Üst Üriner Sistem Tümörlerine Yaklaşım
Özet
Üst üriner sistem ürotelyal karsinomları (ÜÜSÜK), ürotelyal kanserlerin %5-10'unu oluşturan, genellikle ileri yaşlarda ve erkeklerde sık görülen agresif tümörlerdir. Hastalar çoğunlukla hematüri ve yan ağrısı şikayetleriyle başvurmakta, tanı sürecinde BT ürografi, sistoskopi ve üreteroskopi gibi yöntemlerden yararlanılmaktadır. Sigara kullanımı, balkan endemik nefropatisi ve Lynch sendromu gibi faktörler ÜÜSÜK gelişiminde önemli risk etkenleridir. Tedavi yaklaşımı, tümörün evresi, derecesi ve hastanın risk durumuna (düşük veya yüksek risk) göre belirlenir. Düşük riskli vakalarda organ fonksiyonlarını korumak amacıyla üreteroskopik ablasyon veya segmental üreteral rezeksiyon gibi böbrek koruyucu cerrahiler tercih edilirken, yüksek riskli non-metastatik hastalıklarda standart tedavi mesane kafı eksizyonu ile birlikte radikal nefroüreterektomidir (RNÜ). Ayrıca, yüksek riskli hastalarda sağkalım avantajı sağlamak için neoadjuvan veya adjuvan kemoterapi ve immunoterapi gibi sistemik yaklaşımlar tedaviye eklenmektedir. Metastatik hastalıkta ise sisplatin bazlı kombinasyon kemoterapileri ile immün kontrol noktası inhibitörleri temel tedavi seçeneklerini oluşturmaktadır. Hastalarda metakron mesane tümörleri, lokal nüksler ve uzak metastazların erken tespiti için risk sınıflamasına uygun olarak sistoskopi ve BT görüntülemelerini içeren sıkı bir post-operatif takip protokolü uygulanması zorunludur.
Upper urinary tract urothelial carcinomas (UTUC) are aggressive tumors that account for 5-10% of all urothelial cancers, frequently occurring in older men. Patients commonly present with hematuria and flank pain, and diagnosis utilizes CT urography, cystoscopy, and ureteroscopy. Smoking, Balkan endemic nephropathy, and Lynch syndrome represent significant risk factors for developing UTUC. Treatment strategies are guided by tumor stage, grade, and risk classification (low or high risk). For low-risk cases, kidney-sparing surgeries such as ureteroscopic ablation or segmental ureteral resection are preferred to preserve organ function, whereas radical nephroureterectomy (RNU) with bladder cuff excision remains the gold standard for high-risk non-metastatic disease. Additionally, systemic approaches including neoadjuvant or adjuvant chemotherapy and immunotherapy are integrated into high-risk management to improve survival outcomes. Cisplatin-based combination chemotherapies and immune checkpoint inhibitors constitute the primary options for metastatic disease. A strict post-operative follow-up protocol incorporating cystoscopy and CT imaging tailored to risk stratification is mandatory for the early detection of metachronous bladder tumors, local recurrences, and distant metastases.
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