內視鏡腎臟保留手術相較於腎臟及輸尿管全切除手術於上泌尿道泌尿上皮癌之腫瘤相關預後
沈志宇、詹皓程、蔡育賢、歐建慧、楊文宏
國立成功大學醫學院附設醫院 泌尿部
Oncologic outcomes of kidney sparing surgery using endoscopic management compared with radical nephroureterectomy in upper urinary tract urothelial carcinoma
Chih-Yu Shen, Jan Hau-Chern, Yuh-Shyan Tsai, Chien Hui Ou, Wen Horng Yang
Department of Urology, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
Purpose: To report the long-term follow-up of a matched comparison of radical nephroureterectomy(RNU) and kidney-sparing surgery (KSS) in patients with upper tract urothelial carcinoma from 2004 to 2017 .
Materials and Methods: A total of 22 patients who received endoscopic management of urothelial carcinoma at a single center in Taiwan were included from April 2004 to February 2017. Another 66 patients who received RNU were matched according to clinical grade, clinical T stage, age, gender in a 1:3 fashion. Tumors were first biopsied then treated with fulguration, the neodymium:YAG laser and/or the holmium:YAG laser afterwards. The Kaplan-Meier method and stratified Cox proportional hazards model were used to estimate and compare overall and progression free survival.
Results: Of the 22 patients (10 males and 12 females) received KSS, the mean age was 67.86± 12.49 years. 13 (59.09%) patients had cancer progression, of which, 6 patients had bladder recurrence (27.2%), 1 had distant metastasis (4.7%), and 8 had progression and finally underwent radical nephroureterectomy (36.3%). The renal salvage rate was 63.6%. The 5 year overall survival rate was 79.1% in the KSS group and 78.8% in the RNU group (p=0.238) while the 5 year progression-free survival of which was 43.8% and 32.4% (p=0.528), respectively. Subgroup analysis showed 100% five-year overall survival and 66.7% five-year progression free survival for low grade tumor. The same figure for high grade UTUC managed endoscopically is 72.0% and 31.3%, respectively. On univariant analysis, tumor grade (HR:4.053, 95% CI 1.720-9.552, p=0.001) and clinical stage (HR:2.179, 95% CI 1.209-3.928, p=0.010) achieves clinical significance predicting tumor recurrence. On multivariant analysis the presence of high grade tumor was associated with higher tumor recurrence. (HR: 3.498, p=0.05)
Conclusions: In this case-matching study, endoscopic management of urothelial carcinoma is a feasible approach. Despite the risk of local recurrence, patients receiving endoscopic management had similiar postoperative outcomes in regards of overall survival and progression free survival compared with radical nephroureterectomy. Besides, the benefit of renal function preservation should also be considered with this modality. It is therefore, a reasonable approach to treat selected patients with a meticulous and stringent postoperative follow up schedule.