What is the surgical management for a patient with a double collecting system and urothelial cancer?

Surgical Management of Double Collecting System with Urothelial Cancer

For urothelial carcinoma in a double collecting system, radical nephroureterectomy with bladder cuff excision remains the standard treatment for high-risk disease, while kidney-sparing approaches such as hemi-nephroureterectomy can be considered for low-risk tumors confined to one moiety in carefully selected patients. 1, 2

Risk Stratification Determines Surgical Approach

The surgical strategy hinges on tumor risk classification:

High-Risk Disease (High-Grade, Invasive, or Multifocal)

• Radical nephroureterectomy with bladder cuff excision and regional lymphadenectomy is the definitive treatment for high-risk upper tract urothelial carcinoma (UTUC), regardless of the presence of a double collecting system 1, 3
• This approach removes the entire kidney, both collecting systems, the full length of ureter(s), and a cuff of bladder to ensure complete oncologic resection 1
• Regional lymphadenectomy should be performed for high-grade tumors, though the extent remains at surgeon discretion given variable lymphatic drainage patterns along the ureter 1, 4

Low-Risk Disease (Low-Grade, Non-Invasive, Unifocal)

• Kidney-sparing surgery is the preferred approach for low-risk UTUC, as survival outcomes are similar to radical nephroureterectomy without the morbidity of complete kidney function loss 1, 3
• For double collecting systems specifically, hemi-nephroureterectomy with distal ureterectomy and bladder cuff can be performed when tumor is confined to one moiety 2
• This involves removing only the affected upper or lower pole collecting system, its ureter, and bladder cuff, while preserving the unaffected moiety with ureteral reimplantation if necessary 2

Specific Technical Considerations for Double Collecting Systems

Anatomic Assessment

• Preoperative imaging with CT urography, MRI urogram, or retrograde pyelography is essential to delineate the anatomy of both collecting systems and identify which moiety harbors the tumor 1
• Determine whether the duplication is complete (separate ureters to bladder) or incomplete (ureters join before bladder), as this affects surgical planning 2

Surgical Decision Algorithm

For tumors in one moiety only:

• Low-grade, small (<2 cm), non-invasive → Consider hemi-nephroureterectomy or endoscopic management 1, 2
• High-grade, large (≥2 cm), or invasive → Radical nephroureterectomy with complete removal of both collecting systems 1

For tumors involving both moieties or multifocal disease:

• Radical nephroureterectomy is mandatory regardless of grade, as kidney-sparing approaches cannot achieve adequate oncologic control 1

Critical Surgical Pitfalls

• Do not perform partial ureterectomy without bladder cuff excision - the entire intramural ureter must be removed to prevent recurrence at the ureteral orifice 1
• Ensure muscle is present in the specimen - absence of muscularis propria in the resection indicates inadequate sampling and potential understaging, which occurs in 49% of cases 3, 5
• Avoid endoscopic management for high-grade disease - technical limitations of upper tract sampling lead to understaging, and up to 50% of patients have residual disease on second-look procedures 1, 4

Neoadjuvant and Adjuvant Considerations

• Strongly consider neoadjuvant cisplatin-based chemotherapy before nephroureterectomy for muscle-invasive disease (≥T2), as this is particularly important given the obligatory kidney function loss that occurs with radical surgery 3, 4
• Adjuvant chemotherapy should be considered for pathologic T3-4 disease or positive lymph nodes if neoadjuvant treatment was not given 1, 3
• The loss of renal function after nephroureterectomy may preclude cisplatin-based adjuvant chemotherapy, making neoadjuvant treatment the preferred timing 4

Surveillance After Kidney-Sparing Surgery

For patients who undergo hemi-nephroureterectomy:

• Second-look ureteroscopy within 8 weeks is mandatory to assess for residual disease, as up to 50% may have persistent tumor 1
• Cystoscopy every 3 months initially, with intervals adjusted based on findings 1
• CT urography or MRI urogram every 1-2 years to monitor the remaining collecting system for recurrence 3, 5
• Cross-sectional imaging (CT chest/abdomen/pelvis) to evaluate for parenchymal recurrence or metastatic disease, as progression can occur despite apparent local control 6