Kenigsberg Alexander P, Meng Xiaosong, Ghandour Rashed, Margulis Vitaly
Department of Urology, University of Texas Southwestern Medical Center, Dallas, TX, USA.
Institute for Urology and Reproductive Health, Sechenov University, Moscow, Russia.
Transl Androl Urol. 2020 Aug;9(4):1841-1852. doi: 10.21037/tau.2019.12.29.
Radical nephroureterectomy is the mainstay of surgical treatment for upper tract urothelial carcinoma (UTUC), a disease which comprises approximately 5% of urothelial malignancies. Minimally-invasive and nephron-sparing interventions have been explored, although thus far have not shown comparable oncologic outcomes except in a relatively narrow set of patients. Due to the relative rarity of the disease, it has taken decades and multi-disciplinary efforts to sufficiently identify prognostic factors of oncologic outcomes. Despite these efforts, however, oncologic outcomes of nephroureterectomy have remained remarkably stable over the past 30 years. New techniques, such as laparoscopic and robotic surgery, have been applied to this procedure. High level evidence regarding equivalent oncologic outcomes is lacking and open surgery remains the standard of care for high-stage disease, although there is a role for laparoscopic and robotic nephroureterectomy. The importance of bladder cuff removal in improving oncologic outcomes has been broadly accepted, although there is no consensus as to the most oncologically appropriate technique. There does appear to be evidence that endoscopic techniques confer worse oncologic control. The role of lymphadenectomy remains controversial, although there is evidence that increased nodal yield could have oncologic benefit. Given disease heterogeneity and varied technical approaches to the procedure, no consensus standardized template has been identified. There is level 1 evidence for the use of intravesical chemotherapy peri-operatively and that this intervention can improve the risk of intravesical recurrence. Advances in systemic neoadjuvant and adjuvant chemotherapy have yielded promising results and are likely to become standard of care for patients without contraindications. Immunotherapy and targeted biologic agents are also likely to improve the surgical efficacy of radical nephroureterectomy as well. Ultimately, more high level evidence is needed to identify successful surgical and medical approaches to UTUC and multi-institutional collaboration is critical to this progress.
根治性肾输尿管切除术是上尿路尿路上皮癌（UTUC）外科治疗的主要手段，该疾病约占尿路上皮恶性肿瘤的5%。人们已经探索了微创和保留肾单位的干预措施，尽管到目前为止，除了在相对狭窄的一组患者中，这些措施尚未显示出可比的肿瘤学结局。由于该疾病相对罕见，经过数十年的多学科努力才充分确定肿瘤学结局的预后因素。然而，尽管做出了这些努力，肾输尿管切除术的肿瘤学结局在过去30年中一直保持相当稳定。新技术，如腹腔镜手术和机器人手术，已应用于该手术。缺乏关于等效肿瘤学结局的高级别证据，开放手术仍然是高分期疾病的标准治疗方法，尽管腹腔镜和机器人肾输尿管切除术也有一定作用。广泛接受了切除膀胱袖口在改善肿瘤学结局方面的重要性，尽管对于最符合肿瘤学原则的技术尚无共识。似乎有证据表明内镜技术的肿瘤学控制效果较差。淋巴结清扫术的作用仍存在争议，尽管有证据表明增加淋巴结切除量可能具有肿瘤学益处。鉴于疾病的异质性和该手术的不同技术方法，尚未确定共识性的标准化模板。有1级证据支持围手术期使用膀胱内化疗，并且这种干预可以降低膀胱内复发的风险。全身新辅助化疗和辅助化疗的进展已取得了有希望的结果，并且可能成为无禁忌证患者的标准治疗方法。免疫疗法和靶向生物制剂也可能提高根治性肾输尿管切除术的手术疗效。最终，需要更多的高级别证据来确定成功的UTUC手术和医学方法，多机构合作对于这一进展至关重要。
