Introduction:
The urothelial tumor at the level of the renal pelvis and ureter represents 5-10% of urothelial carcinoma of the upper urinary tract. Of these, its highest incidence is located at the renal pelvis level (60%). Bilateral involvement occurs in 1.6-6% of cases. The treatment of choice is surgical, but in some cases, as low-grade lesions, solitary kidney or renal failure; you can perform kidney-sparing managenement. This treatment can be complemented with instillation with BCG or mitomycin C in the upper urinary tract. This latter option implies an increase in the need of cystoscopy. We present the case of a patient with bilateral urothelial carcinoma of the upper urinary tract with endoscopic management plus instillation of Mitomycin C using a Black-star magnetized catheter.
Clinical case:
54-year-old male patient who consulted for the first time due to episode of hematuria. Cystoscopy was performed without objectifying the lesion at the bladder level, which is why UroTC was performed, objectifying a filling defect at the level of the proximal right ureter. In February 2017 he underwent a right nephroureterectomy laparoscopy with an anatomopathological result of high-grade urothelial carcinoma pT2N0R0. Subsequently performs successive controls according to protocol established by European clinical guidelines.
During the follow-up, very poor tolerance was observed for the performance of control cystoscopies.
In UroTC, requested in November 2018, a 6x9 mm filling defect was found in the left renal pelvis, highly suggestive of the neoformative process.
Given the patient's age, solitary-kindey and the size of the lesion we decided to perform an endoscopic treatment. A neoformative lesion was observed at the level of the left renal pelvis, which is treated, in its entirety, by Holmium laser after a biopsy was taken; left JJ catheter is left magnetized Black-star. The anatomopathological result turned out to be high-grade urothelial carcinoma pTaG3.
Local treatment with chemotherapeutic agent (Mitomycin C) with a retrograde approach during 6 sessions + subsequent endoscopic control.
Given the poor tolerance of the patient to cystoscopy, we chose to tune the urinary tract with JJ Black-star catheter, thus reducing the need for cystoscopy.
Next we explain procedure (images):
1. Material
2. Magnetic probe for catheter removal + black-star catheter
3. Removal of catheter and introduction of open-end ureteral catheter Pollack 5Fr and pass of guide to left renal pelvis.
4. Retrograde pyelography and placement of ureteral catheter in affected calyx. Placement of Foley bladder catheter 16Ch bladder drainage.
5. Ureteral instillation with Mitomycin C
After completion of the 6 sessions, we perform a satisfaction questionnaire of cystoscopy vs retrograde instillation with a Black-star catheter, aiming at a better tolerance to the procedure and fewer side effects with the Black-star catheter instillation. Likewise, it is proposed to the patient if a new instillation was necessary, which treatment option would be his option and he chose for instillation using a Black-star magnetized catheter.
Conclusions:
Endoscopic treatment of lesions in the renal pelvis and ureter is not standardized. It may be an option in patients with low grade tumors, solitary kidney or impaired renal function. The instillation of Bacillus-Calmette-Guerin or mitomycin C in the urinary tract by percutaneous nephrostomy or via ureteric stent is technically feasible after kidney-sparing management or for treatment of carcinoma in situ. However, the benefits have not been confirmed. In cases like our patient, it can be a good treatment option, as long as close follow-up is carried out.
In this work, we present the use of a Black-star magnetized catheter for the retrograde instillation of Mitomycin C, which avoids the need for cystoscopy to perform the procedure, considerably improving the patient's tolerance to treatment. This is an option to be taken into account in patients who have very poor tolerance to cystoscopy.
