Laser therapy for upper urinary tract transitional cell carcinoma: indications and management.

CONTEXT

Ureteroscopically guided laser techniques are commonly used in the treatment of upper urinary tract transitional cell carcinoma (UUTT); however, there is an ongoing debate with regard to indication and management.

OBJECTIVE

To review the indication, feasibility, and treatment outcome of laser application for definitive endoscopic treatment of UUTT, focusing on technical aspects of different laser devices and their impact on tissue.

EVIDENCE ACQUISITION

PubMed and Medline were searched for reports on laser therapy in UUTT from 1980 to 2008, with particular focus on the technical background of various laser systems.

EVIDENCE SYNTHESIS

For decades, nephroureterectomy has been considered the gold standard for treating UUTT. With the intent to preserve functioning renal parenchyma, minimally invasive approaches, initially advocated for patients requiring a nephron-sparing approach (ie, single functioning kidney, renal insufficiency or significant comorbidities), have gained widespread acceptance due to advances in ureteroscopy, percutaneous renal surgery, and laparoscopy. Ureteroscopically guided laser ablation has been used successfully, resulting in recurrence rates ranging from 31% to 65% and disease-free rates of 35% to 86%, depending on stage and grade at diagnosis.

CONCLUSIONS

To obtain the highest treatment success, the initial staging and grading of the tumour is crucial. Because low-grade tumours rarely if ever progress in stage or grade, the success rate of ureteroscopic therapy parallels that of endoscopic resection of identical bladder tumours. In the treatment of higher grade, advanced tumours, ureteroscopic therapy is less likely to be curative, and thus, endoscopic manoeuvres can only be palliative. Due to the relatively low prevalence of this tumour and the lack of comparable randomised, multicentre trials, the indications for an endoscopic laser treatment option has to be defined based on the patient's individual situation.