Surgical therapy and approaches

— In the field of upper urinary tract neoplasms there is a need to find a logical linear connection between staging and treatment with surgery performed according to the gravity of the neoplasm. The Authors consider the basic concepts of surgery, discussing the access route and best operation for each clinical situation plus the advantages and disadvantages. The case histories relating to 181 operated patients from the Treviso and Bergamo Units are reported, (141 total nephroureterectomies – of whom 14 with simultaneous cystectomy, 3 nephrectomies in high-risk patients, 6 pyelectomies or heminephrectomies, 19 segmental ureterectomies and 12 endourological procedures). Conservative therapy (rather than endourology) through segmental ureterectomy with removal of the bladder cuff and ureterocystoneostomy was preferred in neoplasms of the distal ureter. In fact, in these cases survival is in relation to the tumour stage and not the type of operation. Cases are reported where conservation of the renal emunctory necessitates conservative treatment. Results of radical therapy (80% of patients, justified by the high malignancy and multifocality of the neoplasms) showed recurrence in the bladder in 28%, contralaterally in 2% and a 5-year survival rate (according to Kaplan-Meyer) of 66%. With conservative treatment there was a high rate of local recurrences (33%) in the upper tract, but only 11 % after segmental ureterectomy for tumours of the pelvic ureter. In the Authors’ experience, total nephroureterectomy guarantees maximum extirpation whereas conservative surgery is the only form of treatment allowing complete tumour removal while maintaining, even if only partially, a renal emunctory.