Percutaneous nephroscopic resection of pyelocaliceal transitional cell carcinoma in solitary kidney
A 72-year-old male presented with intermittent right flank pain and microscopic hematuria for 4 weeks. His left kidney, ipsilateral ureter, and bladder cuff had been removed due to left renal pelvic carcinoma 7 years before. A computed tomography of urinary tract (CTU) demonstrated an intraluminal filling defect, measuring 2 × 2 cm, with hydrocalycosis in middle and lower calyces [Figure and ].\nThere was no evidence of metastases. Since urine cytology was positive for urothelial carcinoma for three times, retrograde ureteroscopy was not performed.\nGiven the chronic renal insufficiency and a solitary kidney, tumor resection with monopolar electrocautery through percutaneous access was carried out after various options were discussed with the patients. With the patients under general anesthesia and in the prone position, the percutaneous nephrostomy puncture of the affected kidney was performed under both C-arm fluoroscopic and ultrasonic guidance. The dilated middle calyces were chosen for puncture. The tract was dilated to 30 Fr before an Amplatz sheath was inserted. A 24 Fr resectoscope (R. Wolf resectoscope) with monopolar electrocautery was used to resect the tumor (settings: Cut, 120; coagulation, 60) through the Amplatz sheath. A sessile cauliflower-like lesion was seen through the resectoscope. In case 1, CT scan of the abdomen on the 4th postoperative day revealed a tumor-like lesion measuring 1 × 1 cm in the middle of the pelvis. A second look was therefore performed for complete removal of the residual tumor 2 weeks after initial resection.\nIn both cases, the ureteropelvic junction (UPJ) appeared to be non-obstructed with a normal contour after the resection. A 22 Fr nephrostomy tube and 6 Fr double J stent were inserted for indwelling drainage.\nThe postoperative courses of the patients were uneventful. The renal function turned to be normal after 3 months in case 1. The serum creatinine increased to 175 umol/l transiently in case 2; so, the patient was discharged 5 days after the surgery. The nephrostomy tube was removed on the 4th postoperative day when CT scan showed no residual cancer in the renal pelvis. Pathologic study confirmed a TCC of T1G1.\nIn an effort to reduce the risk of tumour recurrence and progression, 80 mg of Bacillus Calmette-Guérin (BCG) in 100 ml of diluents was administered weekly via intravesical instillation for topical therapy. Both patients were followed up at 3 months with negative cytology and CTU which suggested free of any filling defects in collecting system. At 6 and 9 months, the patients remained free of recurrence in both collecting system and bladder, and maintained stable renal function. In addition, there was no evidence of metastatic disease.