后腹腔镜联合膀胱电切镜治疗上尿路移行细胞癌

Retroperitoneoscopic nephroureterectomy with transurethral bladder-cuff excision for renal pelvic and ureteral tumors

目的介绍后腹腔镜行肾输尿管全长及膀胱袖状电切治疗上尿路移行细胞癌的经验。方法经后腹腔镜施行肾输尿管全长及膀胱袖状切除术32例。其中输尿管肿瘤20例,肾盂肿瘤12例。肿瘤位于右侧17例,左侧15例。2例输尿管肿瘤合并膀胱肿瘤。经尿道电切镜距输尿管口约0.5 cm环形切透膀胱全层,对输尿管末端电灼彻底封闭输尿管开口。输尿管末端电切结束退出电切镜后留置尿管。采用腰部3个穿刺套管针入路,行根治性肾切除,输尿管尽量向下游离,下腹部行5～9 cm切口,取出肾标本,然后行下端输尿管及膀胱袖状切除。结果31例手术顺利,1例术前有经皮肾镜术史,术中发生十二指肠瘘,手术中转开放修补十二指肠,术后恢复顺利。手术时间2.0～6.5 h,平均3.5 h。出血量25～1 500 ml,平均163 ml。术后随访2～36个月。29例患者无瘤存活;1例患者术后2个月发生膀胱、盆腔转移,目前带瘤存活;1例患者术后2年发生膀胱肿瘤,电切后无瘤存活;1例患者术后第3个月死于心脏疾病。结论经后腹腔镜手术治疗肾盂和输尿管肿瘤,切口明显小于开放手术,术后恢复快。用电切镜环状切除输尿管末端可完整切除输尿管。

Objective To report our experience on retroperitoneoscopie nephroureterectomy with excision of a bladder-cuff for renal pelvic and ureteral tumors. Methods Thirty-two patients （ 18 women and 14 men; mean age, 68 years; age range, 48-83 years） with upper urinary tract tumors underwent retro-peritoneal laparoscopic nephroureterectomy with excision of a bladder-cuff. Of the 32 eases, 12 had pelvic tumors and 20 had ureteral tumors; 17 eases had the tumors on the right side and 15 on the left. Two eases had ureteral tumors combined with bladder tumors. The needle electrode was used to incise the ureter cuff in bladder 0.5 cm away from the ureterostoma. Three trocars in the waist were used for dissecting the kidney. An incision of 5-9 cm was created in the lower abdo- men to allow dissection of the distal ureter and bladder-cuff and intact specimen extraction. Results The operation was successful in 31 patients. One ease transferred to open surgery because of duodenal leakage. The mean operative time was 3. 5 h（range, 2.0-6.5 h）. The mean estimated blood loss was 163 ml（range,25-1 500 ml）. Three cases received blood transfusion. The patient＇s activity recovered in 24-32 h after operation. Postoperative pathology showed transitional cell carcinoma in 30 cases, poorly differentiated ad in 1 （ureter）, squamous cell carcinoma in 1（ureter）. Duodenal leakage occurred in 1 patient who had history of percutaneous nephroseope（PCN） during the operation. The mean hospital stay was 12 d. During a mean follow-up of 15 months（range, 2-36 months）, 1 patient developed pelvic and bladder metastasis after 2 months and was alive with the tumor, 1 patient developed bladder tumor after 2 years and received TURBT, 1 patient died of heart disease after 3 months. The other 29 patients survived free of tumor. Conclusions Our data dem onstrate that retro-Peritoneoscopic nephroureterectomy was minimal invasive treatment for renal pel- vic and ureteral tumors.