Application of kidney sparing surgery based on Thulium laser ablation and systemic therapy in localized high-risk UTUC
Objective To investigate the efficacy and safety of kidney sparing treatment based on Thulium laser ablation and systematic therapy in localized high-risk upper urinary tract urothelial carcinoma(UTUC).Methods The data of 10 patients with UTUC who received combined treatment based on Thulium laser and systematic treatment from January 2020 to December 2021 in West China Hospital were retrospectively analysed.There were 5 males and 5 females with a median age of 76(range 52 to 87)years old.Three cases were renal pelvis tumor and 7 cases were ureter tumor including 5 cases in lower ureter and 2 cases in upper and middle ureter.Five cases were with positive urine cytology and 6 cases were with hydronephrosis.One case was muscular invasion UTUC confirmed by biopsy(cT2+),7 cases were high-grade invasive urothelial carcinoma(cT1+),and 2 cases were high-grade papillary urothelial carcinoma(cTa).Among 10 cases,5 patients refused radical nephroureterectomy(RUN),among whom 3 patients were too old or in poor general condition to tolerate RNU.One case had a solitary kidney and 1 case had bilateral tumours.Patients were treated with Thulium laser tumor ablation under ureteroscopy combined with systemic therapy.The perioperative systemic treatment included platinum-based chemotherapy±immunotherapy,RC48+immunotherapy,and immunotherapy alone.The postoperative treatment was immunotherapy maintenance±local radiotherapy.Strict follow-up was conducted after the completion of treatment.Results Nine patients received systemic therapy before ablation.Four cycles of platinum-based chemotherapy(cisplatin in 2 cases,carboplatin in 1 case)were used in 3 cases,and platinum-based chemotherapy+immunotherapy(6 cycles of cisplatin+toripalimab in 1 case,4 cycles of cisplatin+toripalimab in 1 case,4 cycles of carboplatin+trelizumab in 1 case)was used in 3 cases,four cycle of RC48+immunotherapy(toripalimab or trelizumab)were used in 2 cases,and four cycles of immunotherapy(toripalimab)were used in 1 case.The operations of 10 cases were successfully completed without serious complications during the perioperative period and the laser working time(42.4±15.2)min.Of the 10 cases,4 achieved complete ablation at the first ablation,and 6 patients had incomplete ablation.Among them,2 patients achieved clinical complete remission after 1-2 cycles of systemic therapy,and 4 patients achieved complete ablation after Thulium laser ablation again.All the 10 patients were treated with immunotherapy for 1 year,and 2 of them received additional adjuvant radiotherapy.The patients were followed-up for median 40 months(range 26 to 53 months).Recurrence occurred in 5 cases,of which 3 cases underwent salvage nephroureterectomy and 2 cases underwent Thulium laser ablation under ureteroscopy again.Five patients had no tumor recurrence.None of the 10 patients had distant metastasis.At the last follow-up,1 patient died of complications and 6 patients kept the affected kidney alive.Perioperative complications including macroscopic hematuria(8 cases),fever(3 cases),the long-term complications of ureter stenosis(4 cases).Conclusions For localized high-risk UTUC,local Thulium laser ablation combined with systemic therapy can achieve good tumor control while preserving the affected kidney in selected patients,and its potential application value should be further evaluated.
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