The Graft Ureteral Cancer: A Surgical Method of Graft Kidney Preservation and Planning for Future Upper Tract Follow-Up
Fang-Yu Cha1, Chao-Yuan Huang1, Yu-Chieh Tsai2, Jia-Yuh Sheu3, Jeff S Chueh1 Department of Urology1, Oncology2, and Medical Education3, National Taiwan University Hospital, Taipei, Taiwan
A 30-year-old Taiwanese woman had received a kidney transplant from her aunt 22 years ago. She was diagnosed with high-grade urothelial carcinoma (UC) of the left native renal pelvis and ureter ten years later. She underwent a the retroperitoneal hand-assisted laparoscopic nephroureterectomy and bladder cuff resection on 2010/07/27. The pathology revealed pT2N0M0 in the left ureter and pT1N0M0 in the left renal pelvis, with diffuse carcinoma in situ(CIS). Bladder cancer with high grade UC and CIS was diagnosed two years later after the left nephroureterectomy. Transurethral resection of bladder tumor was performed every six months, yet there was still frequent bladder recurrences.
Besides, deteriorating graft renal function with graft hydronephrosis was noted in 2019 and a pigtail percutaneous nephrostomy (PCN) over the graft kidney was inserted. Further image study showed increased soft tissue at the lower segment of the graft ureter. Biopsy was taken and it showed non-invasive high-grade papillary UC. She underwent graft PCN every three months thereafter.
However, image follow up in 2021 disclosed right native ureteral tumors with hydronephrosis and cortical thinning. Surgical intervention was suggested, but she and her family insisted on preserving her graft kidney. Thus, an antegrade flexible ureteroscopy exploration of graft pelvis and ureter was performed via her PCN tract first to evaluate the extent of the graft ureteral tumor and it showed large sessile hypervascular tumors at middle and distal ureter; the tumors extended below 6cm from graft ureteropelvic junction (UPJ), but the graft pelvis, all calyces and the upper ureter were tumor-free. Also, antegrade pyelography confiromed total obstruction at middle graft ureter and there was no filling defect in graft kidney calyces. Retrograde pyelography showed total graft ureter length around 14cm. Cystoscopy revealed no biopsy-proven tumor in the bladder.
A laparoscopic right native nephroureterectomy with bladder cuff resection and distal graft ureteral segmental ureterectomy, along with Boari flap from her urinary bladder was done 2021/10/06. Bladder instillation of chemotherapy was performed during the right laparoscopic nephroureterectomy. Intraoperative ultrasound was used to check the position and depth of the graft ureteral tumor and a surgical clip was clamped over the proximal graft ureter to prevent urinary reflux and lower the chance of tumor seeding. The distal part of the graft ureter with graft ureteral tumor was resected. Frozen section was sent and showed adequate safety margin. A trapezoid bladder wall was dissected, and further flipped over to reach graft renal pelvis. Suturing with 4-0 monocryl was performed between the residual graft renal ureter and the bladder wall Boari’s flap. Traditionally, creation of a submucosal tunnel was an important step in anti-refluxing ureteric implantation. However, in order to provide adequate quality of examination for further endoscopic follow up, submucosal tunnel was not done intentionally in this case. The final pathology revealed pT3 diseases in both right native kidney and graft ureter. All the margins including the graft proximal/distal ureter and right native urinary bladder cuff margin were uninvolved by invasive carcinoma. She had 6 coursed of adjuvant chemotherapy. Further image follow-up, cystoscopic and retrograde ureteroscopy biopsy showed no signs of recurrence.