許智凱、張廷瑞、陳世亮

台南市立醫院 泌尿科

Chih-Kai Hsu, Ting-Jui Chang, Shih-Liang Chen

Divisions of Urology, Tainan Municipal Hospital, Tainan, Taiwan

 

Background: Organ sparing techniques are the fashion way in the modern sugeries. Laser ablation for ureter tumors are used for preserved the organ and prevented complications of traditional surgery. But ureteral stricture is the most serious problem after laser ablation, especially for the large and the long segment lesions. Endoscopic submucosal dissection(ESD) is a method that used to applied under panendoscopy and colonscopy for treatment of GI tract tumors. We presented our case that used the ESD to treat ureteral tumor.

Case Report: A 61 y/o man has history of hypertension, DM and recurrent urolithiasis formation. Left hydronephrosis with upper ureter obstruction had been noted 10 years ago. URS was performed at that time, that mucosal thickening with pathologic diagnosis of squamous metaplasia was obtained by endoscopic biopsy. He did not come back to our clinic for further follow up, but he showed up again for the exacerbated left flank pain 10 years after. Sonography and IVP showed progressive left hydronephrosis without ureter stone. URS showed mucosal lesion in a whole circle with 2cm in length and lumen narrowing. Tissue biopsy showed the same diagnosis without malignant changes. After discussion with the patient, URS ESD was arranged for this patient. The dissection was started from the distal end for lesion, Ho-YAG laser was used to break up the mucosal and explored into submucosal layer. And then the mucosa with the lesion on it was peeled off and push forward and forward. After beyond the lesion, the connected mucosa layer was cut off, and the tissue was removed as a whole by grasping forceps. A 6Fr. 26cm ureteral stent was indwelled for 3 months. At the 3-month follow up, URS was performed again, the mucosa at the surgical field was well recovered without stricture ring, and re-biopsy showed normal urothelium layers.

Discussion:. ESD is an advanced technique of therapeutic endoscopy for superficial gastrointestinal neoplasms, and used for more than 10 year. They use electrosurgical knives for cutting and submucosal dissection was made by saline infusion. ESD can achieve a better en-bloc resection rate, and a clear view during the deep layer resection, that cause less complications like perforation and bleeding. Laser ablation for ureter tumors are now widely accepted in small lesion, but ureteral stricture after treatment that due to muscle layer injury or even ureter perforation will cause obstructive uropathy bothered a lot. We used the same concept to treat the ureter tumor and achieved a good short-term result, but long time follow up is needed for the proof of reliability.