Surgical Treatment of Upper Tract Urothelial Carcinoma

[Dr. Shahrokh Shariat]
When you and I were in training together, percutaneous biopsies, we didn't want to do that because ureteroscopies became a really fashionable great thing. And we certainly were very scared and ureter carcinoma is such that the biopsy core could lead to metastasis or seeding there. So I wouldn't really see a big benefit if you can stay within the system. But do I think, is it a devil, as it used to be in the past? No, because our biopsy technique and everything has changed and I'm not sure, but the question is if we can get endoscopically to it, and if the cytology is negative and you can get to it endoscopically because you need some tissue proof of the cancer before you deliver the therapy. I will try to go endoscopically and not get it by cutaneous biopsy, but I wouldn't feel as terrible as I used to feel in the past, I have to admit. What do you think?

[Dr. Aditya Bagrodia]
Yeah, absolutely. I think once upon a time, anything percutaneous, as it pertains to upper tract was anathema that, you know, you're going to get roasted. If it's an infiltrative mass and say our oncologist really wants some tissue prior to treatment, I'm pretty much okay with it. I think with the coaxial techniques it's safe and the risk of seeding is fairly minimal. I wouldn't feel comfortable leaving a nephrostomy tube in. I don't like that strategy. I think the likelihood of seeding that track is pretty real, but older sicker patients save them an anesthetic, do it under local. I do think there's maybe a bit more of a role and a bit more of this kind of dogma surrounding upper tract. And I know this is kind of getting into the weeds on some of the practical things, but this is what, you know, these are the decisions we have to make, I suppose. So, you know, my, my stance is if it's infiltrative, you just need to get a tissue diagnosis. It's pretty reasonable. And as you're clearly aware, sometimes you go in and the imaging suggests there's going to be something super obvious and you don't see anything. And you know, whether that's growing extra luminally into the parenchyma, et cetera, can be a bit of a bit of a quandary.

[Dr. Aditya Bagrodia]
I mean, [distal ureterectomies] are rare, it's an older sicker patient and the things that I typically try to teach the residents and fellows are make sure you clear the remainder of the upper tract. You know, they need to get a comprehensive ureteroscopy at some point. And then, I think it can be tricky, say it's a distal ureterectomy, I like to clip above and ideally below. But if it really extends down to the bladder cuff, when you're doing the bladder cuff, I think technically to really get through the perivesical fat, get through the detrusor, have your mucosa out, isolate that. So you're not having tumor spilled and where you're literally holding your you've got your stay stitch in so that you're not having any tumor spill into the peritoneum for instance, or putting yourself at a higher risk of a low local bladder recurrence, any kind of surgical tricks on that Shahrokh?

[Dr. Shahrokh Shariat]
We have tried to look at what is the best management of the distal ureter, doing radical nephroureterectomy, but could be also applied to just distal ureterectomy. What consistent data shows us but I'm not really sure what to make out of it is, number one is you need to remove the whole distal ureter with adequate bladder call. Okay. We kind of all agree with that. That's common sense, but interestingly older, early strategies that we've used to bypass that laparoscopically, doing something stapling across, have been inadequate to consistently achieve a bladder cuff that has sufficient acquisition to ensure that we have a lower risk of intravesical recurrence, which is the end point in many of these tumors.The metastasis in survival, but the intravesical recurrence rate and, you know, in the high-grade tumors also obviously the audit to endpoints. I like to see the superior vesical artery. I like to see the ureter. I like to dissect this all out. If I don't see that I've not dissected far enough and you're always in for a major surprise. How far are you? You feel like you are at the end and you’re still not there. So for me, even robotically. It sounds kind of crazy and overkill, and this is what we've found in all our data. But I think this has to do with selection bias. I open the bladder and I like to look at it from the bladder. So, you know, retro flexing under your ureter, making sure its all out. And I don't like that extravesicular approach, for myself to make sure, but I agree that it, in any concept, it cannot be inferior if you remove the whole specimen, putting the stay suture, as you said. The seeding is always the problem. So you want to ensure that you don't have seeding and one strategy that at UT Southwestern, you and I have learned, and I like a lot, but there's no evidence for that is giving chemotherapy during the surgery. So you start with giving the chemotherapy, you let it in the bladder, you put the three-way catheter, you wash up until you get to that part. It's already out of the system. You may lower them, but you have to make sure you don't have a bladder cancer. The one thing you also want to also make sure you don't do is sew other ureter, you have to have a visualization of the other ureter. Right? So closing that up and making sure that you have a good closure, because that will also determine when you're going to give the postoperative single shot chemotherapy dose. I love the strategy you mentioned, clipping the ureter specifically, radical nephroureterectomy, and immediately clip below the tumor and to decrease it.