Complete urinary tract extirpation: The University of Maryland experience

doi:10.1016/j.urology.2006.01.045

Urology

Volume 68, Issue 1, July 2006, Pages 65-69

https://doi.org/10.1016/j.urology.2006.01.045 Get rights and content

Abstract

Objectives

Complete urinary tract extirpation (CUTE) involves simultaneous bilateral nephroureterectomy, cystectomy or cystoprostatectomy, and the creation of a urinary diversion, if needed. Case reports of this operation have been published, but to our knowledge, this is the largest case series yet reported. We sought to evaluate the characteristics and outcomes of patients who underwent CUTE.

Methods

From 1994 to 2005, 9 patients underwent CUTE at our institution. We performed a retrospective chart review of these patients. The data reviewed included demographics, operative time, length of stay, complications, recurrences, and overall survival.

Results

Nine patients who underwent CUTE were identified. The mean patient age at the operation was 61 years. Five patients were men. The mean operative time was 356 minutes. Two patients required a blood transfusion. The length of stay averaged 10.8 days (range 6 to 47). Four patients had functioning renal allografts before and after surgery. Three patients needing dialysis received renal allografts postoperatively. The overall survival rate at a mean follow-up of 31 months was 86%.

Conclusions

Although this report presented a small number of patients, it has illustrated that CUTE can be performed safely and allow definitive surgical treatment of patients with complex genitourinary pathologic findings.

Section snippets

Material and methods

We performed a retrospective review of patients treated at our institution from 1994 to 2005. A cohort of 9 patients who had undergone CUTE was identified.

The demographic data concerning patient age and sex were recorded. The indication for surgery was established as benign or malignant and further evaluated for the type and nature of the malignancy. The preoperative evaluation was tailored to the underlying pathologic findings. In cases of malignancy, this evaluation included chest x-ray,

Results

Nine patients were identified who underwent CUTE at our institution from 1994 to 2005. All surgeries were performed by one of two surgeons (G.N.S. or S.C.J.).

Five of the patients were men. The mean age for all patients was 61 years. All the patients either required hemodialysis or had functional renal allografts. Six patients had bladder urothelial carcinoma, but only three had synchronous upper and lower tract TCC. Of the remaining three, one had renal cell carcinoma (RCC) in his native right

Comment

Traditionally urinary tract extirpation has been undertaken to treat a small subset of patients with lower tract TCC and bilateral upper tract malignancy. Extirpation was usually completed in a staged fashion according to the temporal occurrence of each malignancy. Physicians were often reluctant to aggressively treat malignancies when a patient’s lifespan was more likely to be determined by their subsequent renal insufficiency. The renal replacement therapies of dialysis and transplantation

Conclusions

The steady progression and success of renal replacement therapies, including dialysis and transplantation, have shifted the balance from conservative management to a preemptive approach in the treatment of patients with complex genitourinary pathologic features. Minimizing recurrence and the need for reoperation, while not adversely affecting the potential for cure, should be the dominant principles in treating eligible patients, rather than concern about the unacceptably high morbidity of

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There are more references available in the full text version of this article.

Cited by (21)

Oncological and Renal Function Outcomes in Patients Who Underwent Simultaneous Radical Cystectomy and Nephroureterectomy for Synchronous or Metachronous Panurothelial Carcinoma
2023, Urology
Citation Excerpt :
Therefore, efforts should be made on finding useful molecular biomarkers for the early identification of patients at risk of developing PanUC. Only patients who underwent RC and unilateral RNU were included in the present study; Although complete urinary tract exenteration has been described as a surgical option for oncological control in patients with PanUC, it should only be an option in two contexts: (1) patients with end-stage renal disease and PanUC, and (2) patients with invasive disease in both upper urinary tracts and the bladder (9, 24, 25). In patients with PanUC without end-stage renal disease, renal preservation should be the goal whenever it is reasonably achievable, bearing in mind: (1) the potential need for chemotherapy during follow-up for oncological control and (2) the negative effect on survival of end-stage disease in patients receiving dialysis (26).
To assess clinical outcomes of patients who underwent simultaneous radical cystectomy (RC) and radical nephroureterectomy (RNU) for panurothelial carcinoma (PanUC).
A retrospective analysis of 67 patients who underwent simultaneous RC and unilateral RNU for PanUC, from 1996 to 2017. Kaplan-Meier estimates for remnant urothelium recurrence-free survival, metastasis-free survival, overall survival (OS), and cancer-specific survival (CSS) were performed. Cox multivariate models were constructed.
The median follow-up was 38 months, 29.8% of patients had a recurrence, 34.3% had metastasis, 67.2% of patients died from any cause, and 37.3% died from urothelial carcinoma. Overall survival and CSS rates at 5 years were 44% and 61%, respectively. In multivariate analysis, progression to muscle-invasive bladder cancer before surgery, presence of muscle-invasive stages at RC and/or RNU, and prostatic urethra involvement were predictors for worse metastasis-free survival and CSS. Forty-one patients (61.2%) had an estimated glomerular filtration rate (eGFR) <60 mL/min before surgery and the number rose to 56 (83.5%) after surgery; 29.8% patients needed renal function replacement therapy after surgery (16 haemodialysis and 4 renal transplant).
Patients with PanUC who undergo simultaneous surgery have adverse oncological (only 4 out of every 10 remain alive at 5 years) and functional outcomes (1 out of 3 will need renal function replacement therapy after surgery). Up to a third of the patients had a recurrence (urethra or contralateral kidney) within 18 months, justifying close surveillance or considering prophylactic urethrectomy. These data should help in counsel on morbidity and life expectancy.
Urologic malignancies in renal transplant candidates and recipients
2016, Progres en Urologie
Rapporter l’épidémiologie et décrire la prise en charge des cancers urologiques chez les candidats et les receveurs d’une transplantation rénale.
Une recherche bibliographique exhaustive à partir de Medline (http://www.ncbi.nlm.nih.gov) et Embase (http://www.embase.com) a été réalisée entre 2000 et 2016 en utilisant les mots clés suivants en combinaison : prostate ; bladder ; testicular ; urologic malignancy ; cancer ; kidney ; transplantation ; renal cell carcinoma ; screening ; solid tumour. Les articles obtenus ont été sélectionnés sur leur méthodologie, leur langue de publication (anglais/français) et leur pertinence. Ainsi, 7730 articles ont été identifiés dont 781 pour les tumeurs solides en général, 1565 pour le carcinome rénal, 2674 pour le cancer de la prostate, 385 pour le carcinome urothélial et 56 pour le cancer testiculaire. Après élimination des doublons et analyse des articles, 221 ont été sélectionnés.
Les receveurs d’une transplantation rénale présentent un sur-risque de cancer urologique tout comme les patients dialysés. Le cancer de la prostate est de présentation similaire à la population générale ; toutes les options thérapeutiques sont possibles. La prostatectomie présente l’avantage de pouvoir préciser le stade et affirmer rapidement le succès thérapeutique. La lymphadénectomie doit être discutée et le dépistage systématique par PSA et toucher rectal doit être proposé. Les cancers des reins natifs sont le plus souvent de bas grade et stade, et sont traités par néphrectomie totale. Pour les patients en attente de transplantation, il est inutile d’imposer un délai de surveillance après traitement d’une tumeur rénale à faible risque de récidive selon les scores prédictifs. Les tumeurs du transplant rénal ont une prévalence de 0,2 à 0,5 %, avec une survie sans retour à la dialyse allant de 40 à 75 % pour des suivis réels de 21,5 à 43 mois. Leur traitement repose sur la chirurgie conservatrice, l’ablation percutanée ou la transplantectomie (immédiate ou différée). Contrairement aux cancers du rein et de la prostate, les carcinomes urothéliaux sont de présentation et de pronostic défavorables par rapport à la population générale. La prise en charge présente des spécificités liées à la diminution de l’efficacité du BCG et à la problématique de la dérivation urinaire.
Dans tous les cas, la décision de transplantectomie doit mettre en balance le bénéfice de l’arrêt de l’immunosuppression avec la diminution de survie (et de qualité de vie) du patient retournant en dialyse ; il n’existe pas de recommandation robuste concernant la modification du traitement immunosuppresseur. Les facteurs pronostiques du cancer et la facilité d’accès à une transplantation ultérieure sont des éléments décisionnels fondamentaux.
To review epidemiology and management of urologic neoplasms in renal transplant candidates and recipients.
Relevant publications were identified through Medline (http://www.ncbi.nlm.nih.gov) and Embase (http://www.embase.com) database using the following keywords, alone or in association, “neoplasms”; “prostate cancer”; “renal carcinoma”; “renal transplantation”; “transitional carcinoma”; “waiting list”. Articles were selected according to methods, language of publication and relevance. A total of 7730 articles were identified including 781 for solid tumors, 1565 for renal cell carcinoma (RCC), 2674 for prostate cancer (Pca), 385 for transitional carcinoma (TC) and 56 for testicular cancer; after careful selection, 221 publications were eligible for our review.
Renal transplant candidates and recipients are at higher risk of urologic neoplasms than general population, but prostate cancer has similar features. Thus, all therapeutic options are valid. Conversely to radiation therapy, radical prostatectomy provides precise staging and immediate affirmation of therapeutic success. Lymph nodes dissection needs to be discussed; systematic screening using PSA level and digital rectal examination should be offered in this specific population. RCC arising in native kidneys are usually low grade and stage and require total nephrectomy. In transplant candidates, there is no need to delay transplantation after treatment of low risk RCC according to published predictive nomograms. RCC of the allograft are rare, with a prevalence of 0.2 to 05% with a dialysis free survival ranging from 40 to 75% at 21.5 to 43 months. Treatment options are nephron sparing surgery, percutaneous ablation and immediate or deferred transplantectomy. Conversely to RCC or PCa, TC present with more unfavorable features as general population. Their management faces specific difficulties such as lower efficacy of BCG instillation or the technical challenge of urinary diversion.
Application of appropriate indication for transplantectomy relies on benefit-risk balance between the interruption of immunosuppressive agents versus survival and quality of life impairment after returning to dialysis. No robust recommendation exists regarding switch of immunosuppressive drugs. Cancer predictive factors and access to a subsequent transplantation are key decisive elements.
Laparoscopic Bilateral Nephro-Ureterectomy Approach for Complete Urinary Tract Extirpation for the Treatment of Multifocal Urothelial Carcinoma in a Kidney Transplant Patient: A Case Report and Literature Review
2015, Transplantation Proceedings
Citation Excerpt :
The experts in this field suggest the removal all native upper urinary urothelium in patients who require radical cystectomy [14]. Holton et al [13] reported the largest series of 9 patients who underwent CUTE. The operations were successfully performed, with a mean operative time of 356 minutes.
Urothelial carcinoma of the transitional epithelium is the most common malignancy in the Thai kidney transplant population.
We report our experience in managing simultaneous upper and lower urinary tract urothelial cancer in a post–kidney transplant recipient through the use of laparoscopic bilateral nephron-ureterectomy and anterior pelvic exenteration with the use of a Studer orthotopic neobladder. A 35-year-old woman with end-stage renal disease underwent living related kidney transplantation in 2009. She presented with gross hematuria 5 years later. Enhanced computer tomography revealed diffuse bladder wall thickening with an intravesical polypoid soft tissue mass at the right ureterovesical junction extending to the right distal ureter. Hydronephrosis of the left native kidney without any demonstrable cause of obstruction was also noted. On trans-urethral resection, the pathological finding was high-grade, non-invasive urothelial cell carcinoma.
The operation was successfully performed without intra- or post-operative complications. The patient could ambulate independently on post-operative day 2. The kidney graft function did not change from her pre-operative baseline. At 6 months' follow-up, the patient had no tumor recurrence, returned to normal activities, and was able to void spontaneously without any need of intermittent catheterization.
Laparoscopic bilateral nephron-ureterectomy for complete urinary tract extirpation is feasible, safe, and associated with low morbidity. This technique avoids a large abdominal midline incision or a bilateral flank incision for nephron-ureterectomy and is a good alternative surgical technique in post–kidney transplant patients who require complete urinary tract extirpation.
Urothelial carcinoma of the bladder in patients on hemodialysis: Clinical characteristics and oncological outcomes
2012, Journal of Urology
Citation Excerpt :
Moreover, the poor prognosis, particularly in those with invasive cancer, should be considered when evaluating potential candidates for future renal transplantation. Should total open or laparoscopic urinary tract exenteration3,10,11 be advocated in all patients on hemodialysis who are deemed to be candidates for radical cystectomy? This issue is pertinent since eliminating the ability to excrete free water, particularly in patients in whom the daily urine output is still substantial, inevitably impairs quality of life.
We characterized the clinical presentation and outcome of patients on hemodialysis diagnosed with urothelial carcinoma of the bladder.
Patients treated for bladder cancer while undergoing maintenance hemodialysis were identified by querying the medical registry of a university affiliated hospital between 1999 and 2010. Clinical, pathological and treatment related data were retrieved and characterized. The study end points were recurrence-free, progression-free and overall survival.
A total of 15 patients met study criteria. Median age at hemodialysis onset was 67 years (IQR 62, 74). Median dialysis duration before the bladder cancer diagnosis was 36 months (IQR 12, 60). Hematuria and bloody urethral discharge were the most common clinical manifestations. Tumors were generally large and multifocal. Of the patients 66% had invasive disease (T1 or greater) at presentation and 73% had high grade tumors. There were no adverse sequelae after transurethral resection or intravesical therapy. Two of the 4 patients treated with total urinary exenteration died soon after surgery and 1 had a grade IV complication. At a median followup of 18 months the estimated recurrence-free survival rate was 54% at 1 year, and 43% each at 2 and 3 years. The progression-free survival rate was 78%, 56% and 42%, and the overall survival rate was 66%, 45% and 23% at 1 to 3 years, respectively.
Bladder cancer diagnosed in patients on hemodialysis often harbors aggressive histological features at presentation. Conservative therapy in patients with noninvasive tumors appears to be well tolerated while urinary tract exenteration is associated with high morbidity and mortality. The prognosis of patients with invasive cancer is generally dismal.
Complete urinary tract exenteration for a dialysis patient with urothelial cancer: Lower midline and extraperitoneal approach in a supine position
2011, Urology
Citation Excerpt :
On the basis of the advancement in the management of uremia and maturation of modern urological surgery, many reports concluded that laparoscopic CUTE decreases pain, accelerates patient recovery, and is a better choice in dialysis patients requiring removal of the total urinary tract in a single setting. However, 2 or more interprocedural positions (other than a complete supine position) are usually necessary for one-stage laparoscopic CUTE.4-6 A complete supine position is associated with the least position-related morbidity,9 but the interference of the operative field by the surrounding intraabdominal organs has been an obstacle in transabdominal laparoscopic nephrectomy.
To report a novel technique of extraperitoneal complete urinary tract exenteration (CUTE) for dialysis patients with multifocal urothelial cancer via a lower midline approach in a supine position (the spread-eagle position [SEP]).
From October 2006 to May 2009, extraperitoneal CUTE was performed in 10 dialysis patients with multifocal urothelial cancer. Patients were placed supine with both legs extended and abducted at 45 to 60 degrees and both arms stretched out to the sides (SEP). CUTE involves simultaneous bilateral hand-assisted retroperitoneoscopic nephroureterectomy (HARN) and cystectomy or cystoprostatectomy. Bilateral HARN was completed via a 7- to 8-cm lower midline incision and 4 laparoscopic ports (2 on each side). Infraumbilical incision was extended to 12 cm and then extraperitoneal cystectomy was performed under direct vision using standard open surgical techniques.
All procedures were successful. The mean operation time of extraperitoneal CUTE was 328 minutes. The time to oral intake was 2.6 days and to ambulation was 4.6 days. The mean parenteral narcotic requirement (morphine) was 43.6 mg (range, 12-88.6). No patient had recurrent transitional cell carcinoma at a mean follow-up of 29.8 months.
Extraperitoneal CUTE via a lower midline incision in a completely supine position is feasible and safe. This technique has the benefit of easy supine positioning, eliminates the need for interprocedural repositioning, avoids bowel interference of the visual field, and reduces the risk of possible mechanical bowel injury of a retroperitoneal approach. This approach is a rational option when CUTE is considered.
Concurrent radical cystectomy and nephroureterectomy indications and outcomes: a systematic review and comparative analysis
2023, Therapeutic Advances in Urology

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Adult urologyComplete urinary tract extirpation: The University of Maryland experience

Abstract

Objectives

Methods

Results

Conclusions

Section snippets

Material and methods

Results

Comment

Conclusions

J Urol

J Urol

Lancet

Urology

Am J Kidney Dis

Transplant Proc

J Urol

Adult urology
Complete urinary tract extirpation: The University of Maryland experience