经尿道钬激光、电切及开放手术处理膀胱袖套-输尿管下段的对照研究  

Comparative analysis of transurethral Holmium laser, electric resection and open surgery for the distal ureter and bladder cuff in the procedure of nephroureterectomy

作　　者：龚宇[1] 杜传军[1] 陈继民[1] 罗尉[1] 白福鼎[1] 

机构地区：[1]浙江大学医学院附属第二医院泌尿外科,杭州310009

出　　处：《中华泌尿外科杂志》2012年第5期347-350,共4页Chinese Journal of Urology

基　　金：浙江省医药卫生科学研究基金（2009A091）

摘　　要：目的评估钬激光、电切及开放手术在上尿路上皮性恶性肿瘤根治术中袖套状切除膀胱-输尿管下段的临床疗效。方法回顾性分析2000年1月至2010年12月162例肾盂癌、中上段输尿管癌患者的资料。肾及近端输尿管切除术采用开放或后腹腔镜法。袖套状切除膀胱-输尿管下段分别采用钬激光（A组）32例、电切（B组）51例及开放手术（C组）79例。经尿道手术组术中插入5F输尿管气囊导管以阻断尿流。病理诊断均为肾盂和（或）输尿管上皮癌，病理分期为TaN0M0～T4N0M0。对3组围手术期指标（手术时间、术中失血量、术中并发症、术后住院时间等）和术后随访结果（肿瘤复发率、肿瘤种植发生率、患者生存率等）进行对照研究。术后随访3个月～8年。结果A、B组手术时间[（203．6±31．5），（207．2±24．3）min]、术中失血量[（127．4±63．2），（135．0±82．7）ml]、术后住院时间[（5．8±1．3），（5．6±1．2）d]显著低于C组[（248．0±42．9）min，（484．5±217．7）ml，（8．7±3．5）d，P〈0．01]。B组术中发生闭孔神经反射6例，膀胱穿孔合并较大出血3例，其中中转开放手术2例。3组术后膀胱肿瘤发生率（16．3％、18．1％、21．7％）、肿瘤种植发生率（均为0）、1、3年生存率（96．3％／90．5％、98．0％／88．6％、95．7％／86．4％）比较差异均无统计学意义（P〉0．05）。结论经尿道术式的创伤程度、手术时间、术中失血量、术后恢复时间等围手术期指标显著优于传统开放手术，膀胱肿瘤发生率、肿瘤种植发生率、生存率等与开放手术相当。袖套状切除膀胱-输尿管下段的手术方式与术后肿瘤复发率无关。钬激光袖套状切除膀胱-输尿管下段是肾盂癌和输尿管癌根治术中安全、微创的方法。Objective To present the innovative transurethral resection of the distal ureter and bladder cuff by Holmium laser and to compare the perioperative and oneologieal outcomes following nephroureterectomy using three different methods of managing the distal ureter and bladder cuff. Methods From January 2000 to December 2010, 162 patients underwent excision of the distal ureter and bladder cuff by transurethral Holmium laser （32 cases, Group A） , transurethral electric resection （51 cases, Group B） or open procedure （79 cases, Group C） combined with open or retroperitoneal laparoscopic nephroureterectomy. 5 French ureteral balloon catheter was inserted into the targeted ureter to prevent possible microscopic tumor seeding. The therapeutic effectiveness, perioperative complications, postoperative recovery and oncologic outcomes were compared among groups. The follow-up time was 3 -96 months. Results Group A and B showed statistically significant better results on the operative time （203.6 ± 31.5 rain and 207.2 ± 24.3 min） , blood loss （127.4 ± 63.2 ml and 135.0 ± 82.7 ml） and postoperative hospital stay （5.8 ± 1.3d and 5.6 ±1.2 d） than those of Group C （248.0 ±42.9 rain, 484.5 ±217.7 ml, 8.7 ±3.5 d） , respectively （ P 〈 0.01 ）. Six eases of obturator nervous reflex occurred in Group B, with 3 eases of bladder perforation and 2 conversions to open procedure. There were no difference in bladder tumor occurrence, retroperitoneal recurrence, tumor cell seeding and cancer-specific survival among the 3 groups. Conclusions Our data have validated the superiority of transurethral approach over conventional open procedure including peri- operative index, recovery and comparable oneologie outcomes with open group. Holmium laser demonstrated better results including fewer complication, cleaner surgical vision and operating accuracy than that of electric resection. Transurethral Holmium laser resection of the distal ureter and bladder cuff has been proved to be a technically innovative m

关 键 词：尿路上皮癌 肾输尿管切除术 钬 激光手术 

分 类 号：R699[医药卫生—泌尿科学]