Introduction: The utility of holmium laser in the management of upper tract urothelial carcinoma is well-known, as urologists often employ its use to ablate such tumors while achieving a minimally-invasive approach. Intraureteral tumors have traditionally posed a unique challenge, as cup biopsy often fails to accurately stage the tumor. We present the novel application of the holmium laser to perform an en bloc resection of an intraureteral urothelial carcinoma.
Methods: The patient is 72-year-old female with a history of laryngeal carcinoma and is status-post chemoradiation, currently with no evidence of disease. She presented to the emergency department with right-sided flank pain, and she was found to have a five-centimeter enhancing ureteral mass on cross-sectional imaging. The patient underwent ureteroscopic biopsy which revealed low grade, Ta urothelial carcinoma, and urine cytology was positive. After a thorough discussion with the patient regarding her treatment options, the patient elected for a minimally-invasive treatment approach. We provide a narrated video that highlights the steps involved in the en bloc resection of her intraureteral tumor.
Results: The tumor was successfully detached from the ureteral wall using the holmium laser and blunt traction. An endoscopic retrieval basket was then used to remove the specimen intact. A retrograde pyelogram performed after the completion of the resection showed no evidence of contrast extravasation. Pathologic examination of the specimen revealed high grade upper tract urothelial carcinoma with focal suspicion for lamina propria invasion.
Conclusions: Holmium laser en bloc resection of intraureteral tumors is feasible in carefully selected cases. This approach may provide a more accurate staging of upper tract urothelial carcinoma when compared to traditional cup biopsy. Further studies are needed to assess the safety and efficacy of this approach.