10 years of clinical experience on the urothelial tumor of the upper urinary tract

Eyüp GÜMÜŞ,Kaya HORASANLI,Orhan TANRIVERDİ,Uğur BOYLU,Cem ÇEVİK,Cengiz MİROĞLU

Abstract

Introduction: Tumors of the upper urinary tract are seen rarely. The standard treatment of upper urinary tract tumors is nephroureterectomy and cuff excision from the bladder. But there is growing evidence that conservative methods such as ureterectomy with end-to-end anastomosis and endoscopic approaches may be enough to control the upper urinary tract cancers. In this retrospective clinical study we evaluated our treatment choices of conservative and invasive surgery and their results for the upper urinary tract tumors. Materials and Methods: Between 1994 and 2004, 21 patients with upper urinary tract tumors were treated with either conservative or invasive surgical approaches in Sisli Etfal Teaching and Research Hospital Department of 2nd Urology. In conservative surgery group patients are treated either with partial ureterectomy with end-to-end anastomosis or endoscopic fulguration/electro-cauterization. In invasive surgery group, patients underwent simple nephroureterectomy with the cuff excision from the bladder. There were 12 (57.1%) patients in conservative surgery group and there were 9 (42.9%) patients in invasive surgery group. Five patients (23.8%) in conservative surgery group underwent partial ureterectomy and end-to-end anastomosis. Seven (33.3%) patients underwent endoscopic fulguration/electro-cauterization. After endoscopic approaches intraureteric chemotherap1oetics are administred. We used Mitomycin C and Bacillus Calmette Guerin (BCG). Mean follow up was 38 months for conservative surgery group and 32 months for invasive surgery group. Results: Of 21 patients 7 women and 14 men with upper urinary tract tumors are evaluated retrospectively. Mean age was 60.3 years. Of 21 patients 2 had tumor in renal pelvis, 5 had in proximal ureter, 5 had in middle ureter and 9 had in distal ureter. Six patients had simultaneous bladder tumor, of which only 2 were primer bladder tumors. There were 4 Ta, 7 T1, 8 T2-3a and 2 T3b-4 tumors; 11 of them were grade 1, 8 of them were grade 2 and 2 of them were grade 3. There was only one (8.3%) tumor recurrence in the conservative surgery and endoscopy group (12 patients) and no patient died of a cancer related cause. Of 9 patients who underwent nephroureterectomy with the cuff excision from the bladder, 2 (22.2%) passed away with local invasions or distant metastasis in 9 to 12 months. Mean survival was 27 months in invasive surgery group. Conclusion: Patients with low-grade low stage upper urinary tract tumors can be treated with conservative surgical approaches without any organ loss.

Özet

Üst üriner sistem tümörleri nadiren görülür. Bu tümörlerde standart tedavi nefroureterektomi ve mesaneden “cuff” çıkartılmasıdır. Ancak literatürde üst üriner sistem tümörlerinin tedavisinde üreterektomi ve endoskopik yaklaşımların yeterli olabileceği yönünde bilgiler vardır. Bu retrospektif klinik çalışmada üretelyal tümörlü olgulara uygulanan tedavi yaklaşımlarının sonuçlarını ve klinik deneyimlerimizi değerlendirmeyi amaçladık. Retrospektif olarak değerlendirilen 21 üst üriner sistem üretelyal tümör olgusundan 12’sine (%57,1) konservatif organ koruyucu veya endoskopik cerrahi uygulandı. Bunlardan 5 olguya (%23,8) parsiyel üreterektomi ve end-to-end anastomoz; 7 olguya da (%33,3) endoskopik yaklaşım (fulgurasyon, elektrokoterizasyon) uygulandı. Endoskopik yaklaşımlardan sonra intraüreterik kemoterapi uygulandı. Kemoterapi için Mitomicin C ve Bacillus Calmette Guerin kullanıldı. Dokuz olguya (%42,9) nefroüreterektomi ve mesaneden cuff çıkarılması işlemi uygulandı. Ortalama izlem konservatif grupta 38 ay, invazif grupta 32 aydı. Yaş ortalaması 60,3 olan toplam 21 hastanın 7’si kadın ve 14’ü erkekti. İki hastanın renal pelviste, 5 hastanın proksimal üreterde, 5 hastanın orta üreterde ve 9 hastanın distal üreterde tümörleri mevcuttu. Altı olgunun eş zamanlı mesane tümörü mevcuttu ve sadece 2 tanesi primer mesane tümörüydü. Dört Ta, 7 T1, 8 T2-3a ve 2 T3b-4 tümör mevcuttu. Bu tümörlerden 11 tanesi G1, 8 tanesi G2 ve 2 tanesi G3 olarak bulundu. Konservatif cerrahi veya endoskopik yaklaşım uygulanan 12 (% 57,1) olgudan sadece 1 olguda (% 8,3)tümör rekürrensi görüldü. Bu olgularda ortalama sağ kalım süreleri 38 ay idi. Nefroüreterektomi uygulanan 9 olgudan (%42,9) 2’sinde (%22,2) ise yaklaşık 9-12 aya arası sürede lokal invazyon ve uzak metastazlar görülerek kaybedildi. Bu olgularda ortalama sağ kalım süreleri 27 ay idi. Üst üriner sistem ürotelyal tümörü olan düşük evre ve grade’li olgularda organ koruyucu konservatif tedavi yaklaşımlarıyla başarılı sonuçlar sağlanabilmektedir.