Ürotelyal Kanserlerde Lazer Ablasyon
Özet
Ürotelyal kanserlerin (mesane ve üst üriner sistem tümörleri) tedavisinde lazer ablasyon yöntemlerinin klinik kullanımı, gelişim süreci ile avantaj ve dezavantajları güncel literatür verileriyle sunulmaktadır. Mesane kanseri tedavisinde konvansiyonel rezeksiyon yöntemleri altın standart olmaya devam etse de; lazer ablasyon (özellikle Ho:YAG ve Tm:YAG), lokal anesteziyle günübirlik uygulanabilirliği, etkin hemostaz gücü ve obturator refleks riskini dışlamasıyla öne çıkmaktadır. En önemli limitasyonu histopatolojik evreleme güçlüğü olsa da, güncel "en bloc" rezeksiyon tekniği bu sorunu aşmada ve ikincil cerrahi ihtiyacını azaltmada başarı sağlamaktadır. Üst üriner sistem tümörlerinde (ÜÜST) ise kılavuzlar, böbrek fonksiyonlarını korumak amacıyla özellikle düşük riskli olgularda ve soliter böbrek gibi zorunlu endikasyonlarda endoskopik lazer ablasyonu öncelikli olarak önermektedir. Geçmişte striktür riskini artıran elektrokoter yöntemlerinin yerini alan Nd:YAG, Ho:YAG ve son dönemde öne çıkan Tm:YAG lazer enerjileri, rijid veya fleksibl üreteroskoplar eşliğinde tümör dokusunu başarıyla eradike etmektedir. Operasyon esnasında tümör hücresi ekimini ve darlık gelişimini önlemek için düşük basınçlı irrigasyon ile erişim kılıflarının kullanımı kritik cerrahi basamakları oluşturmaktadır.
Laser ablation modalities in the management of urothelial cancers, specifically bladder and upper urinary tract tumors (UTUC), offer evolving therapeutic pathways, highlighting their clinical efficacy, advantages, and limitations based on contemporary literature. While conventional resection remains the benchmark for bladder tumors, laser ablation therapies—predominantly Ho:YAG and Tm:YAG—serve as robust alternatives due to their feasibility under local anesthesia, superior hemostasis in anticoagulated patients, and the complete absence of obturator nerve stimulation. The primary diagnostic drawback is the limitation regarding precise histopathological staging; however, the emergence of "en bloc" laser resection significantly addresses this challenge, improving vertical staging and reducing secondary resection requirements. Regarding UTUC, international guidelines prioritize nephron-sparing endoscopic laser ablation for low-risk patients and mandatory indications such as functional solitary kidneys or renal insufficiency. Replacing obsolete electrocautery techniques that carry high stricture risks, modern laser systems (Nd:YAG, Ho:YAG, and increasingly Tm:YAG) combined with rigid or flexible ureteroscopy effectively ablate upper tract malignancies. To mitigate procedural complications such as ureteral strictures or pyelovenous reflux-induced tumor seedling, utilizing ureteral access sheaths and maintaining low-pressure irrigation remain critical intraoperative principles.
Referanslar
Herrmann TR, Liatsikos EN, Nagele U, Traxer O, Merseburger AS; EAU Guidelines Panel on Lasers, Technologies. EAU guidelines on laser technologies. Eur Urol. 2012;61(4):783-95.
Staehler G, Schmiedt E, Hofstetter A. Zerstörung von Blasentumoren durch transurethrale Neodym-YAG-Laserbestrahlung [Destruction of bladder neoplasms by means of transurethral neodym-YAG-laser coagulation]. Helv Chir Acta. 1978;45(3):307-11.
Wong KA, Zisengwe G, Athanasiou T, O'Brien T, Thomas K. Outpatient laser ablation of non-muscle-invasive bladder cancer: is it safe, tolerable and cost-effective? BJU Int. 2013;112(5):561-7.
Hashem A, Mosbah A, El-Tabey NA, Laymon M, Ibrahiem EH, Elhamid MA, Elshal AM. Holmium Laser En-bloc Resection Versus Conventional Transurethral Resection of Bladder Tumors for Treatment of Non-muscle-invasive Bladder Cancer: A Randomized Clinical Trial. Eur Urol Focus. 2021;7(5):1035-43.
Malde S, Grover S, Raj S, Yuan C, Nair R, Thurairaja R, Khan MS. A Systematic Review of the Efficacy and Safety of Outpatient Bladder Tumour Ablation. Eur Urol Focus. 2021:S2405-4569(21)00043-2.
Darrad M, Jah S, Ahmed Z, Syed H. Long-Term Prospective Outcomes of Patients with Non-Muscle Invasive Bladder Cancer After Holmium Laser Ablation. J Endourol. 2019;33(11):938-45.
Hermann GG, Mogensen K, Rosthøj S. Outpatient diode laser treatment of intermediate-risk non-invasive bladder tumors without sedation: efficacy, safety and economic analysis. Scand J Urol. 2018;52(3):194-8.
Rouprêt M, Babjuk M, Burger M, Capoun O, Cohen D, Compérat EM, Cowan NC, Dominguez-Escrig JL, Gontero P, Hugh Mostafid A, Palou J, Peyronnet B, Seisen T, Soukup V, Sylvester RJ, Rhijn BWGV, Zigeuner R, Shariat SF. European Association of Urology Guidelines on Upper Urinary Tract Urothelial Carcinoma: 2020 Update. Eur Urol. 2021;79(1):62-79.
Goodman TM. Ureteroscopy with rigid instruments in the management of distal ureteral disease. J Urol. 1984;132(2):250-3.
Sanguedolce F, Fontana M, Turco M, Territo A, Lucena JB, Cortez JC, Vanacore D, Meneghetti I, Gallioli A, Gaya JM, Redorta JP, Breda A. Endoscopic Management of Upper Urinary Tract Urothelial Carcinoma: Oncologic Outcomes and Prognostic Factors in a Contemporary Cohort. J Endourol. 2021;35(11):1593-600.
Metcalf M, Pierorazio PM. Future strategies to enhance kidney preservation in upper urinary tract urothelial carcinoma. Transl Androl Urol. 2020;9(4):1831-40.
Villa L, Haddad M, Capitanio U, Somani BK, Cloutier J, Doizi S, Salonia A, Briganti A, Montorsi F, Traxer O. Which Patients with Upper Tract Urothelial Carcinoma Can be Safely Treated with Flexible Ureteroscopy with Holmium:YAG Laser Photoablation? Long-Term Results from a High Volume Institution. J Urol. 2018;199(1):66-73.
Raman JD, Park R. Endoscopic management of upper-tract urothelial carcinoma. Expert Rev Anticancer Ther. 2017;17(6):545-54.
Petros FG, Li R, Matin SF. Endoscopic Approaches to Upper Tract Urothelial Carcinoma. Urol Clin North Am. 2018;45(2):267-286.
Defidio L, Antonucci M, De Dominicis M, Fuchs G, Patel A. Thulium-Holmium:YAG Duo Laser in Conservative Upper Tract Urothelial Cancer Treatment: 13 Years Experience from a Tertiary National Referral Center. J Endourol. 2019;33(11):902-8.
Samson P, Smith AD, Hoenig D, Okeke Z. Endoscopic Management of Upper Urinary Tract Urothelial Carcinoma. J Endourol. 2018;32(S1):S10-S16.
Linehan J, Schoenberg M, Seltzer E, Thacker K, Smith AB. Complications Associated With Ureteroscopic Management of Upper Tract Urothelial Carcinoma. Urology. 2021;147:87-95.
Ng Chieng Hin J, Hettiarachchilage D, Gravestock P, Rai B, Somani BK, Veeratterapillay R. Role of Ureteroscopy in Treatment of Upper Tract Urothelial Carcinoma. Curr Urol Rep. 2021;22(10):49.
Bozzini G, Gastaldi C, Besana U, Calori A, Casellato S, Parma P, Pastore A, Macchi A, Breda A, Gozen A, Skolarikos A, Herrmann T, Scoffone C, Eissa A, Sighinolfi MC, Rocco B, Buizza C, Liatsikos E. Thulium-laser retrograde intra renal ablation of upper urinary tract transitional cell carcinoma: an ESUT Study. Minerva Urol Nephrol. 2021;73(1):114-21.
Musi G, Mistretta FA, Marenghi C, Russo A, Catellani M, Nazzani S, Conti A, Luzzago S, Ferro M, Matei DV, Carmignani L, de Cobelli O. Thulium Laser Treatment of Upper Urinary Tract Carcinoma: A Multi-Institutional Analysis of Surgical and Oncological Outcomes. J Endourol. 2018;32(3):257-63.
Yoshida T, Murota T, Matsuzaki T, Nakao K, Ohe C, Matsuda T, Kinoshita H. Photodynamic Diagnosis-guided Dual Laser Ablation for Upper Urinary Tract Carcinoma: Preoperative Preparation, Surgical Technique, and Clinical Outcomes. Eur Urol Open Sci. 2021;28:17-25.
Scotland KB, Kleinmann N, Cason D, Hubbard L, Tanimoto R, Healy KA, Hubosky SG, Bagley DH. Ureteroscopic Management of Large ≥2 cm Upper Tract Urothelial Carcinoma: A Comprehensive 23-Year Experience. Urology. 2018;121:66-73.
