Using Laser to Treat UTUC
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High grade disease should not be treated with laser therapy. Conversely, small, low grade UTUC has been treated ureteroscopically (URS) with laser for more than a decade. Low grade Ta disease <1cm has been a good candidate for URS and possibly tumors >1cm and multifocal. A French study of 92 consecutive patients with UTUC treated with endoscopic laser showed the only predictor of progression free survivial was tumor grade at first treatment. Lesions >1cm and multifocality did not predict progression free survival. This study did have a large recurrence rate with more than 1/5 requiring nephroureterctomy and 8.7% developing metastatic disease. The finding of increased risk of death when high grade UTUC is treated with endoscopic laser has been repeated in multiple studies. (1) EAU guidelines recognize patients with solitary lesion <1cm with no signs of invasion on CT to be suitable candidates for conservative treatment (2). It is important to have surveillance ureteroscopy 6-8 weeks after initial therapy due to persistent or recurrent tumor in up to 50% of cases. (3) Previous studies have shown 55-90% recurrence rates of UTUC after laser therapy (4,5,6,7,8) Multiple biopsies, urine cytology, large basket or large biopsy forceps can help ensure reliable pathologic data. (1)
High grade disease should not be treated with laser therapy. Conversely, small, low grade UTUC has been treated ureteroscopically (URS) with laser for more than a decade. Low grade Ta disease <1cm has been a good candidate for URS and possibly tumors >1cm and multifocal. A French study of 92 consecutive patients with UTUC treated with endoscopic laser showed the only predictor of progression free survivial was tumor grade at first treatment. Lesions >1cm and multifocality did not predict progression free survival. This study did have a large recurrence rate with more than 1/5 requiring nephroureterctomy and 8.7% developing metastatic disease. The finding of increased risk of death when high grade UTUC is treated with endoscopic laser has been repeated in multiple studies. (1) EAU guidelines recognize patients with solitary lesion <1cm with no signs of invasion on CT to be suitable candidates for conservative treatment (2). It is important to have surveillance ureteroscopy 6-8 weeks after initial therapy due to persistent or recurrent tumor in up to 50% of cases. (3) Previous studies have shown 55-90% recurrence rates of UTUC after laser therapy (4,5,6,7,8) Multiple biopsies, urine cytology, large basket or large biopsy forceps can help ensure reliable pathologic data. (1)
- Villa, Luca, et al. "Which patients with upper tract urothelial carcinoma can be safely treated with flexible ureteroscopy with holmium: YAG laser photoablation? Long-term results from a high volume institution." The Journal of urology 199.1 (2018): 66-73.
- Rouprêt, Morgan, et al. "European Association of Urology Guidelines on Upper Urinary Tract Urothelial Carcinoma: 2017 Update." European urology 73.1 (2018): 111-122.
- Villa, Luca, et al. "Early repeated ureteroscopy within 6–8 weeks after a primary endoscopic treatment in patients with upper tract urothelial cell carcinoma: preliminary findings." World journal of urology 34.9 (2016): 1201-1206.
- Grasso, Michael, et al. "Ureteroscopic and extirpative treatment of upper urinary tract urothelial carcinoma: a 15‐year comprehensive review of 160 consecutive patients." BJU international 110.11 (2012): 1618-1626.
- Cutress, Mark L., et al. "Long‐term endoscopic management of upper tract urothelial carcinoma: 20‐year single‐centre experience." BJU international 110.11 (2012): 1608-1617.
- Krambeck, Amy E., et al. "Endoscopic management of upper tract urothelial carcinoma in patients with a history of bladder urothelial carcinoma." The Journal of urology 177.5 (2007): 1721-1726.
- Thompson, R. Houston, et al. "Endoscopic management of upper tract transitional cell carcinoma in patients with normal contralateral kidneys." Urology 71.4 (2008): 713-717.
- Pak, Raymond W., Eric J. Moskowitz, and Demetrius H. Bagley. "What is the cost of maintaining a kidney in upper-tract transitional-cell carcinoma? An objective analysis of cost and survival." Journal of endourology 23.3 (2009): 341-346.