输尿管下段肿瘤致自发性尿外渗的临床诊治分析

Clinical diagnosis and treatment of spontaneous urinary extravasation caused by primary lower ureteral tumor

目的探讨输尿管下段肿瘤导致自发性尿外渗的临床诊治特点。方法总结2005年1月至2010年6月北京协和医院泌尿外科8例输尿管下段肿瘤导致自发性尿外渗患者的临床资料。其中男5例、女3例，年龄56～81岁。突发患侧腰痛起病6例，因腰部不适伴发热就诊2例；8例患者CT平扫均显示肾周积液，增强扫描显示积液中有造影剂填充。6例患者术前影像学检查提示输尿管占位性病变，2例未发现肿瘤。结果6例患者行一侧肾输尿管全长切除术，其中5例行腹膜后腹腔镜手术，手术平均时间152（120～235）min，术中平均失血130（100～430）ml，1例行开放手术，手术时间175rain，出血量200ml；1例患者行输尿管局部切除；1例81岁的患者未接受任何治疗；所有患者均经病理证实为尿路上皮癌。2例患者术后行局部放疗，1例放疗结束后接受吉西他滨化疗。随访6～36个月，5例接受一侧肾输尿管全长切除术的患者未见局部复发及转移，1例患者术后3个月全身多发转移，8个月时死于衰竭。1例行局部切除的患者术后6个月发现局部及膀胱内肿瘤复发，经局部放疗和新辅助化疗后一侧肾输尿管全长切除及膀胱切除术。未行手术者每3个月随访提示肿瘤进展。尿外渗部位均未见肿瘤转移。结论输尿管下段肿瘤梗阻导致自发性尿外渗少见，部位多发生在肾盂周围，尿外渗合并原因不明的输尿管梗阻或狭窄时应尽可能取病理除外肿瘤，根治性手术是首选治疗方式。

Objective To explore the chnical characteristics of spontaneous urinary extravasation caused by primary lower ureteral cancer. Methods Eight cases of spontaneous urinary extravasation caused by the obstruction of primary ureteral cancer from January 2005 to June 2010 from Department of Urology, Peking Union Medical College Hospital, were reported. There were 5 males and 3 females with an age range of 56 - 81 years old. Six cases presented with an onset of acute flank pains and 2 cases complained of flank discomforts with a lower fever. All cases had peripelvic fluid collection of varying levels on computed tomography （CT） scan and extravasation of contrast medium was found in delayed enhanced CT. The tumors of ureter were detected in 6 cases through preoperative imaging examinations while another 2 cases had no evidence of tumor. Results Unilateral nephroureterectomy was performed in 6 cases, including 5 cases undergoing retroperitoneal laproscopic surgery and 1 case with open surgery. In 5 laproscopic operations, the mean operative duration was 152 （120 -235） minutes and the mean estimated intraoperative blood loss 130 （100-430） ml. The patient of open nephroureterectomy had an operative duration of 175 minutes and an intraoperative blood loss of 200 ml respectively. One patient underwent a local resection of ureteral carcinoma. A 81-year-old patient was diagnosed of tumor by uteroscopic biopsy and accepted neither surgery or adjunctive therapy. All patients had a pathological diagnosis of urotheial carcinoma. One patient received local radiotherapy and chemotherapy with gemcitabine after nephroureterectomy while another one had local radiotherapy only. During a follow-up period of 6 -36 months, CT showed that five cases undergoing nephroureterectomy were free of recurrence. One patient with local lymphatic metastasis had a local recurrence, developed multiple metastases at Mouth 3 and died of exhaustion at Month 8 post-operation. The patient with a local resection had a local bladder recurrence at Month 6 and underwent unilateral nephroureterectomy and radical cystectomy after local radiotherapy and neoadjuvant chemotherapy. Tumorprogression was found in the patient without surgery. No implantation metastasis was found. Conclusions Spontaneous urinary extravasation caused by tile obstruction of primary lower ureteral cancer is rare and mostly peripelvie. Biopsy may exclude tumors for those patients with no obvious cause of ureteral obstruction. And radical operation is a preferred option.