Gibt es Indikationen zur organerhaltenden Tumorresektion bei Urothelkarzinomen des oberen Harntraktes?

Zusammenfassung

Zielsetzung: Identifikation von Prognosefaktoren für ein Tumorrezidiv in der operierten renalen Einheit und einen Tumorprogress nach organerhaltender Chirurgie. Patienten und Methode: Von 06/1989 bis 02/2003 wurden 43 Patienten (47 renale Einheiten) wegen eines Urothelkarzinoms des oberen Harntrakts organerhaltend operiert, 26 (60,5 %) unter elektiver Indikation (gesunde kontralaterale Niere). Ergebnisse: Der mittlere Follow-up betrug 39,2 Monate (range 10,6 - 168,3). Ipsilaterale Rezidive wurden in 13 reno-ureteralen Einheiten (27,6 %) entdeckt. Rezidive traten signifikant häufiger bei einer Tumorlokalisation im Nierenbecken bzw. -abgang gegenüber einer Lokalisation im Ureter auf (p = 0.018). Ein Tumorprogress trat bei 8 von 43 Patienten (18,6 %) auf und war signifikant verbunden mit dem T- und G-Stadium des Primärtumors. (p = 0.006 und p = 0.002) Von den 47 konservativ behandelten renalen Einheiten wurden 38 (80,8 %) erhalten. Schlussfolgerung: Organerhaltende Resektionen bei Urothelkarzinomen des oberen Harntraktes sind eine Alternative bei einigen Patienten mit gut differenzierten oberflächlichen Tumoren. Ein lebenslanger Follow-up und eine gute Patientencompliance sind erforderlich. Nierenbeckentumore haben eine signifikant höhere Rezidivrate als Harnleitertumore. Entdifferenzierte Tumore sollten nur in Palliativsituationen organerhaltend behandelt werden und bei einigen Patienten mit Einzelniere nach intensive Beratung über hohes Risiko für invasive Rezidive und Ausbildung einer metastasierenden Erkrankung.

Abstract

Purpose: Identification of prognostic factors for tumor recurrence in nephronsparing surgery and tumor progression after organ-preserving surgery. Material and Methods: From June 1989 to February 2003, 43 patients (47 nephron units) underwent organ-preserving surgery or the upper urinary tract because of urothelial carcinoma, with 26 (60.5 %) having an elective indication (healthy contralateral kidney). Results: The mean follow-up was 39.2 months with a range of 10.6 to 168.3 months. Ipsilateral recurrences occurred in 13 (27.6 %) of reno-ureteral units. Recurrences were significantly more common for tumors located in the renal pelvis or opposite the ureteral origin (p = 0.018). Tumor progression occurred in 8 of 43 patients (18.6 %) and significantly correlated with the T- and G-stage of the primary tumor (p = 0.006 and p = 0.002). Of the 47 conservatively treated reno-ureteral units, 38 (80.8 %) could be preserved. Conclusion: Organ-preserving resection of the urothelial carcinoma of the upper urinary tract is an alternative in some patients with well-differentiated superficial tumors. A follow-up for life and a good patient compliance are necessary. Tumors of the renal pelvis have a significantly higher recurrence rate than ureteral tumors. Poorly differentiated tumors should undergo organ-preserving surgery only if the goal is palliation and in patients with solitary kidney after intensive consultation about the high risk of invasive recurrences and the development of metastases.

Schlüsselwörter

Neoplasma - Ureter - Nierenbecken - Harnblase - Übergangsepithelkarzinom

Key words

Neoplasm - ureter - renal pelvis - bladder - transitional cell carcinoma - surgery

Literatur

• 1 Strong D W, Pearse H D, Tank Jr E S, Hodges C V. The ureteral stump after nephroureterectomy.  J Urol. 1976;  115 654-655
• 2 Zincke H, Neves R J. Feasibility of conservative surgery for transitional cell cancer of the upper urinary tract.  Urol Clin North Am. 1984;  11 717-724
• 3 Krogh J, Kvist E, Rye B. Transitional cell carcinoma of the upper urinary tract: prognostic variables and post-operative recurrences.  Br J Urol. 1991;  67 32-36
• 4 Hall M C, Womack S, Sagalowsky A I. et al . Prognostic factors, recurrence, and survival in transitional cell carcinoma of the upper urinary tract: a 30-year experience in 252 patients.  Urology. 1998;  52 594-601
• 5 Park S, Hong B, Kim C S, Ahn H. The impact of tumor location on prognosis of transitional cell carcinoma of the upper urinary tract.  J Urol. 2004;  171 621-625
• 6 Jabbour M E, Desgrandchamps F, Cazin S. et al . Percutaneous management of grade II upper urinary tract transitional cell carcinoma: the long-term outcome.  J Urol. 2000;  163 1105-1107
• 7 Goel M C, Mahendra V, Roberts J G. Percutaneous management of renal pelvic urothelial tumors: long-term follow-up.  J Urol. 2003;  169 925-929
• 8 Elliott D S, Segura J W, Lightner D. et al . Is nephroureterectomy necessary in all cases of upper tract transitional cell carcinoma? Long-term results of conservative endourologic management of upper tract transitional cell carcinoma in individuals with a normal contralateral kidney.  Urology. 2001;  58 174-178
• 9 Chen G L, Bagley D H. Ureteroscopic management of upper tract transitional cell carcinoma in patients with normal contralateral kidneys.  J Urol. 2000;  164 1173-1176
• 10 Gerber G S, Steinberg G D. Endourologic treatment of renal pelvic and ureteral transitional cell carcinoma.  Tech Urol. 1999;  5 77-80
• 11 Deligne E, Colombel M, Badet L. et al . Conservative management of upper urinary tract tumors.  Eur Urol. 2002;  42 43-48
• 12 Suh R S, Faerber G J, Wolf Jr J S. Predictive factors for applicability and success with endoscopic treatment of upper tract urothelial carcinoma.  J Urol. 2003;  170 2209-2216
• 13 Iborra I, Solsona E, Casanova J. et al . Conservative elective treatment of upper urinary tract tumors: a multivariate analysis of prognostic factors for recurrence and progression.  J Urol. 2003;  169 82-85
• 14 Martinez-Pineiro J A, Garcia Matres M J, Martinez-Pineiro L. Endourological treatment of upper tract urothelial carcinomas: analysis of a series of 59 tumors.  J Urol. 1996;  156 377-385
• 15 Maier U, Mertl G, Pummer K. et al . Organ-preserving surgery in patients with urothelial tumors of the upper urinary tract.  Eur Urol. 1990;  18 197-200
• 16 Palou J, Piovesan L F, Huguet J. et al . Percutaneous nephroscopic management of upper urinary tract transitional cell carcinoma: recurrence and long-term follow-up.  J Urol. 2004;  172 66-69
• 17 Clark P E, Streem S B, Geisinger M A. 13-year experience with percutaneous management of upper tract transitional cell carcinoma.  J Urol. 1999;  161 772-775
• 18 Jarrett T W, Sweetser P M, Weiss G H, Smith A D. Percutaneous management of transitional cell carcinoma of the renal collecting system: 9-year experience.  J Urol. 1995;  154 1629-1635
• 19 Mazeman E. Tumours of the upper urinary tract calyces, renal pelvis and ureter.  Eur Urol. 1976;  2 120-126
• 20 Keeley F X, Kulp D A, Bibbo M. et al . Diagnostic accuracy of ureteroscopic biopsy in upper tract transitional cell carcinoma.  J Urol. 1997;  157 33-37
• 21 Chen G L, El Gabry E A, Bagley D H. Surveillance of upper urinary tract transitional cell carcinoma: the role of ureteroscopy, retrograde pyelography, cytology and urinanalysis.  J Urol. 2000;  164 1901-1904
• 22 Komatsu H, Tanabe N, Kubodera S. et al . The role of lymphadenectomy in the treatment of transitional cell carcinoma of the upper urinary tract.  J Urol. 1997;  157 1622-1624
• 23 Leissner J, Ghoneim M A, Abol-Enein H. et al . Extended radical lymphadenectomy in patients with urothelial bladder cancer: results of a prospective multicenter study.  J Urol. 2004;  171 139-144
• 24 Rey A, Lara P C, Redondo E. et al . KI67 proliferation index in tumors of the upper urinary tract as related to established prognostic factors and long-term survival.  Arch Esp Urol. 1998;  51 204-210
• 25 Lee S H, Lin J S, Tzai T S. et al . Prognostic factors of primary transitional cell carcinoma of the upper urinary tract.  Eur Urol. 1996;  29 266-270
• 26 Kamai T, Kawakami S, Koga F. et al . RhoA is associated with invasion and lymph node metastasis in upper urinary tract cancer.  BJU Int. 2003;  91 234-238
• 27 Patel A, Fuchs G J. New techniques for the administration of topical adjuvant therapy after endoscopic ablation of upper urinary tract transitional cell carcinoma.  J Urol. 1998;  159 71-75