Hao Y C, Chen K, Liu Y Q, Lu J, Xiao C L, Ma L L
Department of Urology, Peking University Third Hospital, Beijing 100191, China.
Department of Urology, People's Hospital of Zhengzhou, Zhengzhou 450003, China.
Beijing Da Xue Xue Bao Yi Xue Ban. 2018 Oct 18;50(5):816-821.
To summarize the experience of flexible ureteroscopic holmium laser resection in treatment of renal pelvic carcinoma and to evaluate its value in treatment of renal pelvic carcinoma.
The clinical data of 6 patients with renal pelvic carcinoma treated in Peking University Third Hospital from January 2015 to January 2017 were retrospectively analyzed. The 6 patients were treated by the same experienced urologist and by flexible ureteroscopic holmium laser resection of renal pelvic tumors under general anesthesia. Regarding the intensity of the holmium laser, 10-30 W was generally used with settings of 0.5-1.5 J and 10-20 Hz. In general, a 200 μm end-firing holmium laser fiber was used. Narrow-band imaging (NBI) technique was applicated to search for tumors and check whether the excision was satisfactory. Routine "second flexible ureteroscopy" was performed after 4-6 weeks, and suspected lesions were referred for a biopy, then vaporized and cauterized. The ureteroscopy was examined every 6 months after operation, and color Doppler ultrasound, computed tomography urography (CTU) or magnetic resonance urography (MRU) were performed at the same time. The urine tumor cells were examined for 3 days before the operation, and the urine tumor markers, such as urinary nuclear matrix protein 22 (NMP22) were tested. For cases with highisk urothelial carcinoma and normal renal function, and 6 cycles of systemic adjuvant chemotherapy were performed after operation.
All of the cases were successfully treated. The data were as follows: the operation time 77.5 min (45-115 min), the blood loss 10 mL (5-20 mL), and hospital stay after surgery 3 days (2-5 days). After 13-34 months' followp, two patients had recurrent tumor recurrence and underwent resection operation. Two patients received systemic adjuvant chemotherapy after operation. Case 5 was histopathologically high grade urothelial carcinoma, and 6 cycles of systemic chemotherapy were given after operation. Local recurrence occurred during chemotherapy, and then endoscopic operation was performed, and no recurrence occurred in the follow-up for 12 months after reoperation. In case 6, the pathology was low grade urothelial carcinoma, but the case was multiple tumors in the right renal calyx and the lower calyx. Then 6 cycles of systemic chemotherapy were given, and no recurrence was found in the followp for 13 months.
Transurethral flexible ureteroscopic holmium laser resection is relatively safe for the treatment of renal pelvic carcinoma. It is suitable for special cases of solitary kidney and renal dysfunction, as well as for patients with low risk urinary tract epithelial tumors, but the recurrence rate is high, and the indications need to be strictly controlled. Patients with high-risk urothelial carcinoma who underwent endoscopic resection are advised to receive systemic adjuvant gemcitabine and cisplatin (GC) regimen after surgery, in order to increase the overall survival rate. Systemic chemotherapy combined with endoscopic operation may become a new treatment for upper tract urothelial carcinoma (UTUC).
总结输尿管软镜钬激光切除术治疗肾盂癌的经验，评估其在肾盂癌治疗中的价值。
回顾性分析2015年1月至2017年1月在北京大学第三医院接受治疗的6例肾盂癌患者的临床资料。这6例患者均由同一位经验丰富的泌尿外科医生在全身麻醉下采用输尿管软镜钬激光切除肾盂肿瘤。钬激光强度一般采用10 - 30W，设置为0.5 - 1.5J、10 - 20Hz。一般使用200μm侧射钬激光光纤。应用窄带成像（NBI）技术查找肿瘤并检查切除是否满意。术后4 - 6周进行常规“二次输尿管软镜检查”，对可疑病变进行活检，然后汽化烧灼。术后每6个月检查输尿管镜，并同时进行彩色多普勒超声、计算机断层扫描尿路造影（CTU）或磁共振尿路造影（MRU）。术前检测3天尿肿瘤细胞，并检测尿肿瘤标志物，如尿核基质蛋白22（NMP22）。对于高危尿路上皮癌且肾功能正常的病例，术后进行6周期全身辅助化疗。
所有病例均成功治疗。数据如下：手术时间77.5分钟（45 - 115分钟），出血量10毫升（5 - 20毫升），术后住院天数3天（2 - 5天）。随访13 - 34个月后，2例患者肿瘤复发并接受了切除手术。2例患者术后接受了全身辅助化疗。病例5病理为高级别尿路上皮癌，术后给予6周期全身化疗。化疗期间出现局部复发，随后进行了内镜手术，再次手术后随访12个月无复发。病例6病理为低级别尿路上皮癌，但该病例为右肾盏和下盏多发肿瘤。随后给予6周期全身化疗，随访13个月无复发。
经尿道输尿管软镜钬激光切除术治疗肾盂癌相对安全。适用于孤立肾、肾功能不全等特殊情况以及低危尿路上皮肿瘤患者，但复发率较高，适应证需严格把控。建议接受内镜切除的高危尿路上皮癌患者术后接受吉西他滨和顺铂（GC）方案全身辅助化疗，以提高总体生存率。全身化疗联合内镜手术可能成为上尿路尿路上皮癌（UTUC）的一种新治疗方式。
