Surgical and minimally invasive management of upper urinary tract tumours

Primary urothelial carcinoma (UCa) of the upper tract (ureter and renal pelvis) is a relatively rare urological cancer. The disease usually manifests as haematuria and is often multifocal with a high tendency for local and systemic recurrences. The current standard of surgical treatment for patients with upper tract urothelial tumours is complete excision of kidney, ureter and a cuff of urinary bladder (radical nephroureterectomy). As an approach for all types of upper tract transitional cell carcinoma, it has been debated, especially with the introduction of minimally invasive approaches for selected group of patients. Laparoscopic radical nephrouretectomy has been adopted as an alternative to open surgery for the past couple of decades. Endoscopic approaches (percutaneous or ureteroscopic) for selected patients with or without adjuvant treatments are being practised at many centres across the world with good oncological and functional outcomes. Role of adjuvant endocavitary or systemic chemotherapy is under focus to prevent recurrences. Higher local recurrences in endoscopic management of these tumours could be attributed to the failure to visualize these lesions using white light ureteroscopy and this is being addressed with new technique such as blue light uretersoscopy and narrow band imaging. The role of pre-operative ureteroscopic biopsy in the era of multidetector CT urogram remains to be examined. This chapter aims to focus on surgical and minimally invasive treatment of the disease with objectives to discuss some of the recent advancements and delineate areas of future work.