输尿管末段肿瘤行保肾手术临床效果分析
[摘要] 目的:总结原发性输尿管肿瘤的诊断和治疗经验,提高该病的诊治水平。方法:对12例行保肾手术的原发性输尿管肿瘤患者进行回顾性分析,对不同病理类型肿瘤的预后进行初步评估。结果:12例输尿管末段肿瘤患者经开放手术,10例经输尿管镜手术,2例于电灼前钳取病灶组织,手术后进行病理诊断,其中输尿管移行细胞癌11例(G1 4例、G2 5例、G3 2例)。鳞癌1例。分期为T1 6例、T2 4例、T3 1例、T4 1例。对本组12例输尿管末段肿瘤患者进行随访6个月~5年,有9例患者获得随访,3例患者失访;9例中术后3个月~3年出现膀胱移行细胞癌6例;术后2年同侧输尿管复发1例;术后1年发现对侧上尿路肿瘤1例。术后5个月发现肺部转移1例鳞癌(T4期),于术后10个月死亡。结论:影像学联合输尿管镜组织活检是原发性输尿管肿瘤的最佳诊断途径,其预后与病理类型密切相关。保肾手术有复发风险,需进行随访,但对早期、低级别原发性输尿管肿瘤手术效果良好。
[关键词] 输尿管;末段;肿瘤;保肾手术
[中图分类号] R737.13 [文献标识码]C[文章编号]1674-4721(2011)07(a)-184-02
Clinical effect analysis of kidneys surgery with ureteral tumor last paragraph
ZHANG Yanming, HUANG Suifu, LV Dong
Uropoiesis Surgical Depatment of the First People"s Hospital of Kaifeng City, Hehan Province, Kaifeng 475000, China
[Abstract] Objective: To summarize the primary ureteral tumor diagnosis and treatment experience and improve diagnosis and treatment of disease. Methods: Retrospectivly analyzed the 12 cases of primary ureteral surgery and kidneys, tumored of different pathological types of tumors a preliminary assessment of the prognosis. Results: 12 patients with ureteral tumor last paragraph were treated with open surgery, 10 cases were treated with ureteroscopy, 2 cases were forceped clip tissue forceps before fulguration, pathological diagnosed after surgery in which 11 cases of transitional cell carcinoma of the ureter (G1 4 cases, G2 5 cases, G3 2 cases), squamous cell carcinoma in 1 case. The staging was T1 6 cases, T2 4 cases, T3 1 case, T4 1 case. 12 cases of ureteral tumor last paragraph patients were followed up for 6 months to 5 years, 9 patients were followed up, 3 patients were lost to follow; After 3 months to 3 years of transitional cell carcinoma of the bladder occurred 6 cases in 9 cases, 1 case of ipsilateral ureter recurrence after 2 years; 1 case of contralateral upper urinary tract tumor after 1 year, 1 case of squamous cell carcinoma lung metastasis (T4 period) after 5 months, who was dead after 10 months. Conclusion: Imaging united ureteral mirror biopsy is the best diagnosis primary ureteral tumor way and it is closely related to the prognosis and pathological type. The kidney surgery has the risk of recurrence, needs to undertake follow-up, but to early, low level of primary ureteral tumor surgery effect is good.
[Key words] Ureter; The last paragraph; Tumor; Kidneys surgery
原发性输尿管肿瘤比较少见,仅占泌尿系肿瘤的1%,早诊断、早治疗是提高肾输尿管癌长期生存的关键,但其临床表现无特异性而致早期诊断困难,缺乏特异性症状和诊断方法,漏误诊率较高[1]。本院2000年11月~2005年3月共收治输尿管末段肿瘤12例,笔者进行总结并报道如下:
1 资料与方法
1.1 一般资料
本组2000年11月~2005年3月收治的12例输尿管末段肿瘤患者,其中,男4例,女8例;年龄48~81岁,平均60.8岁;术前均行超声检查,肿瘤位于左侧5例,右侧7例;其中合并输尿管扩张7例,肾积水9例,输尿管内明显占位3例。10例有肉眼血尿,3例患侧腰部不适,4例无明显症状。
1.2 方法
本组12例输尿管末段肿瘤患者手术原则为保留肾脏为基础下进行手术治疗。经活检获取病理后经输尿管镜行肿瘤电灼术2例;行输尿管末端及膀胱袖口状切除、输尿管膀胱再植术10例,术中均经快速冰冻病理证实断端切缘为阴性。所有病例手术后均行膀胱灌注化疗。
2 结果
12例输尿管末段肿瘤患者经开放手术10例及经输尿管镜手术2例于电灼前钳取病灶组织,手术后进行病理诊断其中输尿管移行细胞癌11例(G1 4例、G2 5例、G3 2例)。鳞癌1例。分期:T1 6例、T2 4例、T3 1例、T4 1例;对本组12例输尿管末段肿瘤患者进行随访6个月~5年,有9例患者获得随访,3例患者失访; 9例中术后3个月~3年出现膀胱移行细胞癌6例;术后2年同侧输尿管复发1例;术后1年发现对侧上尿路肿瘤1例。术后5个月发现肺部转移1例鳞癌(T4期),于术后10个月死亡。
3 讨论
输尿管肿瘤少见,占尿路上皮肿瘤l%~2%。移行细胞癌占90%以上,鳞癌、腺癌罕见,与结石、长期梗阻、炎症等刺激因素有关。原发性输尿管肿瘤临床表现主要为肉眼血尿,输尿管癌临床表现主要是出现反复的肉眼血尿。输尿管癌目前常用的诊断方法有B超、MRI、CT、IVP、逆行尿路造影、膀胱镜检查、尿脱落细胞学检查、荧光原位杂交技术(FISH)、输尿管镜检查[2]等。对临床上表现为反复肉眼血尿并有单侧腰痛和肾积水患者,经检查排除泌尿系结石后,就应考虑输尿管有占位性病变的可能,应进行必要的逆行尿路造影、膀胱镜检查、输尿管镜检查。
原发性输尿管肿瘤的预后与肿瘤的临床分期和病理类型密切相关[4]。T2期以下分化较好的尿路上皮肿瘤术后10年的存活率比较高,因此,早发现、早治疗是改善输尿管癌预后的关键。本组2年内死亡的2例患者临床分期均在T3期以上,3例无瘤生存5年以上者均为T2期以下患者。鳞癌的预后较移行细胞癌差。
针对输尿管癌采用保肾手术方式[5]主要有腹腔镜或开放性输尿管病变处切除端端吻合,内镜下逆行或顺行性病灶切除或烧灼,输尿管末端及膀胱袖口状切除、输尿管次全切除,输尿管膀胱再植术等术式,近年来随着腔镜技术和设备的完善,经过输尿管镜治疗已经成为本病治疗的热点[4]。
采用保留肾脏的手术方式治疗输尿管癌适应证:高龄、合并有心、肺、脑等重要脏器严重疾病,身体一般状况差,不能耐受大手术者;孤立肾或双侧病变无法行根治性切除者;对侧肾患有可能导致肾功能受损的病变者,肿瘤晚期,无法彻底切除,且有严重血尿、疼痛等症状影响日常生活的患者;低级别、低分期肿瘤,即非浸润性的1~2 级上皮肿瘤;高级别(3 级)或浸润性肿瘤,必须保留肾功能者;有多处复发倾向者。
手术过程中为防止播散及种植,术中应尽量避免挤压肿瘤,并早期于距肿瘤边缘1~2 cm 处结扎近端及远端输尿管。手术切缘通常需距肿瘤边缘>1 cm ,在长度允许情况下,可尽量多切除输尿管,并于术中快速冰冻病理保证切缘阴性。
总之,针对输尿管肿瘤患者的健肾功能、身体状况、肿瘤的生长方式、分期、分级来确定采取保肾手术方式及手术范围从而达到最佳治疗效果,达到改善患者生活质量和延长患者生命。
[参考文献]
[1]杨堃.输尿管癌临床特性及误漏诊断原因的探讨[J].现代泌尿外科杂志,2008,13(2):103.
[2]Mercedes.Utility of fluorescence in situ hybridization as a non-invasive technique in the diagnosis of upper urinary tract urothelial carcinoma[J].European Urology,2007,51:409-415.
[3]刘先东.保留肾脏术式治疗输尿管肿瘤临床分析[J].中华实用诊断与治疗杂志,2009,24(2):195-197.
[4]刘连地.原发性输尿管癌的诊断与治疗(附13例报告)[J].现代泌尿外科杂志,2008,13(1):29-31.
[5]张勇.原发性输尿管肿瘤40例临床分析[J].现代泌尿外科杂志,2009,14(6):465-466.
(收稿日期:2011-03-28)