CURRENT CLINICAL UROLOGY - PART 8 pps

Chapter 14 / Caliceal Diverticula 247 with tube thoracostomy. The average hospital stay was 2.8 days, and all patients were dis- charged home with a 22-Fr nephrostomy tube that was removed 1 week later. In published series, overall stone-free and symptom-free rates of 89 and 89%, respec- tively, have been achieved (Table 2). Furthermore, in 60% of cases, the diverticula were successfully obliterated. For caliceal diverticula approached directly the overall success rate (obliteration of diverticulum) was 63% (88/139) vs indirectly which was 9% (2/22). Complication rates are slightly higher with a percutaneous approach (15%) compared with a retrograde ureteroscopic approach (9%) (Tables 1 and 2). Laparoscopic Approach A total of 13 cases of laparoscopic unroofing of caliceal diverticula have been reported in the literature, including a transperitoneal approach in 1 case and a retroperitoneal approach in 12 cases (29–33). Operative times ranged from 60 to 215 minutes, and the overall complication rate was 7.7%, with the only reported complication consisting of bleeding requiring transfusion. Radiographic studies demonstrated obliteration of the diverticula in all 13 cases and all patients were rendered symptom free at a mean follow- up of 6 months. The laparoscopic approach is generally reserved for large diverticula (>5 cm) or anteriorly located diverticula with thin overlying parenchyma. TIPS AND TRICKS Ureteroscopic Approach • Contrast injected through the ureteroscope helps to identify the calyx with which the diverticulum is associated. • Passage of a guidewire into the diverticula confirms proper identification of the ostium and opens up the diverticular neck sufficiently to position a laser fiber for incision. • Dilation of the diverticular neck after incision separates the incised edges and facilitates clearance of stones fragments from the diverticulum. Percutaneous Approach • After percutaneous puncture, a moveable core guidewire or J-wire coiled within the diverticulum provides moderately secure guidewire access over which a dilating bal- loon can be passed. • Injection of indigo carmine-stained saline or air via the occlusion balloon catheter facil- itates identification of the diverticular neck, which can then be cannulated with a guidewire. • Fulguration of the diverticulum prior to dilation or incision of the diverticular neck pre- vents inadvertent fulguration of the collecting system urothelium. • The transdiverticular approach is an alternative method of treating the diverticulum that provides secure access into the collecting system. CONCLUSIONS Therapeutic options for treatment of symptomatic caliceal diverticula include SWL, ureteroscopy, percutaneous nephrostolithotomy/ablation, and laparoscopic unroofing. SWL is associated with the lowest stone-free rates, although in a surprising number of patients symptoms resolve despite persistence of the diverticulum and stone fragments. 248 Matsumoto and Pearle SWL therapy is best reserved for patients with a small stone burden (≤15 mm) in a mid- or upper pole caliceal diverticulum with a radiographically patient diverticular neck. Retrograde ureteroscopy should be considered for upper- and midcaliceal diverticula associated with a stone burden of 15 mm or less, when the infundibulopelvic angle is favorable for ureteroscopic access (7). Likewise, anteriorly located diverticula with a modest stone burden are effectively accessed via a ureteroscopic approach, which is safer than a percutaneous approach and less invasive than a laparoscopic approach. Although the diverticulum is rarely successfully obliterated, high stone-free rates can be achieved and improved drainage of the diverticulum attained. A percutaneous approach offers the best chance of achieving a stone-free and symptom-free state and is the only endoscopic option in which the diverticulum can be directly treated. A direct percutaneous approach is preferable to the indirect approach, and if direct access cannot be safely performed, a ureteroscopic approach should be consid- ered if the diverticulum and/or stone burden is small. An indirect approach is still favored over ureteroscopy for a large stone burden or a large diverticulum (>2 cm), particularly if a rigid nephroscope can be used to access the diverticulum and fulgurate the urothelium. Management of the diverticular neck is controversial. Whether it is necessary or preferable to dilate or incise the neck vs simply fulgurate the diverticulum has not been firmly established. Likewise, if treatment of the diverticular neck proves superior to simple fulguration, the advantage of one modality over another (incision vs dilation) will remain to be proven. Until further information is available, it is advisable to dilate or incise the diverticular neck if the ostium can be identified after fulguration of the diverticulum. If the diverticular neck cannot be identified, fulguration of the urothelial lining may be sufficient. For large diverticula (>5 cm) or for anteriorly located diverticula with thin overlying parenchyma and large stones, laparoscopic unroofing offers the most expeditious treat- ment, resulting in successful stone removal and resolution of the diverticula. REFERENCES 1. Wulfsohn MA. Pyelocaliceal diverticula. J Urol 1980; 123: 1–8. 2. Middleton AW Jr., Pfister RC. Stone-containing pyelocaliceal diverticulum: embryogenic, anatomic, radiologic and clinical characteristics. J Urol 1974; 111: 2–6. 3. Timmons JW Jr., Malek RS, Hattery RR, Deweerd JH. Caliceal diverticulum. J Urol 1975; 114: 6–9. 4. Williams G, Blandy JP, Tresidder GC. Communicating cysts and diverticula of the renal pelvis. Br J Urol 1969; 41: 163–170. 5. Yow RM, Bunts RC. Calyceal diverticulum. J Urol 1955; 73: 663–670. 6. Devine CJ Jr., Guzman JA, Devine PC, Poutasse EF. Calyceal diverticulum. J Urol 1969; 101: 8–11. 7. Chong TW, Bui MH, Fuchs GJ. Calyceal diverticula. Ureteroscopic management. Urol Clin North Am 2000; 27: 647–654. 8. Fuchs GJ, David RD. Flexible ureterorenoscopy, dilatation of narrow caliceal neck and ESWL: A new minimally invasive approach to stones in caliceal diverticulua. J Endourol 1989; 3: 255–263. 9. Bennett JD, Brown TC, Kozak RI, Sales J, Denstedt JD. Transdiverticular percutaneous nephrostomy for caliceal diverticular stenosis. J Urol 1992; 6: 55–57. 10. Auge BK, Munver R, Kourambas J, Newman GE, Wu NZ, Preminger GM. Neoinfundibulotomy for the management of symptomatic caliceal diverticula. J Urol 2002; 167: 1616–1620. 11. Al-Basam S, Bennett JD, Layton ZA, Denstedt JD, Razvi H. Treatment of caliceal diverticular stones: transdiverticular percutaneous nephrolithotomy with creation of a neoinfundibulum. J Vasc Interv Radiol 2000; 11: 885–889. 12. Hulbert JC, Reddy PK, Hunter DW, Castaneda-Zuniga W, Amplatz K, Lange PH. Percutaneous tech- niques for the management of caliceal diverticula containing calculi. J Urol 1986; 135: 225–227. 13. Eshghi M, Tuong W, Fernandez F, Addonizio JC. Percutaneous (Endo) Infundibulotomy. J Endourol 1987; 1: (2)107–113. 14. Wilbert DM, Jenny E, Stoeckle M, Ridemiller H, Jacobi G. Calyceal diverticar stones: is ESWL worthwhile? J Urol 1986; 135: 183A 15. Psihramis KE, Dretler SP. Extracorporeal shock wave lithotripsy of caliceal diverticula calculi. J Urol 1987; 138: 707–711. 16. Ritchie AW, Parr NJ, Moussa SA, Tolley DA. Lithotripsy for calculi in caliceal diverticula? Br J Urol 1990; 66: 6–8. 17. Jones JA, Lingeman JE, Steidle CP. The roles of extracorporeal shock wave lithotripsy and percuta- neous nephrostolithotomy in the management of pyelocaliceal diverticula. J Urol 1991; 146: 724–727. 18. Hendrikx AJ, Bierkens AF, Bos R, Oosterhof GO, Debruyne FM. Treatment of stones in caliceal diverticula: extracorporeal shock wave lithotripsy versus percutaneous nephrolitholapaxy. Br J Urol 1992; 70: 478–482. 19. Streem SB, Yost A. Treatment of caliceal diverticular calculi with extracorporeal shock wave lithotripsy: patient selection and extended followup. J Urol 1992; 148: 1043–1046. 20. Pang K, David RD, Fuchs GJ. Treatment of stones in caliceal diverticuli using retrograde endoscopic approach: Critical assessment after 2 years. J Endourol 1992; 6(suppl): S80. 21. Grasso M, Lang G, Loisides P, Bagley D, Taylor F. Endoscopic management of the symptomatic cal- iceal diverticular calculus. J Urol 1995; 153: 1878–1881. 22. Batter SJ, Dretler SP. Ureterorenoscopic approach to the symptomatic caliceal diverticulum. J Urol 1997; 158: 709–713. 23. Chong TW, Bui MH, Fuchs GJ. Calyceal diverticula. Ureteroscopic management. Urol Clin North Am 2000; 27: 647–654. 24. Auge BK, Munver R, Kourambas J, Newman GE, Preminger GM. Endoscopic management of symp- tomatic caliceal diverticula: a retrospective comparison of percutaneous nephrolithotripsy and ureteroscopy. J Endourol 2002; 16: 557–563. 25. Hulbert JC, Hernandez-Graulau JM, Hunter DW, Castaneda-Zuniga W. Current concepts in the man- agement of pyelocaliceal diverticula. J Endourol 1988; 2: 11–17. 26. Hedelin H, Geterud K, Grenabo L, Henriksson C, Pettersson S, Zachrisson BF. Percutaneous surgery for stones in pyelocaliceal diverticula. Br J Urol 1988; 62: 206–208. 27. Ellis JH, Patterson SK, Sonda LP, Platt JF, Sheffner SE, Woolsey EJ. Stones and infection in renal caliceal diverticula: treatment with percutaneous procedures. AJR Am J Roentgenol 1991; 156: 995–1000. 28. Shalhav AL, Soble JJ, Nakada SY, Wolf JS Jr, McClennan BL, Clayman RV. Long-term outcome of caliceal diverticula following percutaneous endosurgical management. J Urol 1998; 160: 1635–1639. 29. Ruckle HC, Segura JW. Laparoscopic treatment of a stone-filled, caliceal diverticulum: a definitive, minimally invasive therapeutic option. J Urol 1994; 151: 122–124. 30. Hoznek A, Herard A, Ogiez N, Amsellem D, Chopin DK, Abbou CC. Symptomatic caliceal divertic- ula treated with extraperitoneal laparoscopic marsupialization fulguration and gelatin resorcinol formaldehyde glue obliteration. J Urol 1998; 160: 352–355. 31. Harewood LM, Agarwal D, Lindsay S, Vaughan MG, Cleeve LK, Webb DR. Extraperitoneal laparo- scopic caliceal diverticulectomy. J Endourol 1996; 10: 425–430. 32. Curran MJ, Little AF, Bouyounes B, Nieh PT, Bihrle W 3rd. Retroperitoneoscopic technique for treat- ing symptomatic caliceal diverticula. J Endourol 1999; 13: 723–725. 33. Miller SD, Ng CS, Streem SB, Gill IS. Laparoscopic management of caliceal diverticular calculi. J Urol 2002; 167: 1248–1252. 34. Lang EK. Percutaneous infundibuloplasty: management of calyceal diverticula and infundibular stenosis. Radiology 1991; 181: 871–877. 35. Bellman GC, Silverstein JI, Blickensderfer S, Smith AD. Technique and follow-up of percutaneous management of caliceal diverticula. Urology 1993; 42: 21–25. 36. Donnellan SM, Harewood LM, Webb DR. Percutaneous management of caliceal diverticular calculi: technique and outcome. J Endourol 1999; 13: 83-88. 37. Monga M, Smith R, Ferral H, Thomas R. Percutaneous ablation of caliceal diverticulum: long-term followup. J Urol 2000; 163: 28–32. Chapter 14 / Caliceal Diverticula 249 IV ABLATIVE THERAPY SUMMARY The “gold standard” for treatment of upper tract urothelial carcinoma is nephrourterec- tomy. In some cases, however, organ-sparing endoscopic therapy via percutaneous or ureteroscopic approaches should be considered. The percutaneous approach is generally used for cases of larger volume renal disease and those not accessible by ureteroscopic techniques. This chapter will review the indications, technique, complications, and results of this technique. Key Words: TCC; percutaneous; management. NATURAL HISTORY OF UPPER URINARY TRACT TRANSITIONAL CELL CARCINOMAS AND INDICATIONS FOR CONSERVATIVE THERAPY Upper urinary tract (UUT) urothelial tumors are rare accounting for 1 to 2% of all genitourinary tumors (1). The vast majority are transitional cell carcinomas (TCC) (90%), whereas only 10% are squamous cell carcinomas and 1% adenocarcinomas (2). From: Advanced Endourology: The Complete Clinical Guide Edited by: S. Y. Nakada and M. S. Pearle © Humana Press Inc., Totowa, NJ 253 Percutaneous Approach to Upper Urinary Tract Tumors Ioannis M. Varkarakis MD, PhD and Thomas W. Jarrett, MD C ONTENTS NATURAL HISTORY OF UPPER URINARY TRACT TRANSITIONAL CELL CARCINOMAS AND INDICATIONS FOR CONSERVATIVE THERAPY I NSTRUMENTATION TECHNIQUE RESULTS T IPS AND TRICKS CONCLUSION REFERENCES 15 Urothelial tumors of the renal pelvis are three to four times more frequent than those located in the ureter (3). The incidence of UUT TCC increases with age in both genders and appears most fre- quently during the sixth and seventh decades of life. Males present with this disease three times more frequently than women (4). Like that of the bladder, upper TCC most likely represents a field change disease with multiple recurrences in both time and space. This polychronotopism is generally confined to the ipsilateral renal unit or to the bladder. Although recurrence at an additional site in the genitourinary system will occur in 30 to 50% of patients (5), recurrence in the controlateral renal unit will develop only in 1 to 5.8% (6,7). This natural history makes nephroureterec- tomy with resection of a bladder cuff safe and effective for therapy of an UUT TCC. Rates of local or ipsilateral recurrence after nephron preserving surgery are high and therefore conservative management with renal sparing procedures has been implemented only when preservation of renal function is necessary. This includes patients with an anatomically or functionally solitary kidney, those with bilateral disease, and patients who refuse or are unable to tolerate open surgery because of medical comorbidities. Recent advances in endoscopic technology with the development of better optics, actively deflecting telescopes, and adjunctive instrumentation made it possible for us to diagnose and stage more accurately patients with upper urinary TCC. In fact direct visualization of the tumor allows obtaining a tumor biopsy and selective urine cytol- ogy. Tumor grading in this setting is very accurate and is 90% in agreement with the grade of the final pathological specimen. Unfortunately ureteroscopic biopsy is unre- liable in determining stage (8). However several studies have suggested a good corre- lation between the grade of TCC and the stage of the tumor (9,10) and high accuracy of the Computed tomography (CT) scan in detecting evidence of tumor extending beyond the wall of the ureter or renal pelvis (11). Therefore the combination of low grade on biopsy and absence of frank extension outside of the urinary tract by CT scan strongly suggests the disease is superficial (12,13). These criteria create a new subset of patients with small and low-grade tumors that can potentially be managed by endo- scopic management only, even in the presence of a healthy controlateral kidney (14). Although the cancer-related risks are greater for any treatment short of the gold stan- dard nephroureterectomy, some patients are better treated by parenchymal sparing sur- gery, provided they know the risks and are committed to vigilant follow-up. Both ureteroscopic and percutaneous tumor resection are possible and are used in selected centers for up to 15% of patients with upper urinary TCC (15). The percutaneous access is preferred for larger tumors located proximally in the renal pelvis and or upper ureter. The main advantage of the percutaneous approach is the abil- ity to remove a larger tumor volume from any portion of the collecting system owing to the use of instruments with larger working channels, which allows better visualization and faster resection. Deeper biopsies can be obtained when compared to those taken with ureteroscopy, whereas the percutaneous approach may avoid the limitations encountered even by flexible ureteroscopy, especially in complicated caliceal systems or areas difficult to access, such as the lower pole calyx or the UUT of patients with uri- nary diversion. Access to any renal unit is possible irrespective of any prior operative intervention such as urinary diversion. With a percutaneous approach, the established nephrostomy tract can be maintained for immediate postoperative nephroscopy and administration of topical adjuvant therapy. The main disadvantage with the antegrade access is the increased morbidity compared to ureteroscopy. Nephrostomy tube placement has inherent risks and therefore requires 254 Varkarakis and Jarrett inpatient admission. In addition, loss of urothelial integrity and exposure of nonurothelial surfaces to tumor cells carries the risk for tumor seeding along the nephrostomy tract (16). INSTRUMENTATION Imaging Guidance • C-arm configuration fluoroscopy equipment (preferred) or • Real-time diagnostic ultrasonography or • CT fluoroscopy Access Equipment • 18 or 21-gage needle for puncture of the collecting system • Guidewires: 0.018-, 0.035-, 0.038-in.; stiff or soft bodied; straight or angled tipped; soft or hard tipped; Teflon or hydrophilic coated • Conversion catheter • Fascia incising needle Dilatation and Maintenance of the Nephrostomy Tract • Progressive fascial dilators • Amplatz renal dilator sets • Metal coaxial dilators • High-pressure balloon systems Tumor Resection/Ablation • Working Amplatz or plastic sheath • Rigid or flexible nephroscope • Resectoscope • Ho:YAG or Nd:YAG laser • Foley-type urinary drainage catheters • Self-locking pigtail nephrostomy catheters TECHNIQUE Patient Preparation Preoperative evaluation should include a coagulation profile with negative urine cul- tures. We favor a single stage approach for access, tract dilatation, and tumor resection. Patient Positioning and Stent Placement Anesthesia induction is usually performed in the operating room but on the patient’s preoperative stretcher. After the patient is intubated and ready from an anesthesia end point the patient is flipped into the prone position on the operative table. Use of two gel- foam rolls placed under the patient allows the flank area of interest to be presented in a better manner. After patient positioning is complete, cystoscopy is performed with the patient in a prone position and an open-ended ureteral catheter is placed in the renal pelvis. The use of the flexible cystoscope allows the surgeon to evaluate the bladder and catheterize the ureter even after the patient has been moved in the prone position. Alternatively anesthesia induction on the operative table and stent placement with the patient in the supine position can be performed but we have found that changing position is less cumbersome when the patient is simply rolled off the preoperative Chapter 15 / Percutaneous Management of UUT TCC 255 stretcher. The ureteral stent is available for retrograde injection at all times during the operation. Finally the patient is prepped and draped in the standard sterile fashion. Establishment of the Nephrostomy Tract Contrast medium is injected through the ureteral catheter to define the caliceal anatomy and tumor location. A percutaneous nephrostomy tract is established through the desired calyx. In some cases additional percutaneous accesses are required to resect all tumor com- pletely. Access under the 12th rib is usually preferred. Supracostal approaches may be used if necessary but at the risk of pleural injury. Tumors in peripheral calyces are best approached with direct puncture distal to the tumor (Fig. 1). Disease in the renal pelvis and upper ureter is best approached through an upper or middle pole (Fig. 1) access to allow scope maneuvering through the collecting system and down the ureteropelvic junction. After a needle is passed through the desirable calyx and a guidewire is manipulated prefer- ably down the ureter, the tract is then dilated using either sequential (Amplatz) or balloon dilatation so as to accommodate a 30-Fr sheath. Access to the desired calyx and correct positioning of the nephrostomy tract is crucial to the success of the procedure and should be done by the urologist or by the radiologist after direct consultation with the operating surgeon. After 30-Fr is reached, the nephroscope is inserted and the ureteral catheter is grasped, brought out of the tract, and exchanged for a stiff guidewire, thus providing 256 Varkarakis and Jarrett Fig. 1. Nephrostomy tract puncture site. Position of the nephrostomy is important for successful per- cutaneous resection of transitonal cell carcinomas of the renal collecting system and upper ureter. Tumors located in peripheral calyces (A–C) are best approached by direct puncture. Tumors located in the renal pelvis and upper ureter (D,E) are best approached by puncture to an upper or middle calyx. (Reprinted from ref. 17 with permission from Elsevier.) both antegrade and retrograde control. This is the second safety guidewire and helps maintain access should the original wire be inadvertently removed. Biopsy and Definitive Therapy Through the 30-Fr inner diameter nephrostomy sheath, which is used to maintain a low-pressure system, the collecting system is evaluated thoroughly using rigid and flexible endoscopes when necessary (Fig. 2). Any suspicion of upper ureteral involvement Chapter 15 / Percutaneous Management of UUT TCC 257 Fig. 2. Technique for percutaneous removal of transitional cell carcinomas of the renal collecting sys- tem. (A) The tumor is removed to its base with the big biopsy forceps and its base after being biop- sied in fulgurated. (B) Alternatively the tumor may be resected using the standard resectoscope. (C) For tumors smaller in size laser ablation can be used. (D) Laser fibers through flexible scopes can be used to reach tumors located even in the most difficult of positions. (Reprinted from ref. 17, with permission from Elsevier.) warrants antegrade ureteroscopy. After identification, cold-cup biopsies of the tumor (if not already sampled) and surrounding mucosa are performed to evaluate the extent of the disease and to rule out the possibility of carcinoma in situ. If the tumor is small enough the cold-cup biopsy forceps can be used also for complete tumor removal. In such a case, the bulk of the tumor is grasped using forceps (Fig. 2) and removed in piecemeal fashion until the base is reached. A separate biopsy of the base is performed for staging purposes and the base is cauterized using a Bugbee electrode and cautery. Low-grade papillary lesions on a thin stalk are easily treated in this manner with mini- mal bleeding. Alternatively a cutting loop (Fig. 2) from a standard resectoscope is used to remove the tumor to its base. Because the relatively small capacity of the renal pelvis, the specimen must be removed after each loop and irrigation drained in order to keep visualization optimal and prevent migration of specimen. Once again, the base should be resected and sent separately for staging purposes. This approach is more effective for larger broad based-tumors for which simple debulking to a stalk is not possible. In addi- tion, when resecting care must be taken not to go too deep, because the pelvicalyceal system lacks a thick muscle layer and, therefore, perforation with parenchymal and vas- cular injury is always possible. Alternatively a Holmium:YAG or Ho:YAG or Neodymium:YAG (Nd:YAG) laser (at set- tings of 25–30 and 15–20 W respectively for three exposures) can be used to ablate the tumor after an adequate cold-cup biopsy has been obtained (Fig. 2). Some authors (8) pre- fer using a combination of both. The Nd:YAG laser can be used to coagulate the major vol- ume of tumor because it can penetrate to several millimeters, while the coagulated tissue can then be removed with the Ho:YAG laser taking advantage of its more shallow penetration which makes its use more controllable (19). The ability to control the energy settings and the fact that the thermal effect on adjacent tissues declines with distance makes laser energy safe especially for the thin pelvic/ureteral wall. In fact, the lower risk of perforation and the absence of bleeding, decrease the risk of stricture and tumor cell extravasation as well. Other means of tumor resection have been used as well but in fewer patients. Nakada et al (20) reported the use of electrovaporization using high levels of pure cut energy for ablation of relatively large tumors. Electrovaporization was found to be effective, safe, fast, and simple in use, but cold-cup biopsies were necessary before the treatment in order to establish a diagnosis. At the end of the procedure, a 24-Fr nephrostomy tube is always left in place. This access can be used for second look follow-up nephroscopy to ensure complete tumor removal. Second-Look Nephroscopy Follow up nephroscopy is performed 4 to 14 days later to allow for adequate healing (Fig. 3). The tumor site is identified and any residual tumor is removed. If no tumor is identified the base should be biopsied and treated using cautery or the Nd:YAG laser (15–20 W and 3-second exposures) because of its very superficial effect. The nephro- stomy tube can be removed several days later if all tumors have been resected. Some authors advocate a third look with random biopsies before the nephrostomy tube is finally removed (20). If the patient is being considered for adjuvant topical therapy then a small 8-Fr nephrostomy tube is left to provide access for instillations. The nephrostomy tube is removed after the patient successfully tolerates clamping of the tube for several hours. 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