Category: Laparoscopy: Upper Tract - Malignant
Introduction & Objective :
Radical nephro-ureterectomy (RNU) is the standard treatment of upper tract urothelial carcinoma (UTUC). Despite that, an endourological approach may be considered in imperative cases. We present the case of a patient who underwent conservative treatment for multiple high grade UTUC.
Explorative rigid ureteroscopy and flexible ureteroscopy (fURS) (K. Storz) were performed in order to detect the lesions. IMAGE1 S™ (Karl Storz) technology increases dynamic contrast of the lesions. Real-time confocal laser endomicroscopy (CLE) with Cellvizio System® provided in vivo microscopic evaluation of the tissue lesions using a low-energy laser light source. Therefore, biopsies were taken using 3 devices: Piranha, Bigopsy (COOK), and 2.2 Fr Nitinol Baskets. Tumor ablation using holmium (30 W-COOK) and thulium (Revolix – Lisa Laser) was performed.
The age of the patient was 83 with past medical history of high grade (HG) bladder cancer and a functional solitary kidney. Multiple lesions (mean diameter 1.5 cm) were pre-operatively identified at CT scan. Pre-operative serum creatinine and GFR were 1.18 mg/dl and 40 ml/min/1.73 m² respectively. Cellvizio® characterized the lesions as high grade UTUC. A total of 7 biopsies were taken; all the specimens were positive for HG UTUC at the final histopathological results. Cellvizio® found correspondence between the CLE images and the histopathological results. Serum creatinine was 1.40 mg/dl and GFR was 38 ml/min/1.73 m² on postoperative day 7. Postoperative drop of hemoglobin to 8.5 required two units of blood and patient recovered fine. CT scan at two months follow-up was negative for recurrence.
Multiple and/or high-grade UTUC may be treated endoscopically in patients with imperative indications, particularly in old population. The combination of holmium and thulium laser allows a satisfactory ablation of UTUC. Due to the high risk of tumor recurrence and progression, a strict follow-up is mandatory.
Alberto Breda– Barcelona, Catalonia, Spain
Angelo Territo– licata, Sicilia, Italy
Giuseppe Basile– Reggio Calabria, Calabria, Italy
Helena Vila-Reyes– Barcelona, Catalonia, Spain
Jose maria Gaya– Barcelona, Catalonia, Spain
Joan Palou– Chairman of Urology Departmentt at Fundacio Puigvert. Chair of the European School of Urology, Fundació Puigvert, Autonomous University of Barcelona, Barcelona, Spain, Barcelona, Catalonia, Spain