Diode Laser for the Management of Upper Tract Urothelial Cancer (UTUC) – Case Series.

Abstract

Background and Objective: Upper tract urothelial carcinoma (UTUC) is uncommon; however, at the time of diagnosis, they are usually more invasive than bladder urothelial carcinomas. Although nephroureterectomy (NU) has been the gold-standard treatment, guidelines have been set for kidney-sparing treatment in selected groups of patients. While these guidelines are aimed towards patients fit for salvage radical treatment, little has been published on managing the symptomatic patient not fit for NU. Various modalities of endoscopic ablation in managing UTUC have been described in the literature, but there is currently no reported use of the diode laser. Therefore, we aim to assess its efficacy and safety profile in the ablation of UTUC in patients unfit for major abdominal surgery in radical nephroureterectomy regardless of the tumour grade and size.
 Patients and method: A single centre retrospective review of patients who underwent Diode Laser treatment for UTUC over 4 years was done. Follow up through 6 monthly ureteroscopy alternating with computed tomography (CT) urogram was done to assess the need for further treatment.
 Results: 30 patients were identified, with mean age 76 years (64-88) and variable tumour locations, including lower and mid ureter and renal pelvis, upper and lower calyces. 76.7% were ASA 3 and 20% ASA 4. The mean tumour size was 3.8 cm (2-7 cm). The mean number of sessions was 2.1 (1-6). 63.3% of the tumours were grade 2, while 30% were grade 3. A case of metastatic renal-cell carcinoma was diagnosed as a 4 cm filling defect in the kidney where the diode laser was used for resection biopsy and ablation. 16.7% experienced Clavien-Dindo grades 1-2 complications. A total of 6.7% of patients were converted to an inpatient stay. None of the patients needed blood transfusion nor did any develop a ureteric stricture on subsequent ureteroscopies. 48.3% of patients experienced clinical recurrences of which 57.1% were at a different site. Two of the patients developed metastatic disease. One patient died 3 years after initial treatment with disease progression.
 Conclusion: The management of UTUC with diode laser is a safe and efficacious conservative treatment for disease and symptom control in patients unfit for radical treatment.

Current Evidence on Utility, Outcomes, and Limitations of Endoscopic Laser Ablation for Localized Upper Urinary Tract Urothelial Carcinoma: Results from a Scoping Review

“…Similarly, Martínez-Piñeiro et al [10] , in their retrospective case series of 19 cases, found a recurrence rate of 42.1%. They also reported a poorer prognosis for patients with ureteral tumors than those with renal pelvis [14] . This was attributed to ureteric location, concerns about inadvertent perforation, and poor visibility during endoscopic laser ablation.…”

“…Jimie et al [14] showed that management of UTUC with diode laser was safe and effective, providing symptom control in patients unfit for radical treatment. In their series, the authors reported its successful use in 63.3% of grade 2 tumors and 30% in grade 3 tumors, with an overall rate of 16.7% Clavien grade ≤2 complications, with no patient needing a blood transfusion.…”

“…The remaining 274 full-text papers were evaluated for relevance, and 247 were subsequently excluded. Ultimately, 27 papers were deemed suitable and included in this review [9] , [10] , [11] , [12] , [13] , [14] , [15] , [16] , [17] , [18] , [19] , [20] , [21] , [22] , [23] , [24] , [25] , [26] , [27] , [28] , [29] , [30] , [31] , [32] , [33] , [34] , [35] . Figure 1 illustrates the flowchart of the literature search process.…”

“…Most of the studies were retrospective [9] , [10] , [11] , [12] , [13] , [14] , [16] , [17] , [18] , [19] , [22] , [23] , [24] , [25] , [26] , [27] , [28] , [29] , [30] , [31] , [32] , [33] , [35] , [36] , while four were prospective [15] , [20] , [21] , [34] . There were four comparative studies [16] , [19] , [22] , [32] , and the other ones were single series [9] , [10] , [11] , [12] , [13] , [14] , [15] , [17] , [18] , [20] , [21] , [23] , [24] , [25] , [26] , [27] , [28] , [29] , [30] , [31] , [33] , [34] , [35] . In six studies, the combination between electroresection and laser ablation was applied [9] , [10] , [11] , [12] , [26] , [27] .…”

“…In six studies, the combination between electroresection and laser ablation was applied [9] , [10] , [11] , [12] , [26] , [27] . Three articles employed neodymium laser [9] , [10] , [11] , [12] , [13] , [14] , one diode laser [14] , six holmium laser [15] , [16] , [17] , [18] , [19] , [20] , four thulium laser [21] , [22] , [23] , [24] , six the combination of neodymium and holmium laser [25] , [26] , [27] , [28] , [29] , [30] , [31] , [32] , and three the combination of thulium and holmium laser [33] , [34] , [35] .…”