UroToday - Large urothelial carcinoma of the renal pelvis poses a diagnostic as well as surgical challenge to the urologist. This type of malignancy is frequently mistaken preoperatively for renal cell cancer due to its low incidence (10% of all renal malignancies) especially when associated with tumor extension into the inferior vena cava. The presence of a large renal mass should therefore not dissuade the urologist to perform cystoscopy and cytology in order to complete hematuria work-up. Opening the specimen in the operating room will provide clues for the origin of the tumor.

The surgical management of large urothelial carcinoma of the renal pelvis is radical nephro-ureterectomy, which may be considerably impeded by major desmoplastic reaction and rich collateralization. Particularly in cases of inferior vena cava involvement liver mobilization is required to achieve complete tumor resection.

The department of urology and division of transplantation surgery at University of Miami Miller School of Medicine have collaborated for over 10 years on cases of renal tumors where liver mobilization and inferior vena cava exploration is anticipated. Dr. Gaetano Ciancio bridges the two specialties having completed a urology residency and transplant fellowship at University of Miami. His unique interface allowed the use of liver transplantation techniques for the resection of large renal tumors with or without inferior vena cava involvement. While operative times (mean 7.5 hours) and blood loss (mean 1.5 L) were significant in our series, the tumor could be completely and safely resected in all patients. Nevertheless, mean postoperative survival was only 6 months secondary to disease recurrence. Neoadjuvant chemotherapy may significantly improve survival in such patients as shown previously for muscle-invasive urothelial carcinoma of the bladder, however, it relies on accurate preoperative diagnosis.

A prospective clinical trial is needed to evaluate the impact of neoadjuvant chemotherapy on respectability and disease-specific survival.

Wolfgang H. Cerwinka, MD1, Murugesan Manoharan, MD, Mark S. Soloway, MD, and Gaetano Ciancio, MD as part of Beyond the Abstract on UroToday.

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