Is simultaneous bilateral nephroureterectomy justified for kidney recipients or uremic patients with unilateral upper urinary tract urothelial carcinoma ?

Presented by Yann-Rong Su2012-08-18

TUA Annual Meeting

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.

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 contralateral nephroureterectomy.

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.

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

Ste-BNU

Contralateral NU

Uremic patients or kidney recipients diagnosed with unilateral UUT-UC

pre-operatively

Sim-BNU or unilateral NU?

Sim-BNU

Bilateral UUT-UCor

Unilateral UUT-UC

uni NU with contralateral recurrence

Uni-NU

No contralateral recurrence

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.

Results

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

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)

Discussions

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

metachronous contralateral 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.

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

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

Ste-BNU

Contralateral NU

Uremic patients or kidney recipients diagnosed with unilateral UUT-UC

pre-operatively

Sim-BNU or unilateral NU?

Sim-BNU

Bilateral UUT-UCor

Unilateral UUT-UC

uni NU with contralateral recurrence

Uni-NU

No contralateral recurrence

Limitations

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

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.

Thank for your attention