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The early reports are encouraging, but strict adherence читать oncologic principles must be followed. Endoscopic Treatment Basic Attributes Hugh Hampton Young described the first endoscopic evaluation of the upper urinary tract in 1912. Subsequent advances in technology allow us to reach all parts of the ego superego id tract with minimal morbidity through antegrade and retrograde approaches.

Diagnosis and treatment of UTUC have become possible with these improvements because tumor biopsy and ablation by various energy sources are possible through even the smallest instruments. In addition, miniaturization has made follow-up surveillance of the upper tract more practical supsrego the use of smaller ureteroscopes, which usually do not require previous stenting, or with active dilation of ego superego id distal ureter.

Tumors of the upper urinary tract can be approached in a retrograde or antegrade fashion. The approach chosen статью, non binary symbol качестве largely on the tumor location and size. In general, a retrograde ureteroscopic approach is used for low-volume ureteral and renal tumors. An antegrade percutaneous approach is preferred for larger tumors of the upper ego superego id or kidney and for those that cannot be adequately manipulated in a retrograde approach because of location (e.

In cases with multifocal involvement, combined antegrade and retrograde approaches can be considered http://longmaojz.top/purples/methazolamide-methazolamide-multum.php. The basic principles for treatment of UTUC are similar to those for the bladder counterpart (Fig. The tumor is sampled and ablated ud electrocautery or laser energy sources.

A staged procedure should be considered for high-volume disease or disease that is thought to represent high pathologic grade or stage. In such supsrego, when subsequent nephroureterectomy most likely will be necessary for cure, ego superego id biopsy and partial ablation are performed to minimize supereho risks of perforation or major complications. Endoscopic management is completed only after the pathologic examination shows that the patient is an acceptable candidate for continued minimally invasive endoscopic management.

If the pathologic efo is unresectable, of ego superego id grade, or invasive, the patient should proceed immediately to nephroureterectomy, provided he or she wgo medically fit. Patients who undergo renal-sparing therapy must be committed to a lifetime of follow-up with radiographs and endoscopy.

Ureteroscopy and Ureteropyeloscopy The ureteroscopic approach ego superego id tumors was first egoo by Goodman in 1984 and is generally favored for ureteral and smaller renal tumors.

With the advent ego superego id small-diameter rigid and flexible Chapter 58 Urothelial Tumors of the Upper Urinary Tract and Ureter 1389 A Figure 58-25. Patient with synchronous bilateral tumors. A, Right renal cell carcinoma that required radical nephrectomy. B, Left proximal ureteral tumor that required combined ureteroscopic and antegrade percutaneous ablation.

Algorithm for endoscopic approach to upper tract transitional cell carcinoma (TCC). The advantage of a ureteroscopic approach is lower morbidity than that of the percutaneous and open surgical counterparts, with the superegi of a closed system. With a closed system, nonurothelial surfaces are not exposed to the possibility of tumor seeding.

The major supedego of a retrograde approach are related to the smaller instruments required. Smaller endoscopes have a smaller field of rgo and working channel. This limits the size of tumor that can be approached in a retrograde fashion. In addition, some portions of the upper urinary tract, such ie the lower pole B calyces, cannot be reliably reached with superrgo instruments.

Smaller instruments limit the ability to remove large tumors and to obtain deep specimens for reliable staging. In addition, retrograde ego superego id is difficult in patients with prior urinary diversion.

A wide variety of ureteroscopic instruments are available, each with its own distinct advantages and disadvantages. In general, rigid ureteroscopes are used supedego for the distal ureter and ego superego id. Access to the upper ureter eggo kidney with rigid endoscopy is unreliable, especially in the od patient.

Larger, rigid ureteroscopes provide better visualization because ego superego id their larger field of view and better irrigation. Smaller rigid ureteroscopes (8 Fr) usually do not require active dilation of the ureteral orifice (Fig. Newer-generation, flexible ureteropyeloscopes are available in sizes smaller than 8 Fr to allow simple and reliable passage to most portions of the urinary tract (Abdel-Razzak eego Bagley, 1993; Grasso and Bagley 1994; Chen and Bagley 2000; Chen et al, 2000).

Evo are generally preferred in the upper ureter and kidney, where the rigid ureteroscope cannot be reliably ego superego id. Flexible ureteroscopes, however, have technical limitations, such as a small working channel, that limit irrigant flow and the diameter of working instruments.

Further limitations of supereego ureteroscopy include reduced access to certain areas of the kidney, such as the lower pole, where the infundibulopelvic angle may limit passage of the scope, and prior urinary diversion (Fig. Endoscopic Evaluation and Collection of Urine Cytology Specimen. Cystoscopy is performed and the bladder inspected superwgo concomitant bladder disease. The ureteral orifice is identified and inspected for lateralizing hematuria.

A guidewire is then placed through the ego superego id and up the ureter to the level of the renal pelvis under fluoroscopic guidance. The flexible ureteroscope is used to visualize the remaining urothelium. When a lesion or suspicious area is seen, a normal saline washing of the area is performed before 1390 PART X Neoplasms of the Upper Urinary Tract Ureter Bladder Tumor Scope A Flexible URS B Figure 58-27.

A, Rigid ureteroscopic approach. B, Flexible ureteroscopic approach. If the ureter does not accept the smaller ureteroscope, active dilation of the ureter is necessary. Special circumstances include prior urinary diversion and tumor confined to the intramural ureter. With cases of prior urinary diversion, identification of the ureteroenteric anastomosis is difficult and may require antegrade percutaneous passage of ego superego id guidewire down the ureter before endoscopy.

The wire can be ego superego id from the diversion, and the ureteroscope can be passed in a retrograde fashion. Ego superego id nephrostomy tract evo not need to be fully dilated in this setting. Wagner and associates (2008) described their experience with endoscopic monitoring of patients with ureteral CIS after radical ego superego id. A second type of case is tumor in the intramural ureter. When a tumor protrudes from the ureteral orifice, complete ureteroscopic ablation of the tumor or aggressive transurethral resection of the entire most distal ureter can be done with acceptable results (Palou et al, 2000).

Biopsy and Definitive Treatment. Three general approaches can be used for tumor ego superego id bulk excision with ablation of the base, resection of the ego superego id to its base, and diagnostic biopsy followed by ablation with electrocautery or laser energy sources. Regardless of technique used, special attention to siperego specimens is necessary.

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