V5-04: A Novel Approach to Intraureteral Resection of Neoplasms: En Bloc Laser Fulguration of Metastatic Renal Carcinoma
We present a novel approach to resection of a nodular mass in the ureter in the setting of metastatic clear cell renal cell carcinoma (ccRCC), via en bloc resection with a holmium laser. We provide narrated video and bulleted slides to highlight the key steps to safely and efficiently perform the procedure.
A 78-year-old male with a history of unclassified renal cell carcinoma metastatic to the adrenal gland, status post nephrectomy and adrenalectomy from time of diagnosis, presented with worsening contralateral hydronephrosis over the course of two years. A retrograde pyelogram demonstrated a filling defect in the proximal ureter, while CT imaging revealed hydronephrosis and the presence of a 1.0 cm nodular density in the proximal ureter. The ureter was dilated above and below this nodule with ureteral dilation extending to the ureterovesical junction. Ureteroscopy and biopsy were recommended. Under general anesthesia, evaluation of the urethra and bladder were normal. After carefully advancing a guidewire and then a semi-rigid ureteroscope into the ureter up to the proximal ureter, a single, calcified soft-tissue mass was observed protruding from the medial wall of the ureter. Using a no-tip four-wire nitinol basket, the mass was placed on traction away from the scope to expose the stalk. A 365-micron laser was inserted and directed towards the base of the lesion. Using 0.5 joules at a rate of 15 Hz, we were able to dissect the mass off the medial ureter, dissecting along the plane of the muscularis mucosa. Careful inspection and retrograde studies showed no extravasation from the ureter, and the tumor was withdrawn.
The procedure was completed in less than one hour without intraoperative or postoperative complications, with estimated blood loss of 5 mL. A stent was left indwelling to facilitate drainage of urine. Final pathology confirmed the diagnosis of metastatic ccRCC. Muscularis propria was present and uninvolved. The patient subsequently followed up with his medical oncologist.
En bloc laser resection of proximal ureteral masses can be safely and successfully performed in the right clinical setting. Given the potential benefit of en bloc resection, with more accurate assessment of tumor architecture and invasion depth, further study of this approach is warranted.
Funding: Supported by the Sidney Kimmel Center for Prostate and Urologic Cancers_x000D_ Dr. Bagrodia is funded by the Urology Care Foundation Research Scholars Program