Patel A, Soonawalla P, Shepherd S F, Dearnaley D P, Kellett M J, Woodhouse C R
Department of Urology, Royal Marsden Hospital, London, United Kingdom.
J Urol. 1996 Mar;155(3):868-74.
The application of conservative surgery has been established in the treatment of transitional cell tumors of the renal pelvis. We reviewed retrospectively the long-term outcome after percutaneous treatment of select patients referred to a tertiary center with transitional cell tumors of the renal pelvis.
We studied 28 patients referred with a presumptive diagnosis of transitional cell carcinoma of the renal pelvis based on filling defects noted on excretory urograms. At percutaneous endoscopy tumor was resected in 26 patients, while no tumor was found in 2. All 19 men and 7 women smoked, and mean age at presentation was 65 years. Of the patients 18 presented with hematuria and 6 had bilateral upper tract tumors. After percutaneous resection, the access tract was irradiated either with iridium wire in 12 patients or a commercial high dose rate radiation delivery system in 12. Thiotepa was instilled into the nephrostomy tube without brachytherapy in 1 patient and 1 received no adjuvant treatment in all. All patients were followed by excretory urography and urine cytology. Cystoscopy and retrograde pyelography were performed when technically possible.
After percutaneous tumor resection 6 patients (23%) had local recurrence in the treated renal pelvis, including 3 at 44, 55 and 60 months, respectively. Further conservative treatment was initially possible in 4 of these patients but ultimately only 2 (both of whom had late recurrences) retained the treated kidney. Of the 11 patients with recurrence elsewhere in the urinary tract the bladder was invariably involved (11), while synchronous or metachronous ureteral recurrence was less common (3). Nine patients remained free of any urothelial recurrence in the upper or lower tract. No patient had recurrent tumor in the nephrostomy tract. Of the patients 7 suffered from procedure-related complications, including 1 who had a persistent urinary fistula that failed to heal after brachytherapy and required nephroureterectomy. There have been 6 deaths during followup, of which 2 were disease related. The 3-year estimated local recurrence-free survival rate was 86% (95% confidence interval 63 to 95%), cause-specific survival rate 91% (95% confidence interval 67 to 98%) and overall survival rate 78% (95% confidence interval 55 to 90%). Differences in recurrence-free survival, comparing those with recurrence in the treated renal pelvis or elsewhere in the urothelium and those remaining disease-free, did not translate to a significant overall survival difference (p < 0.5) between these groups.
Our results suggest that the combination of percutaneous local resection and tract irradiation offers an effective long-term alternative to radical extirpation in the management of select patients with superficial transitional cell carcinoma confined to the renal pelvis. When the postoperative nephrostogram demonstrates a leaking renal pelvis, tract irradiation should not be given.
保守手术已被应用于肾盂移行细胞肿瘤的治疗。我们回顾性分析了在一家三级医疗中心接受经皮治疗的肾盂移行细胞肿瘤患者的长期预后。
我们研究了28例根据排泄性尿路造影发现充盈缺损而被初步诊断为肾盂移行细胞癌的患者。26例患者在经皮内镜下切除肿瘤，2例未发现肿瘤。所有19例男性和7例女性均吸烟，就诊时的平均年龄为65岁。18例患者出现血尿，6例患有双侧上尿路肿瘤。经皮切除术后，12例患者用铱丝照射穿刺通道，12例患者用商用高剂量率放射治疗系统照射。1例患者在没有近距离放射治疗的情况下将噻替派注入肾造瘘管，1例患者未接受任何辅助治疗。所有患者均接受排泄性尿路造影和尿液细胞学检查。在技术可行时进行膀胱镜检查和逆行肾盂造影。
经皮肿瘤切除术后，6例（23%）患者在治疗的肾盂出现局部复发，其中3例分别在44、55和60个月复发。这些患者中最初有4例可行进一步的保守治疗，但最终只有2例（均为晚期复发）保留了接受治疗的肾脏。在尿路其他部位复发的11例患者中，膀胱均受累（11例），而输尿管同时或异时复发较少见（3例）。9例患者上尿路或下尿路未出现任何尿路上皮复发。没有患者在肾造瘘通道出现肿瘤复发。7例患者出现与手术相关的并发症，其中1例出现持续性尿瘘，近距离放射治疗后未愈合，需要进行肾输尿管切除术。随访期间有6例死亡，其中2例与疾病相关。3年估计局部无复发生存率为86%（95%置信区间63%至95%），病因特异性生存率为91%（95%置信区间67%至98%），总生存率为78%（95%置信区间55%至90%）。比较在治疗的肾盂或尿路上皮其他部位复发的患者与无疾病复发的患者，无复发生存率的差异并未转化为这些组之间显著的总生存差异（p<0.5）。
我们的结果表明，对于局限于肾盂的浅表性移行细胞癌患者，经皮局部切除和通道照射相结合为根治性切除提供了一种有效的长期替代方法。当术后肾造影片显示肾盂渗漏时，不应进行通道照射。
