上尿路结石合并实质浸润型肾盂癌临床鉴别分析

Clinical differentiation of upper urinary tract stones combined with infiltrative renal pelvis cancer

目的探讨上尿路结石合并影像学难以发现的实质浸润型肾盂癌的临床特点,并进行鉴别诊断分析。方法回顾2019年6月至2022年6月间3例上尿路结石合并实质浸润型肾盂癌患者的临床资料。3例均为男性,年龄50~71岁。分析合并上尿路结石并延迟诊断肾盂肿瘤的原因,总结其鉴别特征。结果3例患者均以腰痛及血尿为首要症状就诊,术前完善腹部CT检查,3例均发现肾结石合并肾积水,2例局部肾实质强化密度减低,因合并肾盂感染,仅考虑为肾皮质局限性炎症改变。3例患者接受经皮肾镜或输尿管软镜碎石后发现合并肾盂肿瘤,后行肿瘤根治手术。1例术后6个月肿瘤多发转移死亡;1例术后15个月发现肿瘤多发转移,行化疗带瘤生存中;1例术后16个月膀胱内肿瘤复发,行经尿道膀胱肿瘤电切术+规律膀胱灌注化疗。结论合并上尿路结石的实质浸润型肾盂癌影像学检查表现不典型,易与感染性疾病混淆,应重视CT或泌尿系CT造影(CTU)检查,对于术前CT发现局部肾实质密度减低的患者应高度怀疑实质浸润型肾盂癌可能,可行穿刺活检明确,必要时可重复活检。高危患者需术中仔细检查肾盂黏膜,必要时多点、足量活检。

Objective To investigate the clinical features of upper urinary tract stones combined with difficult to detect infiltrative renal pelvic by imaging and to analyze the differential diagnosis.Methods The clinical data of three cases of upper urinary tract stones combined with infiltrative renal pelvic carcinoma between June 2019 and June 2022 were reviewed.All 3 patients were male,aged 50-71 years old.The reasons for oncological misdiagnosis were analyzed with case reports of renal pelvic tumors with combined upper urinary tract stones and delayed diagnosis retrieved from the database.Results All three patients presented with primary symptoms of lumbar pain and haematuria.Preoperative abdominal CT examination was performed and all 3 cases were found to have renal stones combined with hydronephrosis,2 cases had localized hypoenhancement of the renal parenchyma which was only considered limited inflammatory changes in the renal cortex due to complicated renal pelvis infection.However,all the patients were found to have combined renal pelvis tumor after percutaneous nephrolithotomy or ureteroscopic lithotripsy.One patient died of multiple tumor metastases 6 months after surgery.One patient was found multiple tumor metastases 15 months after surgery,surviving with current chemotherapy.One patient had tumor recurrence in the bladder 16 months after surgery,who underwent transurethral bladder tumor electrosurgery and regular bladder perfusion chemotherapy.Conclusion Infiltrative renal pelvis carcinoma with upper urinary tract stones has an atypical imaging presentation and is easily confused with infectious disease.Urologists need to pay attention to CT or CTU.For patients with local renal parenchyma density on CT,an invasive renal pelvis carcinoma should be highly suspected,needle biopsy shall be performed,and a repeated biopsy should be performed if necessary.High-risk patients need careful intraoperative examination of the renal pelvic mucosa,with multiple points and adequate biopsies if necessary.