Prognostic factors in laser treatment of upper urinary tract urothelial tumours

INTRODUCTION The standard treatment for upper urinary tract urothelial cell carcinoma (UUT-UCCs) is radical nephroureterectomy with bladder cuff excision. The endoscopic treatment was introduced with promising results in selected cases. The purpose of this study was the retrospective analysis of the factors that can influence the prognosis of the patients with UUT-UCCs who underwent endoscopic treatment. PATIENTS AND METHOD We identified 187 patients who where diagnosed and treated for UUT-UCCs, between 1998 - 2011, in the Urology Department of "Sf. Ioan" Clinical Emergency Hospital, Bucharest. The endoscopic treatment was used in 65 cases. The indications for endoscopic treatment were imperative (41 cases) or elective (24 cases). The retrograde approach (rigid or flexible) was used in 47 cases, while the anterograde approach was preferred in 18 cases. Tumor ablation was performed using electroresection or Nd:YAG laser. The mean follow-up period was 60 months (range between 6 and 120 months). The follow-up protocol included computed tomography or intravenous urography, urinary cytology (selected cases), cystoscopy and ureteroscopy. The recurrence rates were reviewed by retrospective analysis. RESULTS During follow-up 31 patients (47.6%) presented upper urinary tract recurrence. In 20 cases (30.7%) bladder recurrence was present. The median time from diagnosis to first recurrence was of 12.6 months. 18 patients (27.69%) underwent subsequent nephroureterectomy. The survival rates without recurrence at 1, 3 and 5 years were 61% (40 patients), 55.3% (36 patients) and 52.3% (34 patients). The most significant prognostic factors were: history of bladder tumour, tumour location and size, tumour stage and grade. The recurrence rate for pyelocaliceal tumours was 53.84% (21 out of 39 cases) and only 45.45% (10 out of 26 cases) for ureteral tumours. The recurrence rate for low-grade tumours was 36,36% (16 out of 44 cases) and 71.42% (15 out of 21 cases) for high-grade tumours. The tumours over 1.5 cm were associated with a higher recurrence rate compared with tumours below 1.5 cm (64.2 versus 43.13%). CONCLUSIONS Endoscopic management of UUT-UCCs offers the advantage of preserving of renal function. Laser treatment of malignant urothelial lesions in the upper urinary tract should be reserved for a selected patient. The most important prognostic factors for UUT-UCCs evolution are tumours location, size and mostly tumour grade. The patients' compliance is very important for detecting recurrences.