and percutaneous approaches for grade 2 disease were 53.8 and 53.3 months, respectively (P > 0.05). Tumor grade appeared to be the most important prognostic indicator in patients with renal TCC regardless of the surgical approach. Grade 3 tumors were more aggressive, presenting in an advanced stage with invasion, and recurrences were usually associated with metastasis. In this population, nephroureterectomy is warranted if the patient is a surgical candidate. The percutaneous option for grade 1 or 2 disease may be extended beyond the population with solitary kidneys and a risk of chronic renal failure to be offered to healthy individuals with normal contralateral kidneys who are willing to abide by a strict and lengthy follow-up.