后腹腔镜下肾输尿管全长切除加经尿道膀胱袖状切除治疗上尿路上皮癌

Clinical outcomes of retroperitoneal laparoscopic nephroureterectomy with bladder-cuff resection of upper urinary tract carcinoma

目的:探讨后腹腔镜下肾输尿管全长切除加经尿道膀胱袖状切除术治疗上尿路上皮癌的临床效果。方法:上尿路上皮癌患者68例,男23例,女45例,平均年龄63(43～78)岁。肾盂癌55例,输尿管上段肿瘤4例,输尿管下段肿瘤9例。其中输尿管下段肿瘤合并膀胱肿瘤1例。经尿道膀胱镜患侧输尿管逆行插入输尿管导管引流肾盂尿,用电切镜针状电极距输尿管口周围约0.5cm环形切透膀胱壁,分离出输尿管开口及膀胱壁内段。拔除输尿管导管,电凝输尿管开口,使开口封闭,减少肿瘤细胞种植机会。采用腰部3个穿刺套管针入路,行后腹腔镜下根治性肾切除,输尿管尽量向下游离,如果是肾盂癌或输尿管上段肿瘤,用腹腔镜分离钳可以将下段输尿管提拉出来,扩大套管切口,将肾输尿管全长完整取出,避免了下腹部开放切口;如果是下段输尿管肿瘤,则需下腹部行5～7cm切口,先取出肾标本,再行输尿管下段切除术。结果:68例手术顺利。手术时间平均120(90～240)min,术中出血量平均60(40～500)ml,1例需输血。术后引流管留置时间平均4(3～7)d,导尿管留置时间平均8(7～15)d,拔除尿管后均行B超检查无膀胱漏尿。术后病理报告均为尿路上皮癌。65例患者获随访平均18(3～38)个月。58例患者无瘤生存,3例死于心脑血管及肺部疾病。4例术后患膀胱肿瘤而行电切治疗。结论:后腹腔镜下肾输尿管全长切除加经尿道膀胱袖状切除治疗上尿路上皮癌,手术安全易行,用电切镜环状切除输尿管开口及膀胱壁内段可完整切除输尿管,对输尿管开口进行电凝封闭可减少肿瘤细胞种植。对肾盂癌及上段输尿管肿瘤患者可避免行下腹部开放切口的输尿管下段切除术,有效减少创伤,疗效可靠,无肿瘤种植转移。

Objective：To investigate the clinical outcomes of retroperitoneoscopic nephroureterectomy with excision of a bladder-cuff for upper urinary tract carcinoma. Method： Sixty-eight patients（23 men and 45 women, mean age 63 years, age range, 43-78 years） with upper urinary tract transitional cell carcinoma （55 cases in renal pelvis, 4 in the upper ureter and 9 in the low ureter, hut one of which was combined with bladder carcinoma）. We insert the ureter catheter under the retrograde motion using the cystoscope in order to drain the renal pelvis urine. The needle electrode was used to circleround incise the bladder thoroughly 0.5 cm away from the ureterostoma, dissected the joint of opening of the ureter and bladder. Then pull out the ureter catheter,congeal and close the o- pening of the ureter to reduce the opportunity of the tumor cells spread. Three troears in the waist were used for dissecting the kidney,and the ureter was dissected as far distally downward. If tile tumor was in the renal pevis or the upper ureter, we could use the pliers to pull out the down ureter, enlarged the cuff cut, then took out the renal and the whole ureter, so we could avoid the abdomen cut. If the tumor was in the lower ureter, then an incision of 5-9 cm was created in the lower abdomen to allow dissected of the distal ureter and intact specimen extraction. Re- suit：All 68 operation procedures were successfully performed without complication. The mean operation time was 120 minutes. The mean hemorrhage was 60 ml （40 500）, one needed blood transfusion. The mean time with drainage and Foley catheter were 4 days （3-7） and 8 days （7-15）, all the patients were given the type-B ultrasonic to evaluate the leakage of urine around the bladder. All the pathological reports were urinary tract urothelial cell carcinomas. The follow up time ranged from 3 to 38 months （mean 18 month）. 58 cases were survivalled withouttumors, 3 died to the cadiovascular disease and pulmonary disease, 4 cases with tumor of bladder underwent the TUR. Conelusion：Retroperitoneoscopie nephrourctterectomy with excision of a bladder-cuff for upper urinary tract carcinoma was safe and easy going, the needlc electrodc was nsed to circleround incise the bladder thoroughly the joint of opening of the ureter and bladder, which can complelely excise the ureter. Then pull out the ureter cathe- ter, congeal and close the opening of the ureter tbrongh electric coagulation to reduce the opportunity of the tumor cells spread. What＇s more, when the tumor in the renal pelvis and upper ureter can avoid the abdomen incision, which can reduce the trauma effectively with a dependable effect and no tumor implantation metastasis.