Grasso M, Fraiman M, Levine M
Department of Urology, New York University School of Medicine, New York, USA.
Urology. 1999 Aug;54(2):240-6. doi: 10.1016/s0090-4295(99)00121-1.
To study the application of endoscopic techniques in treating upper urinary tract urothelial malignancies and to define subgroups that may benefit from these therapies.
During a 3-year period, 20 patients with upper urinary tract transitional cell carcinoma were referred specifically for endoscopic therapy. Indications for treatment included a solitary kidney, bilateral disease, modest renal insufficiency, and/or other significant comorbidities. All patients underwent retrograde ureteropyeloscopy. Lesions were biopsied, and lower grade tumors were treated with electrocautery or laser energy. High-grade lesions not amenable to minimally invasive techniques were palliated or treated with standard open surgery. Surveillance was performed at 3 to 4-month intervals by urine cytology and repeat panendoscopy on a similar schedule to lesions of the bladder treated endoscopically.
Eleven patients (55%) were found to have low-grade, papillary transitional cell carcinoma of the upper urinary tract. Tumors ranged in size from less than 1 cm to filling the entire ureter. All papillary lesions were treated successfully using ureteroscopic techniques without any disease progression. Five small, low-grade recurrences (45%) were defined and treated endoscopically, with a mean follow-up of 17.3 months. Three patients were found at the time of initial diagnostic ureteroscopy to have higher grade lesions and endoscopic treatment was chosen in light of their severe comorbidities. On subsequent imaging, 2 of the 3 patients were suspected of having progression and underwent open surgery, both had carcinoma-in-situ only in the specimen. No tumor progression has been defined in this group to date, with mean follow-up of 16.3 months. A final third group of 6 patients were found to have nonpapillary, high-grade lesions at diagnostic endoscopy and underwent standard surgical resection. The disease of 4 of these 6 patients has progressed with metastases.
Papillary, low-grade, low-stage tumors of the upper urinary tract are amenable to endoscopic resection irrespective of size and location. Patients with high-grade lesions defined endoscopically should be offered radical surgery in light of the high rate of disease progression.
研究内镜技术在上尿路尿路上皮恶性肿瘤治疗中的应用，并确定可能从这些治疗中获益的亚组。
在3年期间，20例上尿路移行细胞癌患者被专门转诊接受内镜治疗。治疗指征包括孤立肾、双侧病变、中度肾功能不全和/或其他严重合并症。所有患者均接受逆行输尿管肾盂镜检查。对病变进行活检，低级别肿瘤采用电灼或激光能量治疗。无法采用微创技术治疗的高级别病变采用姑息治疗或标准开放手术治疗。通过尿细胞学检查每隔3至4个月进行一次监测，并按照与内镜治疗的膀胱病变相似的时间表重复进行全面内镜检查。
11例患者（55%）被发现患有上尿路低级别乳头状移行细胞癌。肿瘤大小从小于1厘米到充满整个输尿管不等。所有乳头状病变均采用输尿管镜技术成功治疗，无疾病进展。确定了5例小的低级别复发病变（45%）并进行了内镜治疗，平均随访17.3个月。3例患者在初次诊断性输尿管镜检查时被发现患有更高级别病变，鉴于其严重合并症而选择了内镜治疗。在随后的影像学检查中，3例患者中有2例被怀疑病情进展并接受了开放手术，两者标本中均仅有原位癌。该组患者迄今为止未发现肿瘤进展，平均随访16.3个月。最后一组6例患者在诊断性内镜检查时被发现患有非乳头状高级别病变，并接受了标准手术切除。这6例患者中有4例疾病已进展并发生转移。
上尿路乳头状、低级别、低分期肿瘤无论大小和位置均可接受内镜切除。鉴于疾病进展率高，内镜检查确定为高级别病变的患者应接受根治性手术。
