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Presented by Yann-Rong Su 2012-08-18

TUA Annual Meeting. Presented by Yann-Rong Su 2012-08-18. Is simultaneous bilateral nephroureterectomy justified for kidney recipients or uremic patients with unilateral upper urinary tract urothelial carcinoma ?. Introduction.

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Presented by Yann-Rong Su 2012-08-18

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  1. TUA Annual Meeting Presented by Yann-Rong Su 2012-08-18 Is simultaneous bilateral nephroureterectomy justified for kidney recipients or uremic patients with unilateral upper urinary tract urothelial carcinoma ?

  2. Introduction • Bilateral disease in the patients with upper urinary tract urohtelial carcinoma (UUT-UC), either synchronous or matachronous, is seen in 1% to 4% of patients. • The incidence of UUT-UC in uremic patients and immunosuppressed organ recipient is higher than general population. • The surgical treatment of choice in UUT-UC is nephroureterectomy (NU) and bladder cuff resection.

  3. Introduction • NU for UUT-UC might be extended to bilateral NU in this population for prophylaxis of contralateral recurrence despite only the evidence of malignancy at one side. • There was no study demonstrating the benefits of prophylactic contralateralnephroureterectomy.

  4. Introduction • We conducted the study to compare the oncological outcome in unilateral UUT-UC patients who underwent simultaneous bilateral nephroureterectomy (simBNU) and those underwent stepwise bilateral nephroureterectomy (steBNU) if contralateral recurrence occurred.

  5. Material and Methods • Retrospective medical chart review at NTUH • January 2001 to November 2011 • Inclusion criteria • Uremic patients with maintenance dialysis or kidney recipients • Unilateral UUT-UC was diagnosed pre-operatively with image study, ureterorenoscopic biopsy or cytology • Bilateral nephroureterectomy and bladder cuff resection were performed in one anasthesia. (Sim-BNU) • Nephroureterectomy was performed in the patients with contralateral recurrence of UUT-UC, who had undergone unilateral nephroureterectomy before. (Ste-BNU) • Urothelial carcinoma was found in specimen

  6. Uremic patients or kidney recipients diagnosed with unilateral UUT-UC pre-operatively Sim-BNU or unilateral NU? Sim-BNU Bilateral UUT-UC or Unilateral UUT-UC Ste-BNU Contralateral NU Uni-NU No contralateral recurrence uni NU with contralateral recurrence

  7. Material and Methods • Exclusion criteria • No malignancy found in pathology • Bilateral UUT-UC diagnosed pre-operatively • Sim-BNU is strongly indicated • Adequate residual native kidney function • Interference of quality of life in decision making • Uremic patients had received regular dialysis for less than 3 months before sim-BNU or 2nd NU of stepwise BNU.

  8. Results

  9. The characteristics of the patients diagnosed with unilateral upper urinary urothelial carcinoma pre-operatively and confirmed with pathology

  10. Oncological outcome • Bilateral disease found in sim-BNU group • 25% (11/44) • 3-year bladder recurrence rate • 31% in sim-BNU v.s. 52% in ste-BNU (p=0.04) • 3-year disease recurrence rate • 10.8% in sim-BNU v.s. 0% in ste-BNU (p=0.18)

  11. Discussions

  12. Bilateral UUT-UC • In patients diagnosed with unilateral UUT-UC and treated with sim-BNU, the positive rate of contralateral UUT-UC was 25% in our series. • Huang et al. reported • Among the 462 patients, 52 (11.3%) developed metachronouscontralateral UC. • The 10-year contralateral disease-free survivals was 75.7%. International Journal of Urology (2006) 13, 864–869 • This might justified prophylactic sim-BNU in uremic patients or kidney recipients.

  13. Bladder Recurrence • The 3-year bladder recurrence rate is lower in sim-BNU group than in ste-BNU group. (31% v.s. 52%) • Kang et al. reported the incidence of recurrent bladder tumors was 31.2%. Cancer (2003) 98,1620-1626

  14. Local Recurence and Metastasis • No difference between sim-BNU and ste-BNU • The incidence of local recurrence is 20% in uni-NU group • Old age • mean 68.5 y/o, 60 and 59 in sim- and ste-BNU respectively • High grade pathology and high T & N stage • 90% high grade UC • T2N0(3), T4N0(1), T2N2(2) in 16 patients

  15. Uremic patients or kidney recipients diagnosed with unilateral UUT-UC pre-operatively Sim-BNU or unilateral NU? Sim-BNU Bilateral UUT-UC or Unilateral UUT-UC Ste-BNU Contralateral NU Uni-NU No contralateral recurrence uni NU with contralateral recurrence

  16. Limitations • Heterogenous patient group • No standardized diagnostic protocol • Small patient number in both group • Selection bias in ste-BNU group

  17. Conclusions • The higher rate of bilateral disease might justified sim-BNU in uremic patients kidney recipients. • Sim-BNU can reduce the urinary bladder recurrence but it failed to reduce the local recurrence and the distant metastases compared with ste-BNU.

  18. Thank for your attention

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