腹腔镜根治性单侧肾、输尿管及全膀胱切除治疗上尿路上皮癌合并膀胱癌的疗效观察

Curative Effect of Laparoscopic Unilateral Radical Nephroureterectomy and Radical Cystectomy for Unilateral UTUC with Bladder Cancer

目的:探讨腹腔镜根治性单侧肾、输尿管及全膀胱切除术治疗上尿路上皮癌合并膀胱癌的安全性及可行性。方法:回顾性分析我院2016年5月至2021年2月收治的9例单侧上尿路上皮癌合并膀胱癌的临床资料,术前结合病史及膀胱镜活检结果、输尿管活检结果、泌尿系增强CT、腹部增强MRI等检查提示单侧上尿路上皮癌合并膀胱浸润性尿路上皮癌,手术方式采用腹腔镜根治性单侧肾、输尿管及全膀胱切除术。统计并分析患者手术及术后相关指标、近期及远期并发症、生活质量评分及复发与转移情况。结果:9例手术均于腹腔镜下顺利完成,女性患者同期切除子宫及附件,9例患者均采用健侧输尿管皮肤造口术。中位手术时间425(260~610)min;中位术中出血量1 200(300~2 500)mL;围术期输血8例,中位输血量1 000(0~2 100)mL;术后中位住院时间13(10~27)d;中位随访时间25(6~63)月。术后4例出现并发症,1例盆腔淋巴漏,1例造瘘口感染、尿路感染、输尿管吻合口狭窄,2例肾功能不全。术后病理:肾盂癌、输尿管癌及浸润性膀胱癌2例,输尿管癌及浸润性膀胱癌6例,肾盂癌及膀胱浸润性癌1例。9例患者生活质量评分术后6月较术前均提高。术后3例行化疗,1例吉西他滨+顺铂方案化疗1周期,1例吉西他滨+顺铂方案化疗2周期,此2例化疗后均因骨髓抑制及自身原因不愿再继续化疗;1例吉西他滨+卡铂方案化疗4周期;另外6例不愿接受化疗。9例均定期复查随访。1例患者术后9月出现肾功能不全进展至尿毒症期,未行透析等治疗,于术后10月死亡;1例患者术后38月出现复发转移,于术后38月死亡,其余患者随访生存良好。结论:上尿路上皮癌合并浸润性膀胱癌临床少见且治疗棘手,手术治疗创伤大,同期腹腔镜单侧肾、输尿管切除+膀胱全切术是一种安全有效的治疗术式,该术式具有创伤小、恢复快等微创优势,提高术后生活质量,肿瘤治疗效果好,可以获得较长的生存期。

Objective:To investigate the safety and feasi bility of unilateral radical nephroureterectomy and total cystectomy in the treatment of unilateral upper tract urothelial carcinoma(UTUC)with bladder cancer.Methods:Clinical data of 9 cases of unilateral UTUC with bladder cancer admitted to our hospital from May 2016 to February 2021 were retrospectively analyzed.They combined with preoperative medical history,cystoscopic biopsy results,ureteral biopsy results,enhanced CT for the urinary system,abdominal enhanced MRI and other examinations revealed unilateral UTUC combined with invasive urothelial carcinoma of the bladder.Surgical methods included laparoscopic unilateral radical nephroureterectomy on the affected side and total cystectomy.Intra-and post-operative indicators,short-and long-term complications,quality of life,recurrence and metastasis were analyzed.Results:All the 9 operations were successfully completed with laparoscopy.Female patients had their uterus and appendages removed at the same time.And all patients underwent ureterocutaneostomy in the uninjured side.Median operation time was 425(260-610)min,with median intraoperative blood loss of 1,200(300-2,500)mL;8 underwent perioperative blood transfusion,with median blood transfusion of 1,325(600-2,100)mL;the median postoperative length of stay was 13(10-27)days;and the median follow-up duration was 25(6-63)months.Postoperative complications occurred in 4 cases,including 1 case of pelvic lymphatic leakage,1 case of stoma infection plus urinary tract infection plus ureteral anastomotic stricture,and 2 cases of renal insufficiency.Postoperative pathology results showed 2 cases of renal pelvis cancer plus ureteral cancer plus invasive bladder cancer,6 cases of ureteral cancer plus invasive bladder cancer,and 1 case of renal p»elvis cancer plus invasive bladder cancer.The life qualify of 9 patients were improved 6 months after operation.Three cases routinely received chemotherapy after surgery,among which one was further treated with gemcitabine plus carboplatin for 4 cycles,and the other two whose regimens were gemcitabine plus cisplatin for 1 and 2 cycles,were reluctant to re-chemotherapy due to myelosuppression or their own reasons;the rest six were unwilling to undergo chemotherapy.All 9 cases were reviewed and followed up regularly.One patient without dialysis developed renal insufficiency and progressed to uremia 9 months after surgery,and died 10 months after surgery;1 patient who developed recurrence and metastasis 38 months after surgery died 38 months after surger-y.The rest patients survived during follow-up.Conclusion:UTUC combined with invasive bladder cancer is clinically rare and difficult to treat.Laparoscopic unilateral radical nephroureterectomy and total cystectomy,unlike traumatic surgical treatment,is a safe and effective treatment method,with good effect,less trauma and fast recovery,improving postoperative quality of life,expecting a longer lifetime.