内镜下治疗上尿路尿路上皮癌的适应证、疗效和安全性分析  

The indications,efficacy and safety of endoscopic treatment of upper urinary tract urothelial carcinoma

作　　者：苏博兴[1] 肖博[1] 胡卫国[1] 唐宇哲[1] 付猛[1] 刘宇保 曾雪 李建兴[1] Su Boxing;Xiao Bo;Hu Weiguo;Tang Yuzhe;Fu Meng;Liu Yubao;Zeng Xue;Li Jianxing(Department of Urology,Beijing Tsinghua Changgung Hospital,Tsinghua University,Clinical Medical School of Tsinghua University,Beijing 102218,China)

机构地区：[1]清华大学附属北京清华长庚医院泌尿外科,清华大学临床医学院,北京102218

出　　处：《中华泌尿外科杂志》2021年第12期901-905,共5页Chinese Journal of Urology

摘　　要：目的探讨内镜下治疗上尿路尿路上皮癌的适应证、疗效和安全性。方法回顾性分析2014年12月至2019年12月北京清华长庚医院收治的14例上尿路尿路上皮癌患者的临床资料。男5例,女9例。中位年龄75.5(44~84)岁。就诊原因为血尿11例,腰痛2例,无症状1例。5例既往有膀胱癌病史,1例有对侧肾盂癌病史。孤立肾4例,肾功能不全3例,双侧肾盂癌1例,因一般状态差(美国麻醉医生协会评分≥3分)无法耐受肾输尿管全长切除术4例,术前病理诊断为低级别非浸润性尿路上皮癌,要求行保肾治疗者2例。14例共15侧肿瘤,肿瘤主体位置位于肾盂6侧、上盏4侧、中盏3侧、下盏2侧。肿瘤直径中位值2.0(0.8~4.0)cm。患者术前经CT/CTU、MRI以及尿脱落细胞学或病理活检确诊为尿路上皮癌。本组14例共15侧手术。13侧行超声引导下经皮肾穿刺扩张,建立F24标准通道,在肾镜下采用1470半导体激光(60~80W)或铥激光(15~20W)汽化消融肿瘤组织,必要时电凝止血;2侧经尿道置入输尿管软镜,镜下采用200μm钬激光光纤行肿瘤消融,并使用钕激光止血。肿瘤汽化消融范围包括肿瘤周围0.5~1.0 cm正常肾盂黏膜,深至肾窦脂肪层,必要时汽化消融结束后基底部再次取活检。结果本组15侧手术均顺利完成,中位手术时间51.7(39~115)min,术中出血量20.0(2~50)ml。术后5例发生并发症,1例为发热(体温>38.5℃);4例为出血需输血(术后血红蛋白<70 g/L),输2~4 U悬浮红细胞,无需肾动脉栓塞患者。病理诊断均为尿路上皮癌,病理分级为高级别6侧,低级别9侧;病理分期T_(a)期8侧,T_(1)期5侧,T_(2)期2侧。中位随访31(11~70)个月,10例术后出现复发,复发中位时间11.3(4~41)个月。4例复发后行保守治疗,包括免疫治疗加放疗1例,全身化疗1例,等待观察2例;3例复发后再次行内镜下治疗,包括经皮肾镜下肿瘤激光消融2例,经尿道膀胱肿瘤切除术1例,术后随访均存活;3例复发�Objective To summarize the preliminary clinical experience of endoscopic treatment of upper urinary tract urothelial carcinoma,and to analyze its indications and efficacy.Methods The clinical data of 14 patients underwent endoscopic treatment for upper urinary tract urothelial carcinoma in our hospital from December 2014 to December 2019 were retrospectively analyzed.Among them,there were 5 males and 9 females,with a median age of 75.5(44-84)years.There were 11 patients with hematuria,2 patients with flank pain and one asymptomatic patient.Five patients had a history of bladder cancer and one had a history of contralateral UTUC.There were 4 patients with solitary kidney,3 patients with renal insufficiency,1 patient with bilateral renal pelvis carcinoma,4 patients prohibitory to nephroureterectomy because of poor general condition(American Society of Anesthesiologists score≥3),and 2 patients were pathologically diagnosed as low-grade non-invasive urothelial carcinoma and requested renal preservation therapy.A total of 15 renal units included.The main tumor sites were renal pelvis in 6 renal units,upper calyx in 4 renal units,middle calyx in 3 renal units,and lower calyx in 2 renal units.The median tumor diameter was 2.0(0.8-4.0)cm.All patients were diagnosed with urothelial carcinoma by preoperative computed tomography(CT/CTU),magnetic resonance imaging(MRI),and cytological or pathological biopsy.In 13 patients,ultrasond-guided percutaneous renal access and tract dilation were performed to establish a F24 standard tract.The tumor tissues were vaporized by 1470 semiconductor laser(60-80 W)or thulium laser(15-20 W)under nephroscopy,and electrocoagulation was used to coagulate the bleeding when necessary.Two patients were treated with felxible ureteroscope,under which tumor ablation was performed with 200μm holmium laser fiber,and neodymium laser was used for hemostasis.The range of tumor vaporization ablation included 0.5-1.0 cm normal renal pelvis mucosa around the tumor,deep to the fatty layer of renal sinus.Bi

关 键 词：癌 上尿路 内镜治疗 肿瘤特异性生存 输尿管软镜 经皮肾镜 

分 类 号：R737.1[医药卫生—肿瘤]