Chitale Sudhanshu, Mbakada Rashidi, Irving Stuart, Burgess Neil
Department of Urology, Norfolk & Norwich University Hospital NHS Trust, Norwich, UK.
Ann R Coll Surg Engl. 2008 Jan;90(1):45-50. doi: 10.1308/003588408X242268.
Nephroureterectomy with excision of a cuff of bladder remains the standard for managing upper tract transitional cell carcinoma (TCC). Increasing use of diagnostic upper tract endoscopy has underlined the importance of obtaining a pre-operative histological diagnosis in order to avoid under-treating high-grade or multifocal disease and over-treating low-grade disease, which could, in selected cases, be managed conservatively. We review nephroureterectomy at our institution over a 10-year period with particular reference to a pre-operative histological diagnosis.
Nephroureterectomy was performed in 113 patients from February 1994 to February 2004. Of these cases, 58 were for upper tract TCC and 50 of these 58 had intravenous urography (IVU): 9 had only IVU, 28 had an additional CT scan, 5 had an additional ultrasonography and 8 had additional CT + ultrasonography for pre-operative work-up. Thirty-four of the 58 cases had retrograde pyelography. Nineteen (32.7%) of the 58 cases had a pre-operative ureteroscopy (URS) and biopsy; 14 of these had rigid URS for tumours in the lower (11) and middle (3) thirds of the ureter and 5 had flexible URS for pelvicalyceal tumours by an experienced endourologist. Thirty-one (53%) of the 58 tumours were within the pelvicalyceal system and 27 within the ureter (upper, 5; middle, 3; lower, 19). Forty-eight patients underwent a total nephroureterectomy: 40 had a two incision approach and 8 had an endoscopic resection of the lower ureter. Five of the 58 cases had a sub-total nephroureterectomy and 5 a laparoscopic nephroureterectomy with open excision of lower ureter.
Nineteen (32.7%) of the 58 patients had a pre-operative histological diagnosis - 17 G2pTa, 1 G1pTa, and 1 G2pT1. Fourteen (74%) biopsies matched the final postoperative histology, but 1 was down-staged, 3 up-staged and 1 up-graded compared to the original histology. Five (12.8%) of 39 patients without pre-operative histology had no TCC in the final surgical specimen: 4 (10.25%) had benign pathology such as capillary haemangioma, urothelial cysts and reactive urothelial changes while one had renal cell carcinoma (RCC).
This study underlines the importance of obtaining a pre-operative histological diagnosis in cases with presumed upper tract TCC. Failure to do so can result in unnecessary ablative surgery for benign disease. Such an approach can also help identify multifocality and grade of disease so that treatment of upper tract TCC can be tailored more appropriately with ablative surgery for high-grade or multifocal disease and conservative (endoscopic) therapy for low-grade disease in selected cases. Patients with suspected TCC of the upper tract should be managed at centres where facilities for the comprehensive evaluation of such tumours exist.
切除一段膀胱袖口状组织的肾输尿管切除术仍是治疗上尿路移行细胞癌（TCC）的标准方法。诊断性上尿路内窥镜检查的使用日益增加，凸显了获得术前组织学诊断的重要性，以避免对高级别或多灶性疾病治疗不足以及对低级别疾病过度治疗，在某些情况下，低级别疾病可采用保守治疗。我们回顾了本机构10年间的肾输尿管切除术，特别关注术前组织学诊断。
1994年2月至2004年2月期间，113例患者接受了肾输尿管切除术。其中，58例为上尿路TCC，这58例中有50例进行了静脉肾盂造影（IVU）：9例仅做了IVU，28例额外进行了CT扫描，5例额外进行了超声检查，8例额外进行了CT +超声检查以进行术前评估。58例中有34例进行了逆行肾盂造影。58例中有19例（32.7%）进行了术前输尿管镜检查（URS）及活检；其中14例由经验丰富的腔内泌尿外科医生对输尿管下三分之一（11例）和中三分之一（3例）的肿瘤进行了硬性URS，5例对肾盂肿瘤进行了软性URS。58例肿瘤中有31例（53%）位于肾盂系统内，27例位于输尿管（上段5例；中段3例；下段19例）。48例患者接受了根治性肾输尿管切除术：40例采用两切口入路，8例采用输尿管下段内镜切除术。58例中有5例进行了次全肾输尿管切除术，5例进行了腹腔镜肾输尿管切除术并开放切除输尿管下段。
58例患者中有19例（32.7%）获得了术前组织学诊断——17例为G2pTa，1例为G1pTa，1例为G2pT1。14例（74%）活检结果与最终术后组织学相符，但与原始组织学相比，1例分级降低，3例分级升高，1例升级。39例未进行术前组织学检查的患者中有5例（12.8%）最终手术标本中未发现TCC：4例（10.25%）有良性病变，如毛细血管瘤、尿路上皮囊肿和反应性尿路上皮改变，1例为肾细胞癌（RCC）。
本研究强调了对疑似上尿路TCC病例进行术前组织学诊断的重要性。未进行术前组织学诊断可能导致对良性疾病进行不必要的切除手术。这种方法还可以帮助确定疾病的多灶性和分级，以便对上尿路TCC进行更合适的治疗，对于高级别或多灶性疾病采用切除手术，在某些情况下，对于低级别疾病采用保守（内镜）治疗。疑似上尿路TCC的患者应在具备全面评估此类肿瘤设施的中心进行治疗。
