Introduction:In the management of upper tract urothelial cell carcinoma(UTUC)endoscopic,nephron sparing procedures like ureterorenoscopy(URS)or percutaneous tumour resection(PCTR)still play a very limited role.This co...Introduction:In the management of upper tract urothelial cell carcinoma(UTUC)endoscopic,nephron sparing procedures like ureterorenoscopy(URS)or percutaneous tumour resection(PCTR)still play a very limited role.This could lead to possible unnecessary radical nephroureterectomies(RNU),still being the gold standard treatment.The risk of chronic kidney disease(CKD)later in life is important.In this study we present the results of 24-year experience with PCTR in a single institution.Methods:We identified 44 patients who underwent PCTR between 1992 and 2015.Radical resection was achieved in 40 patients who were included in this study.Demographic and clinical data,including tumour recurrence,progression to RNU,tumour grade and overall survival(OS)were retrospectively acquired.An outcome analysis was conducted.Results:Median age at diagnosis was 68 years(range 42-94 years).Low grade tumours were found in 37 patients(92.5%)and high grade tumours in three patients(7.5%).Median followup was 53 months during which 20 patients developed upper tract recurrences(50.0%).The longest time to recurrence was 97 months.At follow-up 11 patients(27.5%)underwent an RNU and two patients died from UTUC.RNU could be avoided in 29 patients(72.5%).In this study we found that multifocality is a significant risk factor for recurrence,but not for stage progression to RNU.Conclusion:PCTR is a surgically and oncologically safe procedure.Renal preservation in patients with UTUC who are eligible for percutaneous resection can be achieved in the majority of patients.Selection criteria for PCTR should be further refined,leading to a wider application of PCTR in the future.Follow-up needs invasive procedures and should be long term.展开更多
目的探讨单次锚定法经腹机器人辅助肾输尿管切除术的技术特点及疗效。方法回顾性分析2016年1月至2019年11月中山大学孙逸仙纪念医院收治的44例患者的病例资料,男31例,女13例。中位年龄61.5(55.5~72.5)岁。既往有腹部手术史2例(4.6%),吸...目的探讨单次锚定法经腹机器人辅助肾输尿管切除术的技术特点及疗效。方法回顾性分析2016年1月至2019年11月中山大学孙逸仙纪念医院收治的44例患者的病例资料,男31例,女13例。中位年龄61.5(55.5~72.5)岁。既往有腹部手术史2例(4.6%),吸烟史12例(27.3%)。中位体质指数为23.08(21.55~24.60)kg/m^2。肿瘤位于左侧25例(56.8%)、右侧19例(43.2%)。Charlson合并症指数:24例(54.5%)为2~4,16例(36.1%)为5~6,4例(9.4%)为≥7。美国麻醉医师协会(American Society of Anesthesiologists,ASA)评分:0~1分8例(18.2%),2~3分36例(81.8%)。术前诊断为输尿管癌26例(59.1%),肾盂癌14例(31.8%),输尿管癌合并肾盂癌4例(9.1%),均符合肾输尿管切除术指征。44例均由同一术者行单次锚定法经腹机器人辅助肾输尿管切除术。手术均采用全麻,患者取80°健侧卧位,头低足高10°。镜头套管位于患侧脐旁1横指处。以右侧手术为例,1号臂套管位于右侧腹直肌外侧缘脐上8 cm水平,2号臂套管位于右侧腹直肌外侧缘脐下8 cm水平,辅助套管1位于前正中线与2号臂套管-镜头套管连线中垂线的交点,辅助套管2位于前正中线剑突下。左侧手术套管位置与右侧手术大致对称,但辅助套管2的位置移至耻骨联合上3横指处。沿结肠外侧的Toldt线切开侧腹膜,沿结肠系膜与肾周筋膜间的平面游离至显露下腔静脉(左侧至显露腹主动脉),Hem-o-lok夹闭并离断肾动静脉,充分游离肾脏,然后在肾下极平面找到输尿管,向下游离至近髂血管处。用Hem-o-lok夹闭肿瘤远端输尿管。将视野转向足侧,助手向头侧牵引输尿管,术者继续向下游离输尿管至膀胱壁段,直视下切除输尿管膀胱开口处并缝合膀胱。游离肾和输尿管的同时行淋巴结清扫。将切除的标本放入标本袋,延长下腹部切口取出,放置引流管后逐层关腹。结果本组44例手术均顺利完成。中位手术时间145(130~175)min,机械臂操作时间119(108.5~136.0)min,中位膀胱缝合时间12(10~15)min。术中失血量50(20~100)ml,输血3例(6.8%)。术后Clavien-Dindo 2级并发症6例:乳糜漏2例,延长引流管留置时间后缓解;使用止血药物1例,术后输血1例(500 ml);深静脉血栓形成1例,行抗凝治疗;急性冠脉综合征1例,按胸痛流程诊治。术后中位住院时间8(6.5~10.0)d。术后中位随访时间12个月,死亡5例,其中3例为肿瘤进展所致;术后肿瘤进展4例,其中3例死亡,1例存活。术后2年总体生存率为68.2%,无进展生存率为77.9%。结论单次锚定法经腹机器人辅助肾输尿管切除术能较好地提升机械臂的操作效率,手术时间短,术中及术后并发症发生率低,短期随访结果满意。展开更多
文摘Introduction:In the management of upper tract urothelial cell carcinoma(UTUC)endoscopic,nephron sparing procedures like ureterorenoscopy(URS)or percutaneous tumour resection(PCTR)still play a very limited role.This could lead to possible unnecessary radical nephroureterectomies(RNU),still being the gold standard treatment.The risk of chronic kidney disease(CKD)later in life is important.In this study we present the results of 24-year experience with PCTR in a single institution.Methods:We identified 44 patients who underwent PCTR between 1992 and 2015.Radical resection was achieved in 40 patients who were included in this study.Demographic and clinical data,including tumour recurrence,progression to RNU,tumour grade and overall survival(OS)were retrospectively acquired.An outcome analysis was conducted.Results:Median age at diagnosis was 68 years(range 42-94 years).Low grade tumours were found in 37 patients(92.5%)and high grade tumours in three patients(7.5%).Median followup was 53 months during which 20 patients developed upper tract recurrences(50.0%).The longest time to recurrence was 97 months.At follow-up 11 patients(27.5%)underwent an RNU and two patients died from UTUC.RNU could be avoided in 29 patients(72.5%).In this study we found that multifocality is a significant risk factor for recurrence,but not for stage progression to RNU.Conclusion:PCTR is a surgically and oncologically safe procedure.Renal preservation in patients with UTUC who are eligible for percutaneous resection can be achieved in the majority of patients.Selection criteria for PCTR should be further refined,leading to a wider application of PCTR in the future.Follow-up needs invasive procedures and should be long term.
文摘目的探讨单次锚定法经腹机器人辅助肾输尿管切除术的技术特点及疗效。方法回顾性分析2016年1月至2019年11月中山大学孙逸仙纪念医院收治的44例患者的病例资料,男31例,女13例。中位年龄61.5(55.5~72.5)岁。既往有腹部手术史2例(4.6%),吸烟史12例(27.3%)。中位体质指数为23.08(21.55~24.60)kg/m^2。肿瘤位于左侧25例(56.8%)、右侧19例(43.2%)。Charlson合并症指数:24例(54.5%)为2~4,16例(36.1%)为5~6,4例(9.4%)为≥7。美国麻醉医师协会(American Society of Anesthesiologists,ASA)评分:0~1分8例(18.2%),2~3分36例(81.8%)。术前诊断为输尿管癌26例(59.1%),肾盂癌14例(31.8%),输尿管癌合并肾盂癌4例(9.1%),均符合肾输尿管切除术指征。44例均由同一术者行单次锚定法经腹机器人辅助肾输尿管切除术。手术均采用全麻,患者取80°健侧卧位,头低足高10°。镜头套管位于患侧脐旁1横指处。以右侧手术为例,1号臂套管位于右侧腹直肌外侧缘脐上8 cm水平,2号臂套管位于右侧腹直肌外侧缘脐下8 cm水平,辅助套管1位于前正中线与2号臂套管-镜头套管连线中垂线的交点,辅助套管2位于前正中线剑突下。左侧手术套管位置与右侧手术大致对称,但辅助套管2的位置移至耻骨联合上3横指处。沿结肠外侧的Toldt线切开侧腹膜,沿结肠系膜与肾周筋膜间的平面游离至显露下腔静脉(左侧至显露腹主动脉),Hem-o-lok夹闭并离断肾动静脉,充分游离肾脏,然后在肾下极平面找到输尿管,向下游离至近髂血管处。用Hem-o-lok夹闭肿瘤远端输尿管。将视野转向足侧,助手向头侧牵引输尿管,术者继续向下游离输尿管至膀胱壁段,直视下切除输尿管膀胱开口处并缝合膀胱。游离肾和输尿管的同时行淋巴结清扫。将切除的标本放入标本袋,延长下腹部切口取出,放置引流管后逐层关腹。结果本组44例手术均顺利完成。中位手术时间145(130~175)min,机械臂操作时间119(108.5~136.0)min,中位膀胱缝合时间12(10~15)min。术中失血量50(20~100)ml,输血3例(6.8%)。术后Clavien-Dindo 2级并发症6例:乳糜漏2例,延长引流管留置时间后缓解;使用止血药物1例,术后输血1例(500 ml);深静脉血栓形成1例,行抗凝治疗;急性冠脉综合征1例,按胸痛流程诊治。术后中位住院时间8(6.5~10.0)d。术后中位随访时间12个月,死亡5例,其中3例为肿瘤进展所致;术后肿瘤进展4例,其中3例死亡,1例存活。术后2年总体生存率为68.2%,无进展生存率为77.9%。结论单次锚定法经腹机器人辅助肾输尿管切除术能较好地提升机械臂的操作效率,手术时间短,术中及术后并发症发生率低,短期随访结果满意。
