DIFFERENT TREATMENT STRATEGIES FOR END STAGE RENAL DISEASE IN PATIENTS WITH TRANSITIONAL CELL CARCINOMA CHING-FANG WU, JIA-JEN SHEE, DONG-RU HO, WEN-CHENG CHEN AND CHIH-SHOU CHEN* From the Departments of Surgery (Division of Urology) and Radiation Oncology (W-CC), Chang Gung Memorial Hospital, Chia-Yi, Taiwan, Republic of China ABSTRACT Purpose: Transitional cell carcinoma is the most common urinary tract cancer in Taiwanese patients on dialysis. It is a unique finding compared within Western countries. Due to this geographic difference and a higher recurrence rate a more extensive operation and aggressive followup protocols should be refined for these patients on dialysis. Materials and Methods: We retrospectively reviewed the medical records of all patients with transitional cell carcinoma who had end stage renal disease and underwent hemodialysis. Records were reviewed for hemodialysis duration, initial tumor location, tumor grade, stage, operative method, operative complication and final surgical status. Tumor grade and stage was determined by the WHO and proposed Jewett systems. Six patient groups were classified according to final surgical status for comparative analysis. Results: A total of 30 patients were included in this study. Painless gross hematuria and urethral bloody discharge were the most common complaints. Tumor in 25 of the 30 cases was high grade and all were early stage. Of the patients 11 (36.7%) had undergone bilateral nephroureterectomy and radical cystectomy in as a 1 or multiple step procedure. Six patients (20%) had undergone bilateral nephroureterectomy at 1 or 2 sequential operations. Seven of the 13 patients (53.8%) in whom low urinary tract transitional cell carcinoma was initially treated with transurethral resection unfortunately had recurrent transitional cell carcinoma of the upper urinary tract. Ten of the 14 patients (71.4%) with upper urinary tract transitional cell carcinoma who underwent nephroureterectomy and bladder cuff excision had subsequent transitional cell carcinoma within the bladder. Conclusions: Patients with transitional cell carcinoma on dialysis had a higher recurrence rate in the upper urinary tract than patients not on dialysis. Most cases were at an early stage but with high grade tumor behavior. In 11 patients (36.7%) total exenteration of the urinary tract except the urethra was eventually done. The final bilateral nephroureterectomy rate was 56.7%. Since the rate of total exenteration and bilateral nephrectomy was abnormally high at such a short followup, 1-step bilateral nephroureterectomy and radical cystectomy are a recommended treatment for patients with transitional cell carcinoma on dialysis. KEY WORDS: kidney; carcinoma, transitional cell; dialysis; urinary tract Patients with uremia are at higher risk for urological can- cers even before hemodialysis. 1, 2 Transitional cell carcinoma (TCC) is the most common carcinoma in Taiwanese patients with uremia, as reported previously. 3–6 It is a unique finding in the Asian population compared with the population of Western countries. Renal cell carcinoma is the most common urinary tract carcinoma in Western patients with uremia. In reviewed articles there were no specific treatment protocols mentioned for patients with TCC on dialysis. We have treated these groups as patients with TCC but with normal renal function. In general, patient with ureteral or renal pelvic TCC underwent nephroureterectomy (NU) and blad- der cuff excision. Patient with superficial bladder TCC were treated with a transurethral resection procedure. If the blad- der muscle layer was invaded, radical cystectomy was per- formed. Chemotherapy or radiotherapy was applied depend- ing on tumor stage. Cystoscopy and urine cytology were done every 3 months with excretory urography every half year and computerized tomography yearly. Unfortunately in our clin- ical observations treatment and postoperative followup pro- tocols for patients with TCC not on dialysis are not appro- priate those with TCC on dialysis because of their special characteristics, including a multifocal lesion, a high recur- rence rate, contraindication to contrast imaging and intoler- ance of chemotherapy and radiotherapy. Due to these geo- graphical differences, and the different tumor behaviors and characteristics of patients on dialysis an operative treatment strategy should be reconsidered for these patients, especially if cancer is in early stage. In this retrospective clinical study we present a rational, alternative operative treatment con- cept and strategy for patients with transitional cell carci- noma on dialysis. MATERIALS AND METHODS This retrospective study was done to investigate whether surgical treatment protocols for patients with TCC who have normal renal function are suitable for patients with TCC on hemodialysis. Patients with TCC who had received regu- lar hemodialysis for 3 months and had no other malignancy were enrolled in this study. From January 1988 to January 2000, 30 dialysis cases with TCC was found and reviewed. The underlying pathogenesis of renal failure was not clear Accepted for publication August 22, 2003. * Correspondence and requests for reprints: Division of Urology, Department of Surgery, Chang Gung Memorial Hospital, No. 6, Chia-Pu West Road, Chia-Yi, Taiwan, 613, Republic of China (tele- phone: 886-5-3621000; FAX: 886-5-3621000, extension 2761; e-mail: pettychen@cgmh.org.tw). 0022-5347/04/1711-0126/0 Vol. 171, 126 –129, January 2004 THE JOURNAL OF UROLOGY ® Printed in U.S.A. Copyright © 2004 by AMERICAN UROLOGICAL ASSOCIATION DOI: 10.1097/01.ju.0000101758.41635.28 126