Penatalaksanaan CA Ureter

7/25/2019 Penatalaksanaan CA Ureter

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According to European Association of Urology (EAU) guidelines, conservative

management is appropriate for low-risk upper tract urothelial carcinomas.[!EAU

indications of low risk are as follows"

Unifocal tumor

#umor si$e % cm

&ow-grade tumor (cytology or 'iopsies)

o evidence of an infiltrative lesion on # urography

Understanding of close follow-up

#reatment recommendations (all grade ) for these low-risk tumors are as follows[!"

&aser should 'e used in endoscopic treatments

*le+i'le ureteroscopy is prefera'le to rigid ureteroscopy
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A percutaneous approach can 'e used in small low-grade caliceal tumors unsuita'le for

ureteroscopic treatment

Ureteroureterostomy is indicated for noninvasive low-grade tumors of the pro+imal ureteror midureter that cannot 'e removed completely via endoscopy

omplete distal ureterectomy and neocystostomy is indicated for noninvasive, low-grade

tumors in the distal ureter that cannot 'e removed completely via endoscopy, and for

high-grade, locally invasive tumors

ephroureterectomy with e+cision of the 'ladder cuff is considered the standard therapy

in patients with high-volume renal pelvis transitional cell carcinoma (#), regionally

e+tensive disease, and high-grade or high-stage lesions.

egmental ureterectomy coupled with ureteral reimplantation is indicated in patients withureteral tumors located in the distal ureter, generally of lower grade and stage.

Unfortunately, 'ecause of the multifocal nature of #, the ipsilateral recurrence rate is

/ or greater after segmental ureterectomy.

0enal-sparing surgery, including segmental ureterectomy and endoscopic therapy,maintains a vital role in the management of upper tract urothelial tumors. #ypically,

patients with small, low-grade superficial lesions are the 'est candidates for this

approach. ome investigators use this approach more fre1uently in patients with a solitary

kidney, 'ilateral disease, compromised renal function, synchronous tumors, or greater'aseline operative risk.

Open radical nephroureterectomy

ephroureterectomy is the standard for large, high-grade tumors of the renal pelvis and

pro+imal ureter that are organ-confined or locally advanced. ephroureterectomy is also

recommended for multifocal, recurrent, low-grade tumors, which are found to 'e less

amena'le to ureteroscopic management.

lassically, this procedure involves removal of the kidney, ureter, and 'ladder cuff via athoracoa'dominal or flank approach, with a separate lower-1uadrant 2i'son incision.

&aparoscopic approaches to the radical nephroureterectomy are now commonplace and

offer some postoperative 'enefits.


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3n 'oth open and laparoscopic surgeries, care is taken to e+cise the entire distal ureter and

'ladder cuff to prevent local recurrence.

E+cision of the cuff has a survival 'enefit.[45!

#here are multiple effective approaches,[4!as follows"

6pen e+cision and repair of cystotomy

Endoscopic 7pluck7 techni1ue

#ransurethral resection of the intramural ureter

3ntussusception techni1ue

&ymphadenectomy, which generally re1uires little additional operative time, is performed

for staging purposes and potentially offers a therapeutic 'enefit.

Laparoscopic nephroureterectomy

#he indications and oncologic surgical principles for laparoscopic nephroureterectomy

are similar to those of the open approach.

8ure laparoscopic transperitoneal and retroperitoneal approaches, as well as hand-assistedlaparoscopic approaches, have 'een descri'ed. #he optimal techni1ue depends largely on

surgeon e+perience.

9anagement of the 'ladder cuff remains varia'le. ome investigators prefer hand-

assisted laparoscopic en 'loc e+cision of the distal ureter with closure of the cystotomydefect.

Open versus laparoscopic nephroureterectomy

6perative time is compara'le to that of the standard open procedure.
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&aparoscopic nephroureterectomy offers the 'enefits of minimally invasive surgery,

including less 'lood loss, shorter hospitali$ation, and improved cosmetic result.[4:!

0ecent studies have shown compara'le oncologic outcomes 'etween open and

laparoscopic nephroureterectomy.[4:, 4;!

imone et al conducted a randomi$ed control trial that demonstrated significantly lower'lood loss (!

Ureteroscopic treatment

Ureteroscopy offers a renal-preserving alternative to traditional nephroureterectomy andis used in patients with compromised renal function, 'ilateral upper tract disease, or other

medical contraindications to nephroureterectomy. Ureteroscopic a'lation is now the

preferred choice for low-grade upper tract #. @owever, management of upper tracttumors with this approach is associated with the need for multiple additional procedures

versus more definitive surgical management.

Ureteroscopy allows 'iopsy and treatment of tumors along the entire upper urinary tract.

old-cup 'iopsy forceps or a flat-wire 'asket is used for tissue diagnosis and to

determine tumor grade to plan for future intervention.

#he use of d"BA2 and @o"BA2 lasers, as well as small *-4* electrosurgical devices,

ena'le ureteroscopic resection, coagulation, and a'lation of upper tract tumors underdirect vision.

3n


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ureteroscopic management and ;>/ for percutaneous approach. #he disease-specific

survival rate was >/ for ureteroscopy and =>/ for percutaneous resection.

Also in .;/ and the disease-

specific survival rate was ==.>/ at years.

Another study e+amined >< patients with upper tract # managed endoscopically whohad a history of 'ladder cancer. #hey found that the recurrence-free survival rate at

years was only >/ in this group. #he authors of this study recommended a low

threshold for more aggressive surgical intervention 'ased up stage and grade migration.[5!

2rasso et al pu'lished their -year e+perience of ureteroscopic and e+tirpative therapyand concluded that uteroscopic management was an accepta'le option for managing low-

grade disease.[5!

#he following are technical considerations for ureteroscopic treatment of upper tract

tumors[54!"

6'tain ade1uate tissue during initial 'iopsy for accurate diagnosis and grade

9inimi$e the risk of stricture with the use of laser rather than the more deeply penetrating

electrosurgical devices when a'lating ureteral tumors

Crain the 'ladder with a small catheter or use a ureteral access sheath to improve flowand visi'ility, which can 'e limited 'y 'leeding

*acilitate resection 'y slowing the patientDs respiratory rate, which decreases movement

and sta'ili$es the operative field during resection and a'lation
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Percutaneous treatment

8ercutaneous therapy allows the use of larger scopes with improved maneuvera'ility and

visi'ility to a'late larger tumors in the renal pelvis and upper ureter. 8ercutaneous access

may 'e used to administer topical therapeutic agents such as 2 or mitomycin. #hisapproach is an accepta'le alternative to nephroureterectomy in patients with lowFgrade

disease. @owever, as with all organ-preserving strategies, vigilant follow-up surveillanceis re1uired.

8ercutaneous techni1ues allow a renal-sparing approach and are well suited for large-volume disease of the renal pelvis and pro+imal ureter.

8ercutaneous access to the diseased renal unit is esta'lished, followed 'y tract dilation.

#his allows the passage of nephroscopes, laser fi'ers, 'iopsy forceps, and electrosurgical

resection devices to completely resect and a'late tumors under direct vision.

8ercutaneous access also allows for a deeper resection and more accurate staging thanureteroscopy for tumors of the renal pelvis and kidney.

#umor seeding of the nephrostomy tract, although rare, has 'een reported and is

associated with high-grade lesions.

Radical nephroureterectomy versus conservative, endoscopic management

o randomi$ed studies have 'een performed, and no studies have had good long-term

follow-up. election 'ias confounds nonstandardi$ed studies. #umors treated with

endoscopic management are generally smaller, of low grade, and of low stage.

#he -year disease-specific survival rate in patients with low-grade disease is statisticallysimilar for conservative treatment and immediate nephroureterectomy, at =:.-


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9enurut pedoman Asosiasi Urologi Eropa (EAU), manaGemen konservatif sesuai untuk

U#U yang 'erisiko rendah [! adapun indikasi EAU untuk U#U risiko rendah adalahse'agai 'erikut.

#umor Unifokal

Ukuran tumor % cm

#umor grade rendah (sitologi atau 'iopsi)

#idak ada 'ukti lesi infiltratif pada # urografi

0ekomendasi pengo'atan (semua kelas ) untuk U#U risiko rendah terse'ut adalah

se'agai 'erikut [!"

&aser harus digunakan dalam perawatan endoskopik

Ureteroscopy fleksi'el le'ih 'aik daripada ureteroscopy kaku

9anaGemen perkutan dapat digunakan pada caliceal tumor yang 'erisiko kecil namun

tidak cocok untuk pengo'atan Ureteroscopic Ureteroureterostomy diindikasikan untuk low grade tumor noninvasif dari ureter

proksimal atau midureter yang tidak dapat dihilangkan sepenuhnya melalui

endoskopi Ureterectomy distal lengkap dan neocystostomy diindikasikan untuk noninvasif,

tumor kelas rendah di ureter distal yang tidak dapat dihapus sepenuhnya melalui

endoskopi, dan untuk 'ermutu tinggi, tumor invasif lokal

ephroureterectomy dengan eksisi manset kandung kemih dianggap terapi standar

pada pasien dengan high-volumepelvis ginGal karsinoma sel transisional (#), penyakitregional yang luas, dan tumor dengan stage atau tahap lesi yang tinggi.

Ureterectomy segmental ditam'ah dengan ureter reimplantation diindikasikan pada

pasien dengan tumor ureter yang terletak di ureter distal, umumnya dari kelas yang le'ih

rendah. ayangnya, karena sifat multifokal dari #, tingkat kekam'uhan ipsilateral

adalah / atau le'ih 'esar setelah ureterectomy segmental.6perasiRenal-Sparing, termasuk segmental ureterectomy dan terapi endoskopik,

mempertahankan peran penting dalam pengelolaan U#U. iasanya, pasien dengan lesisuperfisial kecil dan low grademerupakan yang ter'aik untuk pendekatan ini. e'erapa

peneliti menggunakan pendekatan ini le'ih sering pada pasien dengan ginGal soliter,

penyakit 'ilateral, compromised renal function, tumor sinkron, atau risiko operasi dasaryang le'ih 'esar.


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6pen 0adical ephroureterectomy

ephroureterectomy adalah pendekatan standar untuk tumor yang 'esar, tumor

pelvis ginGal yang high-grade dan tumor pada ureter proksimal yang ter'atas pada organ

lokal. ephroureterectomy Guga dianGurkan untuk tumor multifokal, 'erulang, tumorderaGat rendah, yang didapati kurang sesuai untuk manaGemen Ureteroscopic.iasanya,

prosedur ini meli'atkan pengangkatan ginGal, ureter, dan manset kandung kemih melalui

pendekatan thoracoa'dominal atauflank, dengan sayatan pemisahan kuadran rendah2i'son. 8endekatan laparoskopi ke nephroureterectomy radikal sekarang 'iasadilakukan

dan mem'erikan 'e'erapa manfaat pasca operasi.

Calam kedua operasi 'aik yang ter'uka dan laparoskopi, dilakukan pengangkatan

untuk seluruh distal ureter dan kandung kemih manset untuk mencegah kekam'uhanlokal. Eksisi manset ini sendiri memiliki manfaat untuk kelangsungan hidup. [45! Ada

'e'erapa pendekatan yang efektif, [4! se'agai 'erikut"

#er'uka eksisi ter'uka dan per'aikan cystotomy

#eknikPluck Endoskopi

0eseksi transurethral dari ureter intramural

#eknik intususepsi

ephroureterectomy laparoskopi

3ndikasi dan prinsip-prinsip 'edah onkologi untuk nephroureterectomy laparoskopi

mirip dengan pendekatan open nephroureterectomy. Haktu operasi se'anding dengan

prosedur standar open nephroureterectomy. ephroureterectomy laparoskopimenawarkan manfaat operasi minimal invasif, termasuk rendahnya resiko kehilangan

darah, waktu untuk rawat inap le'ih pendek, dan peningkatan hasil kosmetik. [4:!

tudi ter'aru menunGukkan hasil onkologi se'anding antara open nephroureterectomy danlaparoskopi. [4:, 4;!

Ureterectomy distal

alah satu pendekatan 'ermutu tinggi untuk tumor 'esar pada ureter distal yangpaling sering dikelola dengan ureterectomy distal dengan ureterovesical reimplant.

eldres et al menunGukkan dengan pendekatan ini tingkat kelangsungan hidup kanker

tertentu tahun setara 'ila di'andingkan dengan nephroureterectomy, terlepas daristagingnya.

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Penatalaksanaan CA Ureter