经尿道电切联合双J管置入术治疗输尿管口周围膀胱肿瘤的疗效分析

Analysis of the efficacy of treatment of bladder tumors around ureteral orifice by transurethral plasmakinetic resection combined with double J tube placement

目的探讨经尿道等离子电切术(PKRBt)联合双J管置入在处理输尿管口周围膀胱肿瘤中的临床效果。方法回顾性分析我院2011年9月至2017年5月41例输尿管口周围非肌层浸润性膀胱癌(NMIBC)患者的临床资料,其中2014年12月至2017年5月的23例患者作为试验组,手术方式采用PKRBt联合双J管置入术;2011年9月至2014年11月18例患者作为对照组,仅行常规PKRBt术。所有患者术前均经CTU证实无输尿管扩张、肾积水,无上尿路肿瘤,术后均坚持吡柔比星膀胱灌注化疗及膀胱镜定期随访。试验组留置双J管期间,嘱患者口服α受体阻滞剂(坦索罗辛)与M受体阻滞剂(索利那新)改善输尿管支架管相关症状,术后3个月拔除双J管。结果所有手术均顺利完成,无中转开放,试验组患者在留置双J管期间,联合服用坦索罗辛与索利那新后其输尿管支架管相关性躯体疼痛症状得到明显改善,亦未出现持续的不可耐受的尿频尿急尿不尽等下尿路症状;所有患者在维持膀胱灌注化疗药物期间均无严重不良反应发生。经过4~79个月的随访,试验组均未发生输尿管狭窄或肾积水,膀胱镜下见输尿管口外观及喷尿均正常;对照组3例出现患侧输尿管口瘢痕狭窄,其中2例经行输尿管膀胱再植术,1例经行小儿输尿管镜下狭窄段输尿管扩张术。试验组膀胱肿瘤复发8例,对照组7例,复发部位均不在原电切创面,双J管置入后亦未发现上尿路有肿瘤的种植。结论针对输尿管口周围的非肌层浸润性膀胱肿瘤,为了降低PKRBt术后输尿管口狭窄的发生率,常规于电切术前在患侧输尿管内留置双J管,此法不会增加肿瘤细胞逆行种植上尿路的风险,也不会严重影响患者的生活质量,值得临床上推广应用。

Objective To investigate the clinical effect of transurethral plasmakinetic resection combined with double J tube placement for the treatment of bladder tumors around ureteral orifice. Method The clinical data of 41 cases with non-muscle invasive bladder cancer around ureteral orifice between September 2011 and May 2017 were analyzed. In the experiment group, 23 cases underwent PKRBt with double J tube placement, 18 cases in control group were treated with routine PKRBt. All patients were confirmed by CTU without ureteral expansion, hydronephrosis, and upper urinary tract tumors preoperatively. Postoperative intravesical instillation of pirarubicin chemotherapy and cystoscopy were followed up regularly. During the indwelling double J tube in the experimental group, the patients received oral alpha-blocker(Tamsulosin) and M-blocker(Solifenacin) to improve the ureteral stenting associated symptoms, and the double-J tube was removed 3 months after operation. Result All operations were successfully accomplished without conversion to open surgery. In the experiment group, patients had significantly improved their ureteral stentrelated somatic pain symptoms after combined administration of Tamsulosin and Solifenacin during indwelling double-J tubes, and no sustained intolerable urinary frequency,urgent urination, urinary incontinence and other lower urinary tract symptoms was observed. All patients had no serious adverse reactions during bladder infusion chemotherapy. After 4 to 79 months follow-up, no ureteral stenosis or hydronephrosis occurred in the experimental group. The appearance of ureteral orifice and urine spraying were normal under cystoscopy. There were 3 cases of lateral ureteral scar stenosis in the control group, two underwent ureteral bladder replantation and one underwent expansion of narrow ureter in children ureteroscope.There were 8 cases of bladder tumor recurrence in the experimental group and 7 cases in the control group. The recurrence sites were not in the original excision. After the double J tube was placed, no tumors were found in the upper urinary tract. Conclusion For non-muscle-invasive bladder tumors around the ureteral orifice, in order to reduce the incidence of ureteral orifice stenosis after PKRBt, it is routine to place double J-tubes in the ipsilateral ureter before resection. This method will not increase the risk of tumor cells retrograde implantation of upper urinary tract and affect the quality of life of patients, which is worthy of promotion and application in the clinic.