Letter to the Editor

E U R O P E A N U R O L O G Y 5 7 ( 2 0 1 0 ) e 3 1 – e 3 2

ava i lable at www.sciencedirect .com

journal homepage: www.europeanurology.com

Re: Markus J. Bader, Ronald Sroka, Christian Gratzke,

et al. Laser Therapy for Upper Urinary Tract Transitional

Cell Carcinoma: Indications and Management. Eur Urol

2009;56:65–71

We read with interest the review article on laser therapy for

upper urinary tract transitional cell carcinoma (TCC) [1]. In

this article, the authors reviewed the indications, results,

and follow-up for the endoscopic management of upper

tract TCC.

We agree with the authors that some patients, mainly

those with low-grade tumours and complete resection, may

benefit from endoscopic and laser treatment, which allow

for a nephron-sparing surgery [2]. Because the recurrence

rate of these tumours is 31–65% and disease-free rates are

35–86%, depending on stage and grade at diagnosis, it is

clear that these patients need close and lifelong follow-up.

The recommendation from the review by Bader et al. [1]

highlights the importance of a combination of urine

cytology, intravenous pyelography (IVP), retrograde pyelo-

grams, and ureterorenoscopy (URS) for the follow-up of

patients treated with endoscopic resection.

The authors mainly refer to the follow-up strategy

described by Ho and Chow [3]. This strategy includes

cystoscopy and cytology every 3 mo with retrograde

pyelogram and flexible URS every 6 mo for the first 2 yr

and every 6 and 12 mo thereafter. Other articles mentioned

in this review are similar to that of Ho and Chow, with

different time schedules, but with the inclusion of periodic

URS.

In our experience [4,5], patients with low-grade tumours

of the upper tract that have been completely resected

endoscopically (ie, URS or percutaneous treatment) do not

undergo repetitive URS for follow-up. Our follow-up

strategy includes urine cytology, cystoscopy, and IVP at 3,

6, and 12 mo for the first year, every 6 mo for 5 yr, and yearly

thereafter. URS or CT urogram (CTU) are only performed

when clinically indicated [5]. Our overall recurrence rate is

37.8% for URS and 41.2% for percutaneous surgery, with

overall 94% disease-specific survival [4,5]. We strongly

believe, as is also suggested by the literature for bladder

cancer [6], that the early detection of a small TCC recurrence

by URS as opposed to few months later by IVP is not relevant

in low-grade upper tract tumours. Therefore, when urine

DOI of original article: 10.1016/j.eururo.2008.12.012

0302-2838/$ – see back matter # 2009 European Association of Urology. Publis

cytologies and IVP are negative, patients can be managed

expectantly and can avoid unnecessary URS.

When talking about high-grade tumours or carcinoma

in situ (CIS), the situation is completely different, and

endourologic treatment should only be offered to patients

with solitary kidneys or severe comorbidities and/or to

those who are reluctant to accept radical surgery [7].

Different aspects should be considered. First, downstaging

in these cases is high (muscle is not present within the

specimen in a consistent amount of cases, 64.7% in our

series). Therefore, the gold standard treatment for high-

grade tumours of the upper tract is nephroureterectomy.

Second, URS or IVP may not detect upper urinary tract

invasive tumour because the signs may only be

wall thickening or mass forming in the renal parenchyma

[8]; therefore, it is mandatory to follow such cases with

CTU.

In conclusion, the follow-up for the endourologic

management of upper tract tumours is not well established

and is still controversial. In our opinion, when urine

cytologies, cystoscopy, and IVP are negative, it is not

necessary to perform multiple sequential URS in low-grade

tumours. Furthermore, we strongly recommend the use of

CTU, instead of IVP, for high-grade tumours and CIS.

Conflicts of interest: Joan Palou is a company consultant for Sanofi-

Pasteur, Lilly, and AMGEN; has received a speaker honoraria from Sanofi-

Pasteur; and has participated in trials for Lilly and the Zambon Group.

The other authors have nothing to disclose.

References

[1] Bader MJ, Ronald S, Gratzke C, et al. Laser therapy for urinary tract

transitional cell carcinoma: indications and management. Eur Urol

2009;56:65–71.

[2] Oosterlinck W, Solsona E, van der Meijden APM, et al. EAU guide-

lines on diagnosis and treatment of upper urinary tract transitional

cell carcinoma. Eur Urol 2004;46:147–54.

[3] Ho KL, Chow GK. Ureteroscopic resection of upper-tract transitional

cell carcinoma. J Endourol 2005;19:841–8.

[4] Palou J, Rosales A, Ribal MJ, Vicente J, Salvador J, Villavicencio H.

Valoracion global de los resultados del tratamiento del carcinoma

urotelial mediante ureteroendoscopia. Arch Esp Urol 2004;57:

299–302.

[5] Palou J, Piovesan LF, Huguet J, Salvador J, Vicente J, Villavicencio H.

Percutaneous nephroscopic management of upper urinary tract

hed by Elsevier B.V. All rights reserved. doi:10.1016/j.eururo.2009.12.004

E U R O P E A N U R O L O G Y 5 7 ( 2 0 1 0 ) e 3 1 – e 3 2e32

transitional cell carcinoma: recurrence and long-term follow up.

J Urol 2004;172:66–9.

[6] Soloway MS, Bruck DS, Kim SS. Expectant management of small,

recurrent, non invasive papillary bladder tumours. J Urol 2003;170:

438–41.

[7] Thalmann GN, Markwalder R, Walter B, Studer UE. Long term

experience with bacillus Calmette-Guerin of upper tract transition-

al cell in patients not eligible for surgery. J Urol 2002;168:1381–5.

[8] Okubo K, Ichioba K, Terada N, et al. Intrarenal bacillus Calmette-

Guerin therapy for carcinoma in situ of the upper urinary tract: long

term follow-up and natural course in cases of failure. BJU Int

2001;88:343–7.

Joan Palou*

Oscar Rodrıguez

Alberto Breda

Department of Urology, Division of Oncology,

Fundacio Puigvert, Barcelona, Spain

*Corresponding author

E-mail address: jpalou@fundacio-puigvert.es (J. Palou)

December 3, 2009

Published online on December 8, 2009