骨盆腔廓清術與重建對患有多發性骨盆器官侵犯的第4期上泌尿道尿路上皮癌的額外生存益處

黃偉柏¹, 黃慈恩², 黃文詩³, 林建兆⁴, 林威宇^1,5,6,7

1嘉義長庚紀念醫院外科部泌尿科; 2嘉義長庚紀念醫院內科部腫瘤科; 3嘉義長庚紀念醫院外科部直腸肛門外科; 4嘉義長庚紀念醫院外科部心臟血管外科; 5 嘉義長庚紀念醫院教學部; 6長庚大學醫學系;7國立成功大學醫學院附設醫院泌尿部

Additional Survival Benefit of En-Bloc Iliac Vessel Excision and Reconstruction During Pelvic Exenteration for stage 4 Ureter Urothelium Cancer with Multiple Pelvic Organ Invasion

Wei-Po Huang¹, Ci-En Huang², Wen-Shi Huang³, Jian-Zhao Lin⁴, Wei-Yu Lin^1,5,6,7

1 Division of Urology, Department of Surgery, Chang Gung Memorial Hospital, Chiayi, Taiwan; 2 Division of oncology, Department of Internal Medicine, Chang Gung Memorial Hospital, Chiayi, Taiwan; 3 Division of Proctology, Department of Surgery, Chang Gung Memorial Hospital, Chiayi, Taiwan; 4 Division of Cardiovascular surgery, Department of Surgery, Chang Gung Memorial Hospital, Chiayi, Taiwan; 5 Department of Medical Education, Chang Gung Memorial Hospital, Chiayi, Taiwan; 6 School of Medicine, College of Medicine, Chang Gung University, Taoyuan, Taiwan; 7 Department of Urology, National Cheng Kung University, Tainan, Taiwan

Purpose:

Nephroureterectomy (NU) is a standard treatment for patient with high risk, non-metastatic urinary tract urothelial carcinoma (UTUC) [1], and even possess survival benefit for patient with metastastic UTUC in recent increasing reports [2].  UTUC with pelvic organs invasion is rare and reference related to surgical treatment is lack.  Will aggressive surgical managements have survival impact?  We present a case underwent NU with en bloc iliac vessel excision and reconstruction during pelvic exenteration after neoadjuvant chemotherapy and immunotherapy.

Case presentation:

A 61-year-old male was diagnosed as left low ureter urothelial carcinoma with extension to adjuvant organ (bladder, colon, iliac vessel) and pelvic wall (TNM was cT4aN1aM0,) (Fig 1). After neoadjuvant chemotherapy and immune therapy, a multidisciplinary surgery was performed on April, 2020. Nephroureterectomy, cystoprostatectomy and ileal conduit were undertaken by Urologist, then followed with resection of involved sigmoid colon and transverse colostomy by proctologist. During pelvic exenteration, en-bloc of involved iliac vessel with replacement of artery graft were conducted by CVS surgeon. (Fig 2) The pathology report showed ypT0N0M0, pCR.

Recurrent retroperitoneal LN was identified post operation 18th months and salvage chemotherapy was provided. Over 3 years, the retroperitoneal lymph node was in stationary status and patient was in active physical status by now.

Conclusion:

Multi-disciplined therapy could provide over 3-year survival benefit for UTUC with multiple pelvic organs invasion. Neoadjuvant chemotherapy plus immunotherapy are critical for complete pathological response. Besides NU, aggressive surgical treatments, including pelvic exenteration and en block iliac vessels provide additional survival impact.