Introduction: Nephron-sparing surgery (NSS) for upper tract urothelial carcinoma (UTUC) offers select patients renal preservation but demands close surveillance including routine ureteroscopy that typically require general anesthesia. We report feasibility and our experience in utilizing ureteric orifice meatotomy to facilitate office-based flexible ureteroscopy under local anesthesia.
Methods: A retrospective chart review was conducted including consecutive patients who underwent NSS of UTUC at our tertiary center. Patients underwent ureteric orifice meatotomy followed by attempted flexible ureteroscopy in the office setting under local anesthesia with transurethral 2% lidocaine jelly. Otherwise, patients underwent routine ureteroscopic surveillance under general anesthesia and all patients underwent routine cross-sectional imaging including 3-D ‘virtual ureteroscopy’ by reconstruction of CT urography to evaluate for disease recurrence.
Results: A total of 16 patients (7 male; 9 female) with UTUC were treated with NSS – 9/16 (56%) were initially managed ureteroscopically and 7/16 (44%) percutaneously. Median age at diagnosis was 79 (IQR 71.5, 81.5) and median follow-up was 3 years (IQR 2, 3.5). The majority of patients had high grade disease (75%) and tumor location was typically renal pelvis (10/16; 63%) followed by distal ureter (4), mid ureter (1) and proximal ureter (1). A total of 3/16 (18%) had history of contralateral UTUC, 3/16 (18.8%) had solitary kidney and 10/16 (62%) had concomitant bladder cancer. A total of 10/16 patients (63%) who underwent ureteric orifice meatotomy tolerated flexible ureteroscopy in an office-based setting under local anesthesia, the rest required general anesthesia. Overall, 8/16 (50%) had disease recurrence, typically at the location of their initial site of disease. Of the 10 patients with renal pelvic disease, 6 (60%) recurred in the renal pelvis. Of the 6 patients with ureteral disease, 2 (33%) recurred in the ureter. Of those who recurred, 4 (50%) were successfully managed with ongoing endoscopic therapy and 4 (50%) ultimately underwent radical nephroureterectomy, 3 of which had disease upstaging on final pathology. There were 2 deaths related to comorbidities, both of who had a solitary kidney. There were no UTUC-related deaths.
Conclusions: In select patients with UTUC who undergo NSS, ureteric orifice meatotomy is feasible and allows the majority of patients to tolerate office based flexible ureteroscopy under local anesthesia without compromising oncologic outcomes.
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