該手術還是不該手術

劉致毅1,2、李永進1,2

 1高雄市立小港醫院泌尿科； 2高雄醫學大學附設中和紀念醫院 泌尿部

To surgery or not to surgery

Chih I Liu1,2,  Yung Chin Lee1,2

Division of Urology, Kaohsiung Municipal Siaogang Hospital, Taiwan1; Department of Urology, Kaohsiung Medical University Hospital, Kaohsiung Medical University2

Present Illness: A 80-year-old male patient presented to the urological clinics due to painless gross hematuria, he had previous history of colon cancer post surgical treatment. His initial intravenous pyelography had poor view of the renal pelvis, cystoscopy showed no bladder tumorm urine cytology was negative. However, abdominal computed scan showed: suspect urothelial tumor in the left renal pelvis. Left ureteroscopy biopsy was arranged, the pathology report showed necrosis and few atypical cells. While the washing cytology during surgery showed highly suspicious for malignancy. Then he was admitted two more time for retrograde intra-renal surgery of renal tumor biopsy, we had visualize the renal pelvis tumor using flexible URS, and the tumor biopsy was done without complication. However, both of the RIRS biopsy pathology report showed negative for malignant cell. But the washing cytology actually showed positive for malignant cell.

Image: Abdominal computed scan showed: suspect urothelial tumor in the left renal pelvis. Three times of endoscopic retrograde biopsy surgery showed direct vision of the renal pelvis tumor.
 

Operation: Pure laparoscopic nephroureterectomy with TUI method of bladder cuff excision was done smoothly. Renal pelvis tumor was clearly seen when dissecting open his kidney specimen. The pathology showed: infiltrating urothelial carcinoma, high grade, pT2.

Discussion: Even though we did three times of endoscopic tumor biopsy for his renal tumor, three times of pathology report all showed negative for malignancy. Due to multiple times of urine cytology showed suspicious or positive for malignant, and with the overt appearance of the tumor under endoscopic vision. A multidisciplinary cancer meeting was held , and we discussed with the patient about pros and cons of surgical treatment despite the fact that we had no evidence of pathology proof.

Conclusion: In summary, the case of the 80-year-old male patient with hematuria and a history of colon cancer suspect of urological malignancies. Despite inconclusive biopsy results, the persistence of suspicious findings in urine cytology and the visual confirmation of a renal pelvis tumor guided the decision for surgical intervention. The subsequent laparoscopic nephroureterectomy revealed infiltrating urothelial carcinoma, underscoring the importance of clinical judgment and interdisciplinary collaboration in managing complex cases. This highlights the need for comprehensive assessment and shared decision-making in navigating diagnostic uncertainties in urological oncology.