What Is the Cost of Maintaining a Kidney in Upper-Tract Transitional-Cell Carcinoma? An Objective Analysis of Cost and Survival
For many years, the gold standard in upper urinary tract transitional-cell carcinoma (UT-TCC) management has been nephroureterectomy with excision of the bladder cuff. Advances in endourologic instrumentation have allowed urologists to manage this malignancy. The feasibility and success of conservative measures for UT-TCC have been widely published, but there has not been an objective cost analysis performed to date. Our goal was to examine the direct costs of renal-sparing conservative measures v nephroureterectomy and subsequent chronic kidney disease (CKD) or end-stage renal disease (ESRD). Secondary analysis includes a discussion of survival and quality-of-life issues for both treatment cohorts.
Retrospective review of a cohort of patients treated at our institution with renal-sparing ureteroscopic management of UT-TCC who were followed for a minimum of 2 years. The costs per case were based on equipment, anesthesia, surgeon fees, pathologic evaluation fees, and hospital stay. ESRD and CKD costs were estimated based on published reports.
From 1996 to 2006, 254 patients were evaluated and treated for UT-TCC at our institution. A cohort of 57 patients was examined who had a minimum follow-up period of 2 years. Renal preservation in our series approached 81%, with cancer-specific survival of 94.7%. Assuming a worst-case scenario of a solitary kidney with recurrences at each follow-up for 5 years v nephroureterectomy and dialysis for the same period, an estimated $252,272 U.S. dollars would be saved. This savings would cover the expenses of five cadaveric renal transplantations.
Conservative endoscopic management of UT-TCC in our experience should be the gold standard management for low-grade and superficial-stage disease. From a cost perspective, renal-sparing UT-TCC management is effective in reducing ESRD health care expenses.
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- "The long-term survival rates of patients after RNU and renal-sparing surgery were comparable in several retrospective studies with long-term follow- up[3,5,8,9]. In addition, renal-sparing management is more cost-effective than RNU. Even for patients with "
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- "Patients with low-stage, low-grade tumours respond well to either radical or conservative surgical treatment. In a retrospective review of patients treated with renal-sparing ureteroscopic management, Pak et al.reported that renal preservation approached 81%, with cancer-specific survival of 94.7%. There was significant cost savings over the cost of nephroureterectomy; these authors recommend conservative endoscopic management as the gold standard for low-grade and superficial-stage disease. "
- "This minimally invasive approach can reduce the morbidity of treatment whilst preserving renal function. With the expanding role of renal sparing technique, low grade lesions in patients with normal contralateral kidneys can also be treated ureterorenoscopicaly. Recent reports suggest that endoscopic management can be an alternative treatment option for low grade superficial tumors even as a first line management. "
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ABSTRACT: Instillation of Mitomycin C (MMC) should prevent implantation of cancer cells released during endoscopic treatment and prevent recurrences as seen in carcinoma of the bladder.
TO DEVELOP AND EVALUATE A PROTOCOL FOR A SINGLE DOSE MMC INSTILLATION FOLLOWING HOLMIUM: YAG laser ablation of upper urinary tract transitional cell carcinoma (UUT-TCC).
A single institute prospective study.
MMC instillations protocol was designed and offered to patients between August 2005 and April 2011. Following tumor ablation, MMC was instilled into upper urinary tract (UUT) over 40 minutes. All the patients were regularly followed up.
Twenty UUT units (19 patients) were managed for UUT-TCCs using our MMC protocol. Two UUT units had G1pTa tumors, 14 had G2pTa, 2 had G3pTa, and 2 had G3pT1. At a mean follow-up of 24 months (range 1-72 months), 13/20 (65%) of the UUT units remained cancer-free, 3 (15%) UUT units developed stricture and were treated with endoscopic dilatation, only 1 (5%) of these developed long-term complications. None of the patients developed postoperative renal impairment or systemic side-effects.
Using a set standard protocol, MMC can safely be instilled into the UUT after TCC ablation with minimal complications or side effects, good preservation of renal function, and with a low recurrences rate comparable to the literature.
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