UTUC Flashcards
What other workup needs to be done in a patient with suspected UTUC?
- cystoscopy
- upper tract imaging - CTU preferred. If contraindicated, next is MRU, followed by RUS w/ retrograde pyelograms
What are the differentials for ureteral mass?
UTUC, fungal ball, blood clot, radiolucent kidney stone
What is first step in diagnostic workup for a suspected UTUC?
- ureteroscopy w/ biopsy (retrograde vs antegrade)
- cytology
- can consider therapeutic all at once as well
If the ureter is tight in a patient with suspected UTUC, and it is difficult to advance retrograde, what are your options?
- Place a stent , and return in a couple weeks. You do not want to have ureteral perforations, as risk for seeding, in these patients
- limit use of access sheaths
- do get cytology during the procedure though
Do you check the contralateral ureter if it looks normal on radiograph?
NO
Which syndromes are you investigating in patients with UTUC?
- Lynch syndrome - colorectal, ovarian, pancreatic, prostate, biliary, etc)
- need referral to genetic counselor
- Lynch is AD
How do you workup potential Lynch?
Do IHC (immunohistological) testing with reflexive tests for mismatch repair genes as well as microsatellite instability
What is important to document from an endoscopic perspective?
tumor location, characteristics, number of tumors, tumor appearance, estimate size
Give me the TNM grading for
Ta - noninvasive
Tis - CIS
T1 - subepithelial
T2 - muscle
T3 - periureteral fat, renal pelvis, or beyond renal parenchyma
T4 - perinephric fat or adjacent organ
N1 - < 2cm nodal metastasis
N2 - between 2 and 5 cm
N3 - > 5 cm nodal metastasis
M1 - distant metastasis
Provide me with characteristics for low and high risk categories
Low:
Favorable - low grade, papillary, unifocal, no obstruction, cytology is negative
Tx: ablation
Unfavorable - low grade, papillary, multifocal, obstruction, cytology is negative for HGUC, or has lower urinary tract involvement
Tx: may offer ablation
High:
Favorable - high grade, papillary, unifocal, no obstruction. any cytology
Tx: rarely ablation. should consider neoadjuvant vs adjuvant
Unfavorable - high grade, sessile, obstruction, any cytology, + lymph nodes, + lower urinary tract involvement, + invasion
Tx: palliation ablation only. neoadjuvant vs adjuvant
In a patient with obstruction, is perc or stent preferred?
Stent. Perc precludes to potential tract seeding
What are some risk facts for CKD development post NU?
age, DM, HTN, male, obesity, tobacco, tumor size
What are risks that you must discuss with patient about choosing kidney sparing?
Repeat need for ureteroscopy surveillance, which may lead to strictures, ureteral perforation, etc
What are risks of mitomycin C?
ureteral obstruction, bone marrow suppression
Can mitomycin C clear residual tumor?
Yes - but it should not be relied upon, if endoscopic clearance can be accomplished
How soon to survey after endoscopic management?
3 months
What are some agents that can be delivered post resection?
mitomycin C, gemcitaibine, BCG, docetaxel
Where should these be delivered?
upper urinary tract, and consider bladder.
MUST MAKE SURE NO PERFORATION
When in particular should BCG be used?
for high risk endoscopic removal (includes CIS)
What is treatment for HR UTUC?
radical NU w/ complete bladder cuff excision with lymphadenopathy
What are important considerations for patients undergoing a segmental ureterectomy?
- must make sure to have negative margins
- prior endoscopic assessment
What is preferred surgery for HR or unfavorable LR UTUC in a good kidney patient, with focalized distal disease?
distal ureterectomy with ureteral reimplant
What should be given after any RNU or distal ureterectomy?
intravesical MMC
What are the templates for LND in HR patients?
- pyelocaliceal area - node packets in the renal hilum to IMA
- prox 2/3 ureter - LN from renal hilum to aortic bifurcation
- distal 1/3 ureter - obturator + external iliac LN
