Local Recurrences Port Site And Ureteral Stump

Port site metastasis is a rare event. Biologic, pathophysiologic, and technical factors can facilitate its occurrence, particularly in diseases such as transitional cell carcinoma that

TABLE5 ■ Results of Studies Comparing Laparoscopic and Open Nephroureterectomy for Upper Urinary Tract Transitional Cell Carcinoma

Author, year

No. of

Positive

Recurrences (%)

Cancer-specific

Mean follow-up

(Ref.)

Approach

patients

margins (%)

Port site

Bladder

Local

Distant

survival rate (%)

(mo)

Gill et al., 2000 (18)

Lap

42

7

0

23

8.6

97

11

Open

35

15

37

13

87

34

McNeill et al.,2000 (14)

Lap

25

0

83a

33

Open

42

77a

42

Shalhav et al.,2000 (15)

Lap

25

0

23

15

23

77

24

Open

17

46

23

77

43

Stifelman et al.,2001 (44)b

Lap

11

0

55

9

63a(RFS)

13

Open

11

9

64

63a(RFS)

17

Matsui et al.,2002 (20)

Lap

17

1c

29

6

—d

8.8

Open

17

24

24

12

23

Kawauchi et al.,2003 (27)

Lap

34

9

6

88a (RFS)

13.1

Open

34

38

9

53a (RFS)

48.8

aSurvival rate calculated from data in the publication. bResults calculated from data in the publication. cSee Ref. 47 and Table 6.

dNo significant difference in disease-free survival rate between open and laparoscopic groups (P = 0.6775). Abbreviations: Lap, laparoscopic nephroureterectomy; Open, open nephroureterectomy; RFS, recurrence-free survival. Source: Modified from Ref. 28.

FIGURE3 ■ Stage dependent disease-specific survival after nephroureterectomy for upper tract transitional cell carcinoma. Source: From Ref. 2.

FIGURE3 ■ Stage dependent disease-specific survival after nephroureterectomy for upper tract transitional cell carcinoma. Source: From Ref. 2.

have a propensity for local implantation (50,51). There have been seven reported cases of port site recurrence of transitional cell carcinoma, only three of which occurred during laparoscopic radical nephroureterectomy for suspected transitional cell carcinoma (Table 6) (47,56-58). Of the remaining four, two occurred during laparoscopic pelvic lymph node dissection (59,60), one after laparoscopic biopsy of bladder transitional cell carcinoma (51), and one after nephrectomy for tuberculous kidney harboring unsuspected transitional cell carcinoma (58). The three cases of port site metastasis during laparoscopic radical nephroureterectomy represent less than 1% of all reported cases of laparoscopic radical nephroureterectomy (14-16,18,20,21,24, 26,27,29,44).

Less recognized but possibly more clinically significant is disseminated recurrences after endoscopic excision of the distal ureter and bladder cuff, procedures that predate laparoscopic techniques (52-55). Recurrences after transurethral resection of the ureteral orifice are the most frequently reported. This procedure may be associated with irrigant extravasation, urine spillage from the upper urinary tract into the extraperitoneal space despite attempted "sealing" by fulguration (which is unlikely to provide effective sealing), and residual discontinuous segments of the distal ureter. All these events increase the risk of extravesical tumor recurrence, resulting in iatrogenic T3-4 disease that may not be seen cystoscopically or radiographically (51). At particular risk are patients whose upper urinary tract has not been completely evaluated: an occult distal ureteral tumor or ureteral carcinoma in situ may be present in addition to an obvious renal pelvic tumor. carcinoma in situ of the ureter may not be visible endoscopically or radiographically. Also, patients with distal or intramural ureteral tumors are poor candidates for any form of endoscopic resection of the distal ureter (13,14); in particular, those with possible invasive distal ureteral tumors are best served by an open trans-vesical technique (Table 3).

The outcome in these cases is often grave, the clinical experience is limited, and the optimal choice of therapy is unclear (Table 6). In the absence of distant disease, wide surgical excision appears to offer a chance at a disease-free interval. Radiation therapy for pelvic extravesical disease occurring at the endoscopic site appears to be uniformly followed by death, although local palliation may be provided. In the presence of additional distant disease, an initial trial of up-front systemic therapy may be most preferable, with additional therapy rendered depending on the response to therapy.

TABLE 6 ■ Recurrences Associated with Laparoscopic and Endoscopic Approaches for Upper Tract Transitional Cell Carcinoma

Pathologic

Time to

Author, year

Nephrectomy

Bladder cuff

findings (R: renal

Adjuvant

recurrence (mo),

Recurrence

Treatment of

Last follow-

(Ref.)

technique

technique

pelvis; U: ureter)

therapy

symptoms

site

recurrence

up, status

Hetherington

Open

Transurethral

R: P4G3

No

5, pain

Pelvic

Radiation

9 mo, DOD

et al., 1986 (52)

resection

U: negative

extravesical

therapy

Hetherington

Open

Transurethral

R: P1G1

No

9, hematuria

Pelvic

Radiation

15 mo, DOD

et al., 1986 (52)

resection

U: negative

extravesical

therapy

Abercrombie

Open

Transurethral

R: P1G1

No

3, unknown

Intravesical at

TUR

96 mo, NED

et al., 1988 (37)

resection

U: unknown

endoscopic site

Jones and Moisey,

Open

Transurethral

R: PxG3Nx

No

3, asympto-

Bladder base

Radiation

Unknown

1993 (53)

resection

U: PxG3 R+

matic

at endoscopic site

therapy

Arango et al.,

Open

Transurethral

R: stage 1

No

7, pain

Endoscopic

Salvage

3 mo, DOD

1997 (54)

resection

U: negative

site

cystectomy,

chemotherapy

Fernandez Gomez

Open

Transurethral

R: P3G3N0

No

4, pain

Pelvic

Anterior

9 mo, NED

et al., 1998 (55)

resection

U: PaG3

extravesical

exenteration,

at endo-

chemotherapy

scopic site

Ahmed et al.,

Laparoscopic

Transurethral

R: P3G3

No

8, pain

Periumbilical

Chemotherapy

Unknown

1998 (56)

trans-

resection

U: unknown

port site,

peritoneala

retroperi-

toneum, liver

Ong et al.,

Laparoscopic

Unknownb

R: P1G3, +CIS

No

12,

Trocar sites,

Wide excision

NED at 6 mo

2003 (57)

retro-

U: unknown

asymptomatic

three tumors

peritoneala

Matsui et al.,

Laparoscopic

Open

R: P3 squamous

Chemotherapy

6,

Trocar site

Wide

NED at 6 mo

2004 (47)

retro-

cell carcinoma

asymptomatic

excision

peritoneala

aNone of the specimens in these cases were morcellated.

Presumably open method; ureteral stent placed after ureteroscopy 1 wk previously was seen protruding from the ureter during surgery.

Abbreviations: DOD, died of disease; NED, no evidence of disease; TUR, transurethral resection.

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