预防肾盂输尿管癌术后再发膀胱癌的手术方法研究

Preventing strategies of bladder cancer recurrence after surgery for upper tract urothelial carcinoma

目的探讨预防肾盂输尿管癌术后再发膀胱癌的手术方法。方法对156例单纯肾盂癌、单纯输尿管癌中获随访的139例患者资料进行回顾性总结。肾盂癌78例,输尿管癌61例。肿瘤细胞分级:G119例,G288例,G332例。肿瘤分期:Ta^T138例,T280例,T3~T421例。肿瘤直径0.8~6.0 cm。结果139例均行根治性肾、输尿管及管口周围部分膀胱壁(1.5~2.0 cm)切除术。术后随访1~10年,再发膀胱癌55例,占39.6%。肾盂癌术中先用纱条结扎输尿管后游离切除患肾输尿管及管口周围部分膀胱者术后膀胱癌再发率18.5%(5/27),未先结扎输尿管者再发率27.5%(14/51)。术后当日膀胱灌注化疗者膀胱癌再发率32.3%(10/31),术后3周开始膀胱灌注化疗者膀胱癌再发率34.9%(30/86)。术后当日及术后序贯膀胱灌注化疗者术后膀胱癌再发率20.0%(4/20),单纯术后序贯膀胱灌注化疗者膀胱癌再发率39.3%(26/66),2者比较差异有统计学意义(P<0.01)。结论术后当日及术后序贯膀胱灌注化疗可有效降低肾盂输尿管癌术后膀胱癌的再发率,游离切除肾输尿管前先结扎输尿管对预防肾盂癌术后再发膀胱癌可能有益。

Objective To investigate the methods for preventing bladder cancer recurrence after surgical treatment for upper tract urothelial carcinoma. Methods Of the 156 patients who underwent total nephroureterectomy for clinically localized transitional cell carcinoma of the upper urinary trace, 139 were followed up and their data were retrospectively analyzed. Of the 139 cases,78 had pyelic carcinoma and 61 had ureteral carcinoma. The tumor cell grading showed G1 in 19 cases,G2 in g8 and G3 in 32. The tumor staging showed Ta -T1 in 38 cases,T2 in 80 and T3 - T4 in 21. The tumor diameter ranged from 0.8 to 6.0 em. Results Radical nephroureterectomy and resection of partial bladder wall around the ureteral orifice （ 1.5 - 2.0 cm） were performed in all the 139 patients;of whom 55 （39.6%） experienced subsequent bladder cancer recurrence during a mean follow-up of 52 months （ range ,1 - 10 years）. The bladder cancer recurrence rate was 18.5% （5/27） in patients whose ureter had been ligated before the kidney was dissociated; and the recurrence rate was 27.5% （ 14/51 ） in patients whose ureter had not been firstly ligated. The recurrence rates in those who had prophylactic intravesical instillation immediately after surgery and in those who had the instillation 3 weeks after surgery were 32.3% （ 10/31 ） and 34.9% （30/86）, respectively. The recurrence rate was 20.0% （4/20） in those who had intravesical instillation on the surgical day and 3 weeks after surgery sequentially, which was significantly lower than that （39.3% ,26/66） in those who had the instillation simply 3 weeks after surgery （P 〈 0. 001 ）. Conclusions The prophylactic intravesical chemotherapy on the surgical day and 3 weeks after surgery may be a useful approach for reducing the recurrence of bladder cancer after surgery for upper urinary tract tumors. It may contribute to prevent the recurrence of bladder cancer to ligate the ureter before dissociating and resecting the kidney and ureter.