Nephroureterectomy for Upper Tract Urothelial Cancer in Jaipur

• CT urogram: a CT scan with dye that outlines the inside of the kidney and ureter and shows a tumour as a gap in the dye.
• Urine cytology to look for cancer cells.
• Cystoscopy, because some people also have a tumour in the bladder.
• Ureteroscopy with biopsy: under anaesthesia, a thin semi-rigid or flexible ureteroscope is passed up through the bladder into the ureter and kidney to see the tumour and take a small sample. This gives the grade (low or high).
• Kidney function tests and often a renal scan, to know how well the other kidney works.
• Chest CT for staging.

See also blood in urine and our article on when to see a urologist for haematuria.

Rejoining the ureter to the bladder uses the same technique described on the ureteric reimplantation page.

Urothelial cancer can grow again in any part of the lining that is left. If the lower ureter were left behind, a new tumour could form in that stump. So the kidney, the full length of the ureter and a small cuff of bladder around the ureter’s opening are removed in one piece.

1. General anaesthesia is given.
2. In laparoscopic surgery, the kidney and upper ureter are freed through small ports, as in a laparoscopic nephrectomy. The kidney vessels are sealed and divided.
3. The ureter is followed down to the bladder. The bladder cuff is removed, often through a small cut low in the abdomen, and the bladder is stitched closed.
4. The specimen is removed whole in a bag, without cutting into it. Lymph nodes are removed for higher-risk tumours.
5. A catheter rests the bladder repair, and a drain is placed.

It usually takes three to five hours. Open surgery uses one longer cut or two shorter ones. A single dose of chemotherapy is often put into the bladder after surgery to lower the chance of a bladder tumour. Surgery is at ManglamPlus Medicity, using a laparoscopic camera and instruments, vessel-sealing devices, clips and a retrieval bag.

For a small, single, low-grade tumour, the kidney can sometimes be kept. Using a flexible ureteroscope passed through the urethra and bladder, the tumour is destroyed with a laser or removed with small instruments. There is no cut on the skin, and you usually go home in a day or two with a DJ stent for a few weeks.

The trade-off is closer watching. Biopsies can underestimate a tumour, and new tumours often appear in the lining, so repeat ureteroscopy is needed every few months at first, along with CT urograms and cystoscopies. If a tumour grows or turns out to be high-grade, nephroureterectomy is advised.

Call the clinic for fever, blood clots or no urine through the catheter, wound swelling or discharge, worsening belly pain, or leg swelling.

Possible problems include bleeding, injury to the bowel or other nearby organs, a urine leak from the bladder repair (usually settles with the catheter left longer), infection, blood clots, a change to open surgery, and a hernia at a wound. Kidney function will be lower afterwards. This matters because some chemotherapy drugs need good kidney function, so in some patients the oncologist and urologist discuss chemotherapy before surgery.

After nephroureterectomy, a new tumour can appear in the bladder in a significant number of people, usually within the first two years. Check cystoscopies are therefore done every three months at first and less often later. CT scans check the other kidney, the operated area and the chest.

The pathology report shows how deep the tumour went and whether lymph nodes were involved. For tumours that had grown deeper, medical oncologists may advise chemotherapy after surgery. Stopping smoking helps. See the overview of urology cancer surgery and bladder cancer treatment.