Role of percutaneous nephrostomy inpatients with upper urinary tract transitional cell carcinoma

ENDOUROLOGY

ROLE OF PERCUTANEOUS NEPHROSTOMY IN PATIENTS WTH UPPER URINARY TRACT TRANSITIONAL CELL CARCINOMA BRIAN GUZ, M.D. STEVAN B. STREEM, M.D. ANDREW C. NOVICK, M.D. JAMES E. MONTIE, M.D.

MARGARET G. ZELCH, M.D. MICHAEL A. GEISINGER, M.D. BARBARA RISIUS, M.D.

From the Departments of Urology and Radiology, Cleveland Clinic Foundation, Cleveland, Ohio

~TRACT--Percutaneous nephrostomy has become a well-established procedure for a wide va~i~ of urologic disorders. However, its role in the management of patients with upper urinary ~C! transitional cell carcinoma has not been defined. We utilized percutaneous nephrostomy in 23 ~iiialunits Jor the evatuation or treatment of 21 patients in whom standard techniques were incon!l~m~ or inadequate. 7 he pereutaneo s nephrostomy provzded adequate rehef of obstructzon zn ~!e!a~e of significant azotemia or infection. Diagnostic abilities were improved through the use of i~c~g~ade pyelography, selective cytologic examination, and, at times, by providing direct access ~#eudoscopic, visualization and .biopsy. In select cases, the percutaneous access provided a route for definitive: or adjunctive treatment of the lesion. Complications were few and seeding of the tract or ~b~attumor spread has not occurred at follow-up ranging from one to one hundred twenty-one ~tiiiau 27. 8) months

nt of percutaneous techniques lified access to the renal collectally, pereutaneous nephrostomy i to allow simple decompression :1 collecting system. 1 Over the ereutaneous techniques have ~ad use to manage many paLl or ureteral calculi. With in',nee, this technology has been ii

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;::withbenign disease.>4 More recently, percuta;n;eo~stechniques have been utilized to manage :;:~deet patients with urothelial cancer. 5-v However, the indications and results of such intervention. : have not yet been defined. Therefore, ,m an attempt to help delineate its role, w e !!~es~nt our experience utilizing percutaneous ~o:lephrostomy and related technology for the i~.!a~osis or treatment of patients with urothe~at cancer.

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Material and Methods Since July 1977, 21 patients underwent percutaneous nephrostomy in 23 renal units for evaluation or treatment of upper tract urothelial cancer. There were 18 males and 3 females, ranging in age from forty-nine to eighty-two years (mean 66.4). Eight patients had a prior history of known upper tract transitional cell carcinoma. Fourteen patients had a past history of bladder cancer, 8 of whom had undergone eysteetomy and urinary diversion. Initial findings on intravenous urography (IVP) included hydronephrosis of the involved renal unit in 20 eases, ineluding nonvisualization secondary to obstruction in 7. Discrete filling defects were seen in 5 renal units. In 9 patients, the involved renal unit was the sole functioning kidney. In all eases a standard urologic evaluation including urine cytologic examination, cystoseopy and retrograde pyelography, or loopogram was 331

performed. Ureteropyeloscopy had been attempted in 3 eases. The primary indications for pereutaneous nephrostomy were to better define the collecting system radiographieally or cytologically when standard studies were indeterminate, or to provide relief of obstruction in the face of significant azotemia or infection. The pereutaneous nephrostomy was placed under local anesthesia and intravenous sedation utilizing standard techniques. The collecting system was visualized using fluoroscopy or ultrasonography, depending on renal function. Urine was then sent for selective cytologic examination. A formal antegrade pyelogram was obtained after a variable period of nephrostomy drainage. In select patients, the pereutaneous tract subsequently was dilated to 24F, and percutaneous pyeloscopy and biopsy were performed for a definitive diagnosis. Results

Relief of obstruction The percutaneons nephrostomy was placed in 13 renal units primarily for relief of obstruction. In 8 patients, this was following ileal conduit diversion so that retrograde manipulation was not possible. In 9 cases this was a solitary functioning kidney. Serum creatinine in those 9 patients ranged from 2.7 to 12.5 mg/dL (mean 5.5) prenephrostomy and fell to 1.2 to 2.0 rag/ dL (mean 1.7) following decompression. In these cases, the improved renal function allowed stabilization of the patient prior to systemic or local chemotherapy, or operative intervention. Two of these patients with obstruction in solitary kidneys had metastatic disease at the time of presentation. In both eases the obstruction could not be relieved in a retrograde fashion. Percutaneous access was ultimately used for placement of internal/external stents to provide palliation. In those patients subsequently undergoing open operative intervention, the percutaneous nephrostomy was left in place intraoperatively and postoperatively to provide proximal diversion and access for follow-up antegrade studies as necessary. One patient presented with enterococcus sepsis associated with the obstruction. Urine culture from the nephrostomy tube was positive, and the patient's clinical course rapidly responded to the nephrostomy drainagG antibiotics, and fluids.

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Cytologic evaluation Selective upper tract cy" nephrostomy tube was positi~ in 11 renal units, all of wl quently proved to have cane voided or conduit urine was other 7, the voided or con& positive. In those cases, t nephrostomy was placed prin obstruction or for better loca sion when standard techniqu~ elusive. Nephrostomy urine was 7 lignaney in the remaining 12 1 these, voided cytology was po tient was found to have an cancer. Five of the remaining ative nephrostomy and voide( tology subsequently were pr( eer. In 4 units, the lesion noninvasive transitional cell ipsilateral ureter. In one othq was a high-grade transition~ that was extrinsic to the urete tion. The other 6 patients we~ benign lesions. All these patie undergone surgery for trar cinoma and presented with ureteral anastomosis, subsequ the result of benign fibrosis.

Radiologic evaluation Antegrade pyelography w cases. Filling defects were vis vioealiceal system in 3 pati sions, either filling defects , sions, were found in 16 renal with obstruction at a ureter~ terovesical anastomosis follm for cancer. In 4 patients, si pelvic and ureteral lesions w. In 16 renal units, the lesi grade pyelography subseque: malignant. One patient with ing defect and negative nept was found to have biopsy-p: the 8 renal units with ureter~ struction, 2 had malignant d had positive nephrostomy eyt anastomotic strictures were f( Five of these were treated wi tion via the percutaneous tra~ was successful in 3.

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F~CURE 1. Case 1. (A) IVP reveals polypoid filling defect

(arrow) in upper infundibulum of right kidney and nonvisualization of left kidney.

(B) Left retrograde ureterogram reveals completely obstructing irregular filling defect in distal ureter. (C) Left antegrade pyelogram reveals

multiple filling defects (arrows) and marked pyelocaIicectasis; kidney did not recover any significant function following relief of obstruction.

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¢~rcutaneous pyeloureteroscopy In 3 patients, 2 of whom had solitary fune!i~ning kidneys, the percutaneous tract was ;!!~l~sequently utilized for pereutaneous pyelos~!~lpy a n d biopsy. In 1 patient with a lower in[It0LOGy

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fundibuloealieeal tumor, the treatment proved definitive. 6 In 1 other patient, pereutaneous pyeloseopy and antegrade ureteroseopy with biopsy revealed transitional cell carcinoma of the proximal ureter and nephrouretereetomy 333

FIGURE 2. Case 2. (A) Bight nephrostogram reveals possible filling deJect (arrow) in proximal ureter. (13) Percutaneous flexible pyeloureteroscopy allowed direct visualization and biopsy of the lesion; specimen proved to be low-grade, noninvasive transitional cell carcinoma.

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was performed. The third patient had a history of bladder cancer and was found to have a filling defect in the renal pelvis of a solitary functioning kidney. Selective cytology was negative, and pereutaneous pyeloseopy with biopsy revealed pyelitis. Case Abstracts Examples of the multiple uses of pereutaneous nephr0stomy for these patients are illustrated herein. Case 1

A fifty-four-year-old man presented with gross painless hematuria. IVP revealed a polypoid filling defect in the right upper infundibulum and nonvisualization of the left kidney (Fig. 1A). Retrograde studies confirmed the lesion on the right side and also revealed a eompletely obstructing irregular lesion in the distal left ureter (Fig. 1B). Because the disease was bilateral, a pereutaneous nephrostomy was placed on the left side to determine if there were any recoverable function and whether a "conservative" surgical procedure could be performed on that side. However, antegrade pyelography suggested multifoeal disease (Fig. 1C). In addition, seleetive functional studies from that side showed only negligible function even after relief of obstruction. The patient subsequently underwent left nephrouretereetomy 334

and right partial nephreetomy and do well five years later with no recur Case 2

A sixty-four-year-old man had radical eysteetomy and ileal con& for transitional cell carcinoma of the t Follow-up IVP and loopogram suggest4 ing defect in the right proximal ureter. Urine cytologic findings were negai better define the lesion, a right percti nephrostomy was placed and antegrad!: were obtained, again suggesting a fillir~i (Fig. 2A). However, nephrostomy uri~ ogy was also negative Pereutaneous fl { tegrade ureteroseopy was biopsy of the lesion (Fi~ low-grade, low-stage t~ einoma. The patient th nephrouretereetomy. Complications and follotc ~,.

Complications resulting from the neous nephrostomy were few. One pa a clinical baeteremia immediately folii instrumentation though cultures werei Bleeding requiring transfusion oecurre tient and was resolved after transfusiii of packed cells. At follow-up of one ~!~ dred twenty-one months (mean ~7i8~ tients are alive and free of disease. F:.~ UROLOGY

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~eiated causes, and 3 died of metastatic disLll of whom had metastases at the time of ~,..i~'~,,tation. One other patient with" metastatic" !eaSeat presentation remains alive with shorti~ f0Uow-up. Local seeding of the tract or rirenal implantation of the disease has not

Comment cutaneous nephrostomy was initially utii o r simple decompression of obstructed iting system s.1 More recently, percutatechniques have been refined to allow gement of renal or ureterat calculi, and ;ome nonstone disorders such as calieeal ;icula, ureteropelvie ]unction obstruction, ~opathic renal bleeding. ~-4 Its role in the Ssis or management of patients with uptransitional cell carcinoma has not defined. In most patients, the diagno~s ~f ~pper tract transitional cell carcinoma can i~ade with relatively noninvasive standard ~lag~bstie techniques including IVP, ultrasound ~T scan, retrograde pyelography, selective tp!0gic studies, or brush biopsy. The recent troduetion of ureteropyeloscopy has further Lti~needour diagnostic capabilities in this set-

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i~0wever, there remains a select group of pa@sin whom an accurate diagnosis still cani~!beestablished and who would otherwise re~uite Surgical "exploration." In that setting, the ~pera[ion most often entails an open pyelotomy ~!i areterotomy with or without intraoperative ~ e r o p t i c techniques such as pyeloscopy. An ~ a t i o n for cancer is then compromised by ~ e risk of tumor spillage which in at least one ~ i e ~ is as real as it is theoretical, n The alterna!ire in those cases'is simply to proceed with ~ePhroureterectomy; though if the lesion ~rQves to be benign, a more conservative proiedure would be sufficient. This study was done to help define the role of ercutaneous, nephrostomy in patients with up r tract tranmtlonal cell carcinoma. The most iequent indication was to relieve obstruction in he:face of azotemia or infection when retro!!g?~adeaccess could not be achieved In this se)i~i%inability to gain retrograde access occurred i!m0st Often in the setting of previous intestinal ~0aduit diversion or in the presence of a comlfieMy obstructing ureteral lesion. The placea~ent of a percutaneous nephrostomy also :prOved valuable for those patients in whom a i: t~

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filling defect was visualized but in whom the standard diagnostic regimen was inconclusive. Accurate diagnosis was often achieved by the use of antegrade pyelography and selective urine cytologic examination alone. In some cases, percutaneous pyeloseopy with direct visualization and biopsy of the lesion provided a definitive diagnosis. In select eases, this approach provided definitive management. In fact, a pereutaneous approach for treatment of upper tract lesions has been reported previously. In these very select, high-risk patients, the percutaneous tract allows access for eleetroresection, laser destruction, local irradiation, or topical chemotherapy. ~-v Pereutaneous nephrostomy was particularly useful for patients with solitary kidneys, bilateral urothelial cancer, or otherwise compromised renal function in whom a more conservative surgical approach for cure of the disease was indicated. In these eases the percutaneous nephrostomy allowed excellent delineation of the upper tract, especially the urothelium proximal to an obstructing ureteral lesion. Thus partial uretereetomy could be planned when the lesion proved to be solitary, or eontra-indieated when multiple lesions were visualized. The percutaneous nephrostomy offered the additional advantage of allowing resolution of azotemia or infection in the face of an obstructing lesion so that the patient was better prepared for surgery. Additionally, where a conservative procedure was done, the pereutaneous nephrostomy allowed temporary postoperative urinary diversion and access for antegrade studies. Another benefit of pereutaneous nephrostomy was seen in patients with obstruction in the face of metastatic transitional cell careinoma. Palliation was achieved by relief of obstruction in an antegrade fashion when retrograde access was impossible. The percutaneous tract was ultimately utilized to provide internal diversion via internal/external stents, thus improving quality of life. A secondary use of the percutaneons access was seen in those patients whose obstruction was at a ureteral anastomosis following prior surgery for transitional cell carcinoma. In these cases, it may be difficult to differentiate benign from malignant obstruction. In this series, selective cytology was negative in all 6 patients with a benign stricture and positive in 1 of the 2 with malignancy. The percutaneous access was then utilized for antegrade balloon dilation in

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those patients with a benign stricture. Alternatively, endourologie procedures which allow direct antegrade visualization of the stricture have also been reported. 12 In contrast to balloon dila~ion, these techniques offer the additional potential advantage of endoscopic biopsy of the lesion in eases where the etiology is still unclear. Finally, an obvious concern remains regarding the potential for spread of a tumor when the urothelium is violated. This issue had been addressed elsewhere ~ and at least in this series of patients followed as long as ten years; seeding of the tract or local spread of the disease outside the collecting system has not been seen. In conclusion, pereutaneous nephrostomy has proven to be an effective and safe procedure for select patients with upper tract transitional cell carcinoma. In our series, its most significant role was to provide relief of obstruction and enhanced diagnostic capabilities for those patients in whom standard techniques were inadequate. In most eases, this was in the setting of previous urinary diversion following surgery for cancer, or in patients with a completely obstructing ureteral lesion. Pereutaneous nephrostomy was especially useful in patients with obs t r u c t e d s o l i t a r y k i d n e y s or o t h e r w i s e compromised renal function in w h o m a conservative surgical procedure was ultimately indicated. The pereutaneous approach also provided a route for t r e a t m e n t in very select patients. At times, the treatment was definitive

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though in others it was only adjunctive or liative. Department of Urology, Desk A] Cleveland Clinic Found ati 9500 Euclid A Cleveland, Ohio 441 (DR. STI1EE References 1. Goodwin WE, Casey WC, and Woolf W: Pereutaneou~ ear (needle) nephrostomy in hydronephrosis, lAMA 157i

(1955).

2. Clayman RV, et al: Percutaneous intrarenal eleetrosurg6i Urol 131:864 (1984). 3. Patterson PE, e t a h Endoscopic evaluation and treatme~ patients with idiopathic gross hematuria, J Uro1132:1199 (]~I 4. Badlani G, Eshghi M, and Smith AD: Pereutaneous SU!i for ureteropelvic junction ohstruotiou (ondopyelotomy): t0 nique and early results, J Urol 135:26 (1986). 5. Smith AD, Orihuela E, and Crowley AR: Percuta~ management of renal pelvic tumors: a treatment option[ leered cases, J Urol 137:852 (1987). 6. Streem SB, and Pontes El: Percutaneous managemi upper tract transitional cell carcinoma, J Urol 135:773 (i!i 7. Woodhouse CRJ, Kellett MJ, and Bloom HJG: Percuf~ renal surgery and local radiotherapy in the management iifl pelvic transitional cell carcinoma, Br J Urol 58:245 (198~ 8. Aso Y, e t a h Usefulness of fiberoptic pyeloureteroseop~ diagnosis of the upper urinary tract lesions, Urol IntSt (1984). 9. Huffman JL, et al: Endoscopic diagnosis and treatrhl upper-tract urothelial tumors, Cancer 55:1422 (1985). 1O. Streem SB, Pontes El, Noviek AC, and Montie J,E teropyeloseopy in the evaluation of upper tract filling d~if! Urol 136:383 (1986). :;:"}i 11. Tomera KM, Leary FJ, and Zineke H: Pyeldii urothelial tumors, J Urol 127:1088 (1982). ~'~ 12. Kramolowsky EV, Clayman RV, and Weyman PJ~ ~!i!t* ment of ureterointestinal anastomotic strictures: cornpi:~ open surgie~ and endourologie repair, J Urol 139: 119~

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