上泌尿道泌尿上皮癌經根除性腎臟輸尿管併膀胱袖口切除術及拔除方式後膀胱復發之分析

林奇柏、陳一中、石宏仁、王百孚、林介山、張進寶、嚴孟意、黃勝賢、
陳俊吉、張建祥、陳柏華、潘岳

彰化基督教醫院 外科部 泌尿外科

Analysis for bladder recurrence of upper tract urothelial carcinoma following radical nephroureterectomy with transurethral bladder cuff excision and pluck method

Chi-Bo Lin, Yi-Zhong Chen, Hung-Jen Shih, Pai-Fu Wang, Jesun Lin, Chang-Pao Chang, Meng-Yi Yan, Sheng-Hsien Huang, Chun-Chi Chen, Jian-Xiang Zhang,
Pao-Hwa Chen, Pan Yueh

Division of Urology, Department of Surgery, Changhua Christian Hospital

Purpose:

            Upper tract urinary carcinoma (UTUC) cells have the ability to proliferate through urine and seed the underlying urothelium throughout the urinary system and patients who undergo simple nephrectomy for UTUC have a significant recurrence incidence of 33-70% in the residual ureteral stump. As a result, radical nephroureterectomy (RNU) with bladder cuff excision (BCE) is currently considered as the standard treatment for high-risk UTUC. Surgical methods of BCE include extravesical, intravesical and transurethral approach but there is still no consensus regarding oncological outcomes in current guidelines. In this study, we aimed to assess the outcome and risk factors of the transurethral approach with pluck method on intravesical recurrence.

Materials and Methods:

            We retrospectively reviewed the patients who underwent RNU with BCE from January 2010 to October 2023 in the Changhua Christian Hospital.  Patients as follows: (1) pathological diagnosis of urothelial carcinoma of renal pelvis or ureter, (2) pathological staging T1-4N0M0, (3) surgical method with transurethral resection (TUR) of bladder cuff (Pluck method) were enrolled. Statistical methods with cox regression were used to evaluate risk factors for bladder recurrence after RNU.

Results:

            A total of 149 patients were assessed, including 27 open, 97 laparoscopic, and 25 robotic surgeries. The clinical characteristics of the patients were listed in table 1. Among these patients, 37 (24.8%) developed bladder recurrence of urothelial carcinoma with a median follow-up time 34.7 months (0.4-138.2 months). On univariable cox regression tests, age group, carcinoma in situ (CIS), lymphovascular invasion (LVI) and hypertension (HTN) were all significantly associated with increased bladder recurrence (P < 0.05). On multivariable analyses, only CIS (HR=1.99 ; 95% CI 1.02-3.88, P=0.043), LVI (HR=1.58 ; 95% CI 1.04-2.39, P=0.032) and HTN (HR=1.57 ; 95% CI 1.06-2.33, P=0.025) remained independent predictors of increased bladder recurrence.

Conclusion:

               For patients with upper tract urothelial carcinoma who undergo radical nephroureterectomy and bladder cuff excision with the transurethral pluck method, factors such as carcinoma in situ, lymphovascular invasion, and hypertension may pose a higher risk for bladder recurrence.