Introduction & Objective :
To evaluate the safety and efficacy of retrograde intrarenal Thulium-Holmium:YAG laser treatment of UTUC.
From 2005 to 2016 we enrolled 146 consecutive patients with new diagnosis of UTUC undergoing diagnostic uretero-renoscopy and thulium laser treatment at one referral institution.
The instruments utilized were the Semirigid Ureteroscope 7Fr and Flexible Uretero-renoscope 7.5Fr (KSE).
The Laser source was the Thulium-Holmium YAG (Revolix Duo) at 10 watts, with 270 micron fibers. Biopsies were made with nitinol basket 2.2Fr+3Fr flexible cup forcep.
We applied EAU guidelines follow-up scheme: endoscopic control + cytology initially every 3 months, then every 6 months for 2 years, and then annually; with yearly Uro-CT.
Mean age at surgery was 70.7 years old (range 19-91, SD 8.49).
Median follow-up was 36.7 (range 12-120) months.
Imperative cases consisted of 21 (14.4%) solitary kidney patients. Bilateral UTUC was reported in 9 (6.2%) patients.
Solitary tumours were reported in 91 patients (62.3 %), multiple in 55 patients (37.7%).
Tumors were > 1 cm in dimension in 83 (56.9%) patients, ≤ 1cm in 63 patients (43.1%).
Tumors at diagnoisis, were only above the uretero-pelvic junction (UPJ) in 55 patients (37.7%), and only below the UPJ in 71 patients (48.6%), with 20 patients (13.7%) having synchronous lesions above and below the UPJ.
Biopsies revealed low-grade disease in 98 (67.2%) patients, high-grade in 44 (30.1%) patients, and 4 patients (2.7%) had tumor where grading was not possible (single small initial tumor), but cytology was negative with low grade recurrences during follow-up.
Final stage was pTa in 120 (82.2%), with higher stage lesions (≥T1) in the rest.
At first follow up, 52 patients (35.6%) were recurrence-free, 71 patients (48.6%) had recurrences, and 23 patients (15.8%) underwent nephroureterectomy (21 for >pT1-HG disease + 2 for extensive LG-UTUC not amenable to RIRS).
During follow-up, 61 patients (41.8%) were continuously recurrence-free, 55 patients (37.7%) had multiple recurrences treated conservatively, 30 patients (20.5%) underwent nephro-ureterectomy.
The Kidney Preserving Rate in patients with solitary kidney or bilateral tumors was 91.8%.
No major complication was registered; 90.4% were discharged on the 1st post-op day.
The conservative treatment of UTUC with Thulium-Holmium:YAG Duo laser was safe and oncologically effective over a ten year period.
Complete UTUC Grading, and if possible, Staging, coupled with regular endo-surveillance, are mandatory in order to optimize an individualized therapeutic strategy for each patient, and to have good timely disease control.
Chief of Urology
Cristo Re Hospital, Dept. of Urology, Rome, Italy
Rome, Lazio, Italy