Clinical Application Of 2 Micron Continuous Wave Laser In Treatment Of Urothelial Cancer

Introduction:To observe the organization morphologic and pathologic characteristics of 2 micron continuous wave laser for the treatment of bladder urothelial carcinoma.Methods:A total of 58 patients with 69 bladder tumors underwent 2 micron laser via transurethral by caudal or surface anesthesia from Oct.2007 to Mar.2009. It included 44 male and 14 female cases, and the age range from 27 to 81 years old(average 66.1±12.3years).In the operation, we evaporated and exsected the wall of urinary bladder, including tumor, submucosa and all muscular layers. Specimens were sent for pathology examination. To overview these following variables:operative time, blood loss, complications during and after the operation, pathology staging of the tumor and follow-up visit. The organization morphologic changes of raw surfaces were observed one week, one month, three months, six months and one year postoperation by cystoscopy and pathologic examinations.Results:All the patients tolerated in the operation. Clinical stages of the tumor: Ta～T1:46 cases, T2:12 cases. All cases were followed up for 6 to 18 months, average 12.6months. Tumor recurrences were found in 3 cases, no one has recurrence in situ. The tumor, submucosa and all muscular layers can be resected completely by 2 micron continuous wave laser transurethral partial cystectomy. No tumor residual were deteced on the cutting edges. Pathologic staging can be judged correctly. The umbilication raw surface were infiltrated by fibrous connective tissue and chronic inflammatory cells one week postoperation. The umbilication changed shallow and transitional epithelial cells began to cover it one month postoperation. The umbilication dispeared and transitional epithelial cells cover the raw surface three months postoperation. There was no difference between the raw surface and normal bladder mucosa.Conclusions:2 micron continuous wave laser for the treatment of bladder urothelial carcinoma is a new safety and efficacy method. And it can get the same clinical result as partial cystectomy. The pathologic staging can be judged correctly by the specimens. Due to the 2 micron laser can evaporated and exsected the muscular layers of bladder finely, not only can treatment the superficial bladder tumor efficiently, but also refer to part of invasion bladder tumor. Objective:Laparoscopic retroperitoneal nephroureterectomy(LNU) is a well established technique for managing the upper urinary tract urothelial cancer. However, management of the distal ureter remains a controversial issue. We describe a new method of cystoscopic sleeve resection of the distal ureter by 2 micron continuous wave laser before LNU.Medthods:We performed LNU in 18 patients from Jan 2008 to Mar 2010. The lower end of the ureter was managed by our new technique. We evaporated and exsected the ureteric orifice with a bladder cuff using 2 micron continuous wave laser under local anesthesia preoperation. LNU was performed using the standard technique while leaving the ureter intact. The ureter was dissected to the level of the pelvic brim. Then, the distal ureter was easily detached from the bladder.Result:There were 12 male and 6 female patients. Age ranged from 57 to 75 years (mean,66.7 years).Seventeen cases had history of intermittent painless gross hematuria and one had history of lumbar region paining. Tumors were all in the renal pelvis, seven in left and eleven in right side. We achieved cystoscopic sleeve resection of the distal ureter by 2 micron continuous wave laser in all cases. Total mean operating time was 144 minutes (range,110 to 260 minutes). Mean surgical time for the cystoscopic portion was 17.7 minutes (range,12 to 22 minutes).The pathological results included eight high-level urothelial carcinoma and ten low-level urothelial carcinoma. Irrigation fluid extravasation was minimal during the cystoscopic procedure and none of the patients developed intraoperative or postoperative hyponatremia. Mean blood loss was 69.4 ml, however, cystoscopic dissection was associated with minimal blood loss. No patient required a blood transfusion. The drain was usually removed on postoperative day two or three.Complications occurred in one patient. The patient developed an infection of incision in postoperative period. The foley catheter was routinely removed on postoperative day 7 to 9. We did not routinely performe a cystogram. No patient developed evidence or complication of a urinary leak. Mean hospital stay was 9.6 days (range,5 to 20 days) which is common in our health care system, as patients are hesitant to leave the hospital with an indwelling foley catheter; as a result, most discharge followed successful catheter removal and voiding trial. Intravesical chemotherapy of bladder using epirubicin or pirarubicin was performed while removing the catheter, once a week for eight weeks. The follow-up periods were between 1 to 26 months, and the mean period was 12.5 months. Surveillance cystoscopy results were available for the eighteen patients and bladder recurrence occurred in 2 patients (11%). Two of the patients were found to have bladder tumor recurrence in the ipsilateral hemi bladder close to the ureteral scar/orifice. There was no recurrent tumor at the ureteral scar/orifice or in the perivesical space. No patient had port site metastasis.Conclusions:Our new technique appears to be a simple, less invasive, and oncologically safe method to manage the distal ureter perurethrally.