Abe Takashige, Takada Norikata, Matsumoto Ryuji, Osawa Takahiro, Sazawa Ataru, Maruyama Satoru, Tsuchiya Kunihiko, Harabayashi Toru, Minami Keita, Nagamori Satoshi, Hatanaka Kanako C, Tanaka Yuka, Shinohara Nobuo, Nonomura Katsuya
1 Department of Urology, Hokkaido University Graduate School of Medicine , Sapporo, Japan .
J Endourol. 2015 Mar;29(3):304-9. doi: 10.1089/end.2014.0369. Epub 2014 Nov 4.
To determine the appropriate template of regional lymph node dissection (LND) at the time of laparoscopic nephroureterectomy (LNU) for patients with clinically node- negative urothelial carcinoma of the upper urinary tract.
This prospective study included 45 patients undergoing LND with LNU in accordance with our prospective rules regarding the area of LND. Perioperative, pathologic, and follow-up data were collected. Micrometastasis in lymph nodes (LNs) was later evaluated by immunohistochemistry (IHC). Recurrence-free survival (RFS) was calculated with the Kaplan-Meier method.
The median number of LNs removed was 14 (range 1-33). One patient with pT3 disease had node metastasis based on routine pathologic examination, and IHC revealed micrometastases in two additional patients (pT2 in one and pT3 in one). Therefore, 15% (3/20) of patients with ≥pT2 disease had node disease. After surgery, six patients experienced minor complications (Grade 1 or 2), and Grade 5 gastrointestinal bleeding after aspiration pneumonia developed in one elderly male patient on the 45th postoperative day, which was not considered to be associated with LND. At the last follow-up, lung metastasis developed in four patients (pT1 in one, pT2 in one, and pT3 in two), and presacral lymph node metastasis developed in one patient with a lower ureteral tumor (pT2), which was not included in our prospective template for a lower ureteral tumor. LN recurrence within/ near the LND area was not observed in patients with pelvic/upper ureteral carcinoma. The 2-year nonurothelial RFS rate was 84%.
We consider that the present template represents regional LNs for patients with clinically node-negative pelvic/upper ureteral carcinoma, while presacral LNs may be incorporated into the regional LND template for patients with clinically node-negative lower ureteral carcinoma.
确定临床上淋巴结阴性的上尿路尿路上皮癌患者行腹腔镜肾输尿管切除术（LNU）时区域淋巴结清扫（LND）的合适模板。
这项前瞻性研究纳入了45例按照我们关于LND区域的前瞻性规则接受LND联合LNU的患者。收集围手术期、病理及随访数据。随后通过免疫组织化学（IHC）评估淋巴结（LN）中的微转移。采用Kaplan-Meier法计算无复发生存率（RFS）。
切除的LN中位数为14个（范围1 - 33个）。1例pT3期疾病患者基于常规病理检查发现有淋巴结转移，IHC显示另外2例患者有微转移（1例pT2期，1例pT3期）。因此，≥pT2期疾病患者中有15%（3/20）存在淋巴结疾病。术后，6例患者出现轻微并发症（1级或2级），1例老年男性患者在术后第45天因吸入性肺炎发生5级胃肠道出血，认为与LND无关。在最后一次随访时，4例患者发生肺转移（1例pT1期，1例pT2期，2例pT3期），1例下段输尿管肿瘤患者（pT2期）发生骶前淋巴结转移，该区域未包含在我们针对下段输尿管肿瘤的前瞻性模板中。盆腔/上段输尿管癌患者未观察到LND区域内/附近的LN复发。2年非尿路上皮RFS率为84%。
我们认为当前模板代表了临床上淋巴结阴性的盆腔/上段输尿管癌患者的区域LN，而骶前LN可能应纳入临床上淋巴结阴性的下段输尿管癌患者的区域LND模板。
