上尿路上皮癌手术中输尿管膀胱壁内段3种切除方法的疗效比较

Comparison of three different approaches in managing bladder cuff in nephroureterectomy for patients with upper urinary tract urothelium carcinoma

目的比较开放式袖套状切除、经尿道电切以及经尿道铥激光切除输尿管膀胱壁内段治疗上尿路上皮癌的疗效。方法回顾性分析上海交通大学附属第一人民医院2004年5月至2009年5月利用3种不同方法切除输尿管膀胱壁内段治疗上尿路上皮癌的病例共49例。其中开放性输尿管膀胱壁内段袖套状切除术22例(A组),经尿道电切镜切除输尿管膀胱壁内段15例(B组),经尿道铥激光输尿管膀胱壁内段切除12例(C组)。比较3种方法的手术时间、术中失血量、导尿管留置时间、腹膜后引流管留置时间、术后住院时间以及肿瘤复发率。结果 B、C两组与A组相比,手术时间明显缩短(平均分别为198、183、262min,P<0.05);术中失血量明显减少(平均分别为140、135、363mL,P<0.05);术后住院时间明显缩短(平均10、8、12d,P<0.05);而B、C两组之间比较差异无统计学意义(P>0.05)。3组术后腹膜后引流管与导尿管平均留置时间无明显差异(P>0.05)。中位随访时间49个月(12～72个月),其中A组术后膀胱肿瘤复发5例(22.7%),腹膜后肿瘤复发1例(6.7%);B组术后膀胱肿瘤复发4例(26.7%);C组术后膀胱肿瘤复发2例(16.7%)。对比3组术后膀胱肿瘤复发率,差异无统计学意义(P=0.91)。结论与传统开放手术行输尿管膀胱壁内段袖套状切除术相比较,经尿道输尿管膀胱壁内段电切除术或激光切除术手术时间短、术后出血少、恢复快、不增加术后肿瘤种植及复发率。其中经尿道铥激光输尿管膀胱壁内段切除术更具有切割精确、手术安全性高等特点,有较好的临床应用前景。

Objective To compare the clinical efficacy of open surgery of the urinary bladder cuff, transurethral resection of the ureteral orifice by electrosurgical loop and transurethral resection of the ureteral orifice by thulium laser technique to treat upper urinary tract urothelium carcinoma. Methods Between May 2004 and May 2009, 49 patients with upper urinary tract urothelium carcinoma underwent three different approaches respectively to manage the urinary bladder cuff or ureteral orifice. 22 cases （group A） received open surgery of bladder cuff resection, 15 cases （group B） transurethral resection of the ureteral orifice by electrosurgical loop, and 12 cases （group C） transurethral resection of the ureteral orifice by thulium laser technique. The operation time, intraoperative blood loss, catheterizing time, drainage mounting time, post-operative hospital stays and the malignancy recurrence were compared. Results The mean operation time of group B and C was significantly shorter than that of group A （198 min,183 min vs. 262 rain, P〈0.05）, the mean intraoperative blood loss was significantly less （140 mL,135 mL vs. 363 mL, P〈0.05）, and the mean post-operative hospital stays were significantly reduced （10 d, 8 d vs. 12 d, P〈0. 05）, whereas there was no significant difference between group B and group C in these indexes （P 〈0.05）. There were no significant differences in the duration of postoperative retro-peritoneal drainage and Foley catheterization among the three groups （P〈0.05）. During the follow-up of 12-72 months （average 49 months）, the recurrence rate of urinary bladder urothelial tumor for Group A, B, C was 22.7% （5/22）, 26.7% （4/15） and 16.7% （2/15）, with no significant difference （P=0.91）. Among all the three groups, there was only one case of retroperitoneal urothelial tumor recurrence. Conclusions Compared with open surgery of the urinary bladder cuff, transurethral resection of the ureteral orifice by electrosurgical loop or by thulium laser are minimally invasive, with shorter operating time, quicker recovery and less blood loss, without increasing the risk of neoplasm recurrence. In particular, transurethral resection of the ureteral orifice by thulium laser is safer and more accurate than the other two approaches. Thulium laser technique is a promising technique in the management of ureteral orifice during the radical surgery of the upper urinary tract urothelial carcinoma.