對於透析病患罹患泌尿道上皮細胞癌的治療策略

楊浩誌、黃雲慶、陳志碩

財團法人嘉義長庚紀念醫院 外科部 泌尿科

Treatment Strategy for Dialysis Patient with Urothelial Carcinoma

Hao-Chih Yang, Yun-Ching Huang, Chih-Shou Chen

Division of Urology, Department of Surgery, Chang Gung Memorial Hospital, Chiayi, Taiwan

Purpose: Patients with end-stage renal disease (ESRD), who are on dialysis, have an increased risk of developing urological cancers, including renal cell carcinoma (RCC) and urothelial carcinoma (UC). The role of one-stage complete urinary tract extirpation (CUTE, i.e., bilateral nephroureterectomy with cystectomy or cystoprostatectomy) in dialysis patients with UC remains controversial. The present study compares patients who have undergone one-stage versus multi-stage CUTE.

Materials and Methods: We retrospectively reviewed dialysis patients with newly diagnosed UC, who underwent CUTE at our hospital from January 2004 to December 2015. The inclusion criteria were dialysis patients with pathologically confirmed UC and a final status of CUTE. Patients who started on dialysis after initial radical surgery were excluded. Demographic, medical, perioperative, and pathologic features were collected to determine variables associated with oncologic outcomes.

Results: 84 and 27 dialysis patients, undergoing one-stage and multi-stage CUTE, were enrolled in this study. Although there was no significant difference in mortality between the 2 groups (p=0.333), all 5 (4.5%) patients with Clavien–Dindo grade 5 complications were from the one-stage CUTE group. On multivariate logistic regression analysis, advanced age (p=0.042) and high Charlson comorbidity index (CCI) (p=0.000) were related to postoperative major complications. Compared with multi-stage CUTE, one-stage CUTE had no overall, cancer-specific, and recurrence-free survival benefits (all p > 0.05). According to multivariate analysis with Cox regression, age > 70 years (HR 2.70, 95% CI 1.2–6.12; p=0.017), CCI ≥ 5 (HR 2.16, 95% CI 1.01–4.63; p=0.048), and bladder cancer stage ≥ 3 (HR 12.4, 95% CI 1.82–84.7; p=0.010) were independent, unfavorable prognostic factors for the overall survival.

Conclusion: One-stage CUTE is not associated with superior oncologic outcomes, and all perioperative mortalities in our series occurred in the one-stage CUTE group. Our data do not support prophylactic nephroureterectomy and/or cystectomy for uremic patients with UC.