El Fettouh Hazem Abou, Rassweiler Jens J, Schulze Michael, Salomon Laurent, Allan James, Ramakumar Sanjay, Jarrett Thomas, Abbou Claude C, Tolley David A, Kavoussi Louis R, Gill Inderbir S
Cleveland Clinic Urological Institute, Cleveland, OH, USA.
Eur Urol. 2002 Nov;42(5):447-52. doi: 10.1016/s0302-2838(02)00370-6.
To report a multicenter analysis after laparoscopic radical nephroureterectomy for pathologically confirmed upper tract transitional cell carcinoma.
A total of 116 patients (72 males; mean age 68 years) underwent laparoscopic radical nephroureterectomy at five international institutions: 51 transperitoneally, 65 retroperitoneally. Location of the primary tumor was pelvicalyceal in 70 patients (60%), ureteral in 27 (23%), and multifocal in 19 (17%). In 18 patients (15%), transurethral resection was performed for concomitant bladder tumor. The median follow-up time was 25 months (range 3-93). A minimum follow-up of 1 and 2 years was available in 77 and 41 patients, respectively.
Five patients (4%) were converted to open surgery. The specimen was extracted intact in all 116 patients: using an Endocatch bag in 78 patients, a Lapsac in 5, and manually in 33. Pathologic staging was pTis in 5 (4%), pTa in 41 patients (35%), pT1 in 31 (26%), pT2 in 18 (15%), pT3 in 16 (13%), and pT4 in 5 (4%). Pathological grade was grade I in 26 patients (23%), grade II in 41 (35%), grade III in 34 (29%) and grade IV in 15 (12%). Histopathology revealed a positive surgical margin in five patients (4.5%): renal hilum (one), periureteral soft tissue (two), distal edge of the ureter/ bladder cuff (two). Local recurrence was noted in two patients (1.7%). Bladder recurrence was noted in 28 patients (24%) with a mean time to recurrence of 13.9+/-11.5 months. Distant metastases occurred in 11 patients (9%): lung (5), liver (3), bones (2), adrenal (1); mean time to metastasis was 13 months. Overall, 23 patients (20%) died. One-year and 2-year cancer-specific survival was 92% and 87%, respectively. Two-year cancer-specific survival according to pathologic stage was 89% for patients with pT1 disease, 86% for pT2, 77% for pT3, and 0% for pT4 (p=0.0001). Two-year survival according to pathologic grade was 88% for grade I, 90% for grade II, 80% for grade III, and 90% for grade IV (p>0.05).
Laparoscopic radical nephroureterectomy appears to be an effective minimally invasive treatment for select patients with upper tract transitional cell carcinoma. Although the 2-year survival data reported herein are encouraging, longer follow-up is needed before laparoscopy can be considered as a standard treatment.
报告经病理证实的上尿路移行细胞癌行腹腔镜根治性肾输尿管切除术的多中心分析结果。
共有116例患者（72例男性；平均年龄68岁）在5家国际机构接受了腹腔镜根治性肾输尿管切除术：51例经腹腔入路，65例经腹膜后入路。原发肿瘤位于肾盂肾盏的有70例（60%），输尿管的有27例（23%），多灶性的有19例（17%）。18例患者（15%）因合并膀胱肿瘤接受了经尿道切除术。中位随访时间为25个月（范围3 - 93个月）。分别有77例和41例患者至少有1年和2年的随访资料。
5例患者（4%）中转开腹手术。116例患者标本均完整取出：78例使用Endocatch袋，5例使用Lapsac，33例手动取出。病理分期为pTis的5例（4%），pTa的41例（35%），pT1的31例（26%），pT2的18例（15%），pT3的16例（13%），pT4的5例（4%）。病理分级为Ⅰ级的26例（23%），Ⅱ级的41例（35%），Ⅲ级的34例（29%），Ⅳ级的15例（12%）。组织病理学显示5例患者（4.5%）手术切缘阳性：肾门（1例），输尿管周围软组织（2例），输尿管/膀胱袖口远端边缘（2例）。2例患者（1.7%）出现局部复发。28例患者（24%）出现膀胱复发，复发平均时间为（13.9±11.5）个月。11例患者（9%）发生远处转移：肺（5例），肝（3例），骨（2例），肾上腺（1例）；转移平均时间为13个月。总体上，23例患者（20%）死亡。1年和2年的癌症特异性生存率分别为92%和87%。pT1期患者2年癌症特异性生存率为89%，pT2期为86%，pT3期为77%，pT4期为0%（p = 0.0001）。按病理分级的2年生存率：Ⅰ级为88%，Ⅱ级为90%，Ⅲ级为80%，Ⅳ级为90%（p>0.05）。
腹腔镜根治性肾输尿管切除术似乎是部分上尿路移行细胞癌患者有效的微创治疗方法。尽管本文报告的2年生存数据令人鼓舞，但在腹腔镜手术被视为标准治疗方法之前，还需要更长时间的随访。
