慢性马兜铃酸肾病患者伴发泌尿系统肿瘤

目的探讨慢性马兜铃酸肾病患者伴发泌尿系肿瘤情况。方法回顾分析102例慢性马兜铃酸肾病患者中4例伴发泌尿系肿瘤患者的临床资料。结果(1)4例患者均有长期间断小剂量服含马兜铃酸药物史,并被确诊为慢性马兜铃酸肾病,慢性肾功能不全;(2)4例均有明显血尿,相差显微镜检查呈均一红细胞尿,其中2例有肉眼血尿;(3)膀胱镜检查、逆行尿路造影及手术证实,3例为膀胱乳头状移行细胞癌,1例为肾盂移行细胞癌。结论慢性马兜铃酸肾病患者若出现明显均一红细胞血尿时,即应高度警惕泌尿系肿瘤发生。     

马兜铃酸肾病并发尿路上皮癌的诊断治疗

目的 探讨马兜铃酸肾病并发尿路上皮癌的特点及诊治方法。方法 回顾性分析8例慢性马兜铃酸肾病合并尿路上皮癌患者的临床资料。8例患者均有长期（2～20年）间断小剂量服用含马兜铃酸药物史，其中肾功能不全代偿期1例，肾功能衰竭期7例。8例均合并尿路上皮癌。7例行单侧肾、输尿管全长加膀胱袖套状切除，1例行膀胱全切加双侧输尿管皮肤造口术。结果 5例术后12～48（平均31）个月再发对侧肾盂肿瘤，1例术后再发膀胱肿瘤，1例膀胱全切术后60个月再发双侧肾盂肿瘤。7例均接受了二次手术，仅1例单侧肾盂肿瘤患者术后62个月无肿瘤复发。7例患者二次术后随访10～56个月，平均36个月，存活6例，1例死于癌转移。结论 慢性马兜铃酸肾病出现血尿、尿道出血或膀胱刺激症状时，应警惕合并尿路上皮肿瘤的可能。由于肿瘤常常表现为复发和双侧多发，治疗以双侧上尿路或同时行膀胱全切为宜。     

上尿路上皮癌根治术后对侧上尿路复发危险因素分析

目的:探讨上尿路上皮癌根治术后对侧上尿路复发的危险因素。方法:回顾性分析942例上尿路上皮癌患者临床病理及随访数据,采用Kaplan-Meier生存分析法及Cox回归分析法分析对侧上尿路复发的危险因素。结果:出现对侧上尿路复发的有55例(5.8%),Cox多因素回归分析显示马兜铃酸药物服用史为对侧上尿路复发的独立危险因素。Kaplan-Meier生存分析显示马兜铃酸药物服用患者更易出现对侧上尿路复发(chi-square=12.026,P=0.001)。结论:马兜铃酸药物服用史容易导致上尿路上皮癌患者术后对侧上尿路复发。     

含马兜铃酸成分中药与尿路上皮恶性肿瘤

近年来，对含马兜铃酸（aristolochic acid，AA）成分的中草药所致的肾损害-马兜铃酸肾病（aristolochic acid nephropathy，AAN）国内外已有不少研究报道。目前研究显示，AA不仅有明显的肾脏毒性，而且有显著的致癌作用，特别是容易引起尿路上皮恶性肿瘤，为进一步引起泌尿外科及肾内科医师的重视，特综述如下。     

慢性马兜铃酸肾病伴发尿路上皮恶性肿瘤16例报告

目的提高对慢性马兜铃酸肾病伴发尿路上皮恶性肿瘤的认识。方法回顾性分析16例慢性马兜铃酸肾病伴发尿路上皮恶性肿瘤患者的临床资料。16例均有长期间断小剂量服用含马兜铃酸成分药物病史,根据病史及相关检查均可诊断为慢性马兜铃酸肾病、慢性肾功能不全。患者临床表现均为间歇性无痛肉眼血尿,术前经B超、逆行造影、CT或MRU、输尿管镜等检查明确诊断。膀胱肿瘤6例;上尿路肿瘤10例,其中双侧同时发生肿瘤者6例、伴膀胱肿瘤1例。结果6例膀胱肿瘤行经尿道膀胱肿瘤电切术(TURBt);10例上尿路肿瘤者中6例8侧行保肾手术;4例5侧行根治性切除术,其中1例双侧肾盂肿瘤者另一侧术中探查发现肾周肿瘤明显外浸,粘连明显,手术困难,仅行活检术;1例双侧肾盂及双侧输尿管肿瘤者仅行活检术。术后病理均为移行细胞癌,WHO标准病理分级:Ⅰ级1例、Ⅰ～Ⅱ级4例、Ⅱ级6例、Ⅲ级5例。14例获随访3～37个月,平均14个月。死亡4例,其中1例为未手术的双侧肾盂及双侧输尿管肿瘤患者,术后5个月因瘤死亡;输尿管肿瘤、膀胱肿瘤及双肾盂肿瘤者各1例分别于术后17、19、26个月死于多发转移。4例膀胱肿瘤术后4～9个月复发6次,其中2例为2次复发者;上尿路肿瘤2例术后9～10个月膀胱肿瘤3次复发;3例输尿管肿瘤术后3～32个月复发,其中1例原位复发,2例异位复发;5例未见肿瘤复发。结论慢性马兜铃酸肾病伴发的尿路上皮恶性肿瘤以上尿路肿瘤为主,双侧发病率较高,肿瘤具有多发、易复发及恶性程度高等特点。     

应重视马兜铃酸肾病易感机制的研究

马兜铃酸肾病（AAN）是一种慢性间质性肾脏疾病，其发病与摄取含马兜铃酸的中草药密切相关。目前发现马兜铃酸也是巴尔干肾病的主要致病因素。即便如此，“每年有成千上万人服用中草药，为什么仅少数人出现肾脏损害”？“据估计，暴露于高浓度马兜铃酸（AA）后，仅有1／20人群产生病变。并不是所有服用含AA中草药（植物）者都发生AAN，这一不争事实后面蕴藏的易感差异机制困惑着国内外中、     

马兜铃酸致慢性肾小管-间质损伤发生机制的研究进展

马兜铃酸肾病（aristolochic acid nephrology,AAN）是服含马兜铃酸（aristolochic acid,AA）成分的中药引起的肾脏损害。近年的研究表明,只有AA才是引起所谓“中草药肾病”（chinese herb nephropathy,CHN）的毒性物质。     

马兜铃酸肾病发病机制的研究进展

含马兜铃酸（AA）类成分中药导致的肾损害--马兜铃酸肾病近年受到国内外医药学界的广泛关注，其确切发病机制尚未阐明。本文总结了国内外近年来有关马兜铃酸肾病发病机制的研究概况。     

服用甘露消毒丸导致马兜铃酸肾病的原因分析和探讨

甘露消毒丸是较常见的致马兜铃酸肾病（AAN）的药物,该方剂中含马兜铃酸类关木通成分。龙胆泻肝丸,减肥中草药（均含马兜铃酸类关木通成分）也是临床报道中较常见的致肾损害的药物。我院从2000年3月～2007年1月共有38例尿毒症期AAN患者,对其进行了回顾性分析,现报告如下。     

177例尿路移行细胞癌的临床分析

目的：探讨尿路移行细胞癌(TCC)的发病特点及与预后的关系，提高尿路TCC的治愈率。方法：分析177例TCC患者的诊断措施、手术方法和术后处理资料。结果：肾盂癌17例，输尿管癌8例，膀胱癌152例。发现14例为多中心性和异时性TCC，其中下行性异时性膀胱癌10例。结论：TCC是尿路上皮肿瘤发病率最高的恶性肿瘤，异时性膀胱肿瘤的发生率明显高于上尿路肿瘤，发生肿瘤的异时性对患者预后有一定影响，加强肿瘤术后监测是提高患者生存率的重要手段之一。     

Bladder tumor recurrence after primary surgery for transitional cell carcinoma of the upper urinary tract

OBJECTIVE: Primary transitional cell carcinoma (TCC) of the upper urinary tract represents 6-8% of all TCC cases. Nephroureterectomy with removal of a bladder cuff is the treatment of choice. The rates of TCC recurrence in the bladder after primary upper urinary tract surgery described in the literature range between 12.5 and 37.5%. In a retrospective analysis we examined the occurrence of TCC after nephroureterectomy for upper tract TCC in patients without a previous history of bladder TCC at the time of surgery. METHODS: Between 1990 and 2002, 29 patients underwent primary nephroureterectomy for upper tract TCC. The mean age of the patients was 69.5 years. In 5 cases upper urinary tract tumors were multilocular, in the remaining cases unilocular in the renal pelvis (n=12) or the ureter (n=12). The follow-up was available for 29 patients with a mean follow-up of 3.37 (0.1-11.2) years. RESULTS: 11/29 (37.9%) patients had TCC recurrence with 9/11 patients having bladder TCC diagnosed within 2.5 years (0.9-6.0) after nephroureterectomy. 13/29 patients are alive without TCC recurrence, 3/29 patients died due to systemic TCC progression and 5/29 died of unrelated causes without evidence of TCC recurrence. CONCLUSION: Our data indicate a high incidence of bladder TCC after nephroureterectomy for primary upper tract TCC of up to 6 years after primary surgery. Because of the high incidence of bladder TCC within the first 3 years of surgery, careful follow-up is needed over at least this period.     

上尿路移行细胞癌12例误诊分析

目的探讨上尿路移行细胞癌的误诊原因。方法回顾性分析12例上尿路移行细胞癌患者在诊治过程中的误诊情况。误诊为肾炎4例,上尿路结石3例,泌尿系感染3例,肾结核1例,前列腺增生1例。结果 12例患者均经手术治疗,术后病理证实肾盂移行细胞癌9例,输尿管移行细胞癌3例,伴膀胱移行细胞癌2例。通过B超、静脉尿路造影（IVU）、逆行肾盂造影、CT、输尿管镜及膀胱镜等检查均提示发现肿瘤病灶。8例患者随访6个月~15年,3例死于肿瘤进展,2例术后出现膀胱移行细胞癌。结论对长期血尿病史患者需进一步病因检查,B超、IVU、CT等影像学检查具有重要的诊断价值,同时应提高对检查结果的正确分析和判读能力。     

肾移植术后并发尿路上皮肿瘤的临床分析

目的 分析肾移植患者并发尿路上皮肿瘤的特点，探讨其诊治方法。方法 自1998～2003年肾移植患者1293例，术后发生尿路上皮恶性肿瘤21例（1．6％）。男4例，女17例。17例原发病为慢性问质性肾炎。发生尿路上皮肿瘤距肾移植6～62个月，平均26个月。其中膀胱癌6例，单侧肾盂或输尿管癌6例，单侧肾盂或输尿管、膀胱癌8例，双侧肾盂输尿管癌1例。10例上尿路肿瘤发生部位与移植肾同侧，4例发生于移植肾对侧。临床症状以无痛性肉服血尿和反复泌尿系感染为主。19例行手术治疗，术后所有患者免疫抑制剂用量减少1／3并辅以局部灌注化疗。结果 2例行姑息性治疗的晚期肿瘤患者分别于发现肿瘤5、8个月死亡。余19例现已随访2～5年。13例肿瘤复发，复发部位为膀胱或对侧原。肾、输尿管。所有患者在免疫抑制剂减量期间均未出现急性排斥。2例因切除移植肾恢复透析，17例肾功能正常。结论 慢性间质性。肾炎导致。肾功能衰竭的。肾移植患者和女性肾移植患者易发生移植后尿路上皮肿瘤；移植肾同侧上尿路较对侧好发肿瘤；对移植肾对侧为首发的上尿路发生肿瘤者可预防性行双侧上尿路根治性切除。     

Laparoscopic nephroureterectomy for upper urinary tract transitional cell carcinoma

OBJECTIVE: Open radical nephroureterectomy has been the standard treatment for upper urinary tract transitional cell carcinoma (TCC). Laparoscopic nephroureterectomy (LN) offers the advantages of a minimally invasive approach. We report our experience with both hand-assisted LN (HALN) and total LN. MATERIAL AND METHODS: A retrospective review was performed of all patients who underwent HALN and LN for the treatment of localized upper urinary tract TCC between 2001 and 2005. Histology of the operative specimen confirmed urothelial carcinoma in all cases. Their demographic data, perioperative parameters and follow-up data were assessed. RESULTS: There were 31 patients with a median age of 71 years (range 39-82 years). The mean operating time was 236 min (range 120-350 min) and mean blood loss was 365 ml (range 200-2000 ml). There were no conversions to open surgery. The mean length of hospitalization was 7 days (range 3-30 days). Clear oncological margins were achieved in 27 cases. The mean duration of follow-up was 28 months (range 2-55 months). CONCLUSIONS: HALN and LN are safe and effective alternatives to open surgery for the treatment of upper urinary tract TCC. Medium-term follow-up showed favourable oncological results. A larger sample size and a longer follow-up period are required before HALN and LN can be considered standard treatments for upper urinary tract TCC.     

Superficial transitional cell carcinoma of the ureteral orifice: Higher risk of developing subsequent upper urinary tract tumors

AIM: Reports specifically addressing transitional cell carcinoma (TCC) of the ureteral orifice are scarce. This paper presents our experiences of such tumors, including the characteristics of the disease and the incidence of subsequent upper urinary tract recurrence. METHODS: This study included 572 new cases of TCC of the urinary bladder diagnosed in our institute during a period of 5 years. Thirty-one (5.4%) patients had superficial tumors involving ureteral orifices. All 31 patients underwent transurethral resection of the bladder tumors, including the involved ureteral orifices. After the surgery, patients received regular follow up with cystourethroscopy, urine cytology and periodic intravenous pyelography (IVP). Ureterorenoscopy was performed in cases of suspicious IVP or urine cytology findings. RESULTS: Thirty-one patients with superficial tumors involving the ureteral orifice were followed up for 5-8 years or until death. The pathological stage was Ta in 16 cases and T1 in 15 cases. Bladder tumor recurrence was noted in three (18.8%) of the pTa patients and in seven (46.7%) of the pT1 patients. Subsequent upper urinary tract tumors developed in four (12.9%) patients between 33 and 67 months (mean: 33.5) after the first transurethral resection. All four cases of upper tract recurrence had pT1 primary bladder tumor, which recurred for 1-3 times (mean 1.8) before upper tract recurrence. None of these patients had ureteral stenting after bladder tumor resection. Three of four patients with upper tract recurrence had single lower ureteral tumor, while the remaining one patient had multiple tumors. Patients with subsequent upper urinary tract tumors underwent nephroureterectomy and bladder cuff excision. One died of the disease; the other three cases were free of the disease after the therapy. CONCLUSIONS: Patients with primary superficial bladder transitional cell carcinoma involving the ureteral orifice have a higher risk of developing subsequent upper urinary tract tumors, particularly for pT1 primary bladder tumors. Frequent and close follow up is recommended.     

上尿路移行细胞癌(附71例报告)

目的探讨上尿路移行细胞癌的诊断方法和治疗效果。方法回顾性分析近１０年来收治的７１例经病理证实的上尿路移行细胞癌。术前行尿脱落细胞学检查６０例,ＣＴ检查６１例;行肾输尿管及膀胱袖状切除６４例,术后随访６８例。结果尿细胞学和ＣＴ的阳性率分别为７２％和９３％。２６例术后再发膀胱癌。结论尿脱落细胞学检查是较好的定性诊断方法,ＣＴ检查是重要的定位诊断方法。肾输尿管及膀胱袖状切除术仍是主要的治疗方法。病人的预后与肿瘤部位、临床分期、病理分级及ＤＮＡ的倍体类型有关。     

Transitional cell carcinoma in renal transplant recipients: A single center experience

Objective:   To present a single center experience in managing transitional cell carcinoma (TCC) in Chinese renal transplant (RTx) recipients.
Methods:   In a cohort of 1429 patients who received RTx operation, 27 patients (six males and 21 females) were pathologically diagnosed with TCC in their native urologic system. The data were analyzed retrospectively.
Results:   The incidence of TCC was 1.89% and accounted for 41.5% of the patients with post-transplant de novo malignancies among 1429 recipients. Among the 27 recipients with TCC, 77.8% were female, 59.3% had taken a Chinese herb that contains aristolochic acid for at least 2 months before RTx, 51.9% had painless gross hematuria, while 40.7% had microscopic hematuria and/or repeated urologic infection. Two patients were found to have asymptomatic hydronephrosis during a routine check-up. The patients with upper tract carcinoma underwent simultaneous bilateral nephroureterectomy or unilateral nephroureterectomy and bladder cuff resection. Transurethral resection of the bladder tumor was carried out in patients with concomitant or solitary superficial bladder lesions. Intravesical chemotherapy was started and immunosuppressants were adjusted in all patients immediately after the surgery. Tumor recurrence in the bladder was noted in five patients. In one patient, residual and/or recurrent carcinoma in the contralateral pelvis was detected.
Conclusions:   Transitional cell carcinoma is the predominant malignancy in Chinese RTx recipients. Female sex, the Chinese herb containing aristolochic acid and immunosuppression are markedly associated with the development of TCC. Risk-adapted screening, strict follow up, standard surgical intervention and dose reduction of immunosuppressants are very important for early diagnosis and treatment of TCC.     

A comparison of the pathology of transitional cell carcinoma of the bladder and upper urinary tract

OBJECTIVE: To clarify the histopathological patterns of upper and lower urinary tract transitional cell carcinomas (TCCs), as previous reports suggest that upper urinary tract TCCs have a greater tendency towards high-grade disease than bladder TCCs, of which most are low-grade and low-stage tumours. PATIENTS AND METHODS: All patients presenting with TCC of bladder or upper urinary tract between February 1991 and December 2001 at one institution were identified. Further patient information was obtained from the hospital database and case-note review. RESULTS: In all, 164 patients with upper urinary tract TCC and 2197 with bladder TCC were identified. There was a correlation between grade and stage of both upper urinary tract and bladder TCCs. 35% of the upper tract TCCs were classified as grade 2 and 44% as grade 3, while for bladder TCCs, 31% of lesions were classified as grade 2 and 35% as grade 3 (P = 0.003). Of the upper urinary tract lesions 33% were stage pT2-T4, compared with only 20% of bladder TCCs (P = 0.001). CONCLUSIONS: Upper urinary tract TCC is a higher grade and stage disease than bladder cancer, a finding that emphasizes the need for aggressive treatment of upper urinary tract TCC. If endourological management of upper urinary tract TCC is considered, histopathological determination of tumour grade before treatment is essential.     

肾移植术后并发双侧自体肾盂和输尿管移行细胞癌16例

目的 总结肾移植术后发生双侧自体肾盂、输尿管移行细胞癌的诊治经验.方法 回顾性分析16例肾移植术后发生双侧自体肾盂、输尿管移行细胞癌患者的资料.首次发现上尿路肿瘤的时间为移植后(56.2±33.0)个月.2例同时发现双侧上尿路肿瘤,其余14例双侧上尿路肿瘤先后发现的时间间隔为(8.6±6.7)个月.临床症状和检查阳性结果以血尿和自体肾积水为主.均行自体上尿路根治性切除术,术后行膀胱灌注化疗.结果 16例手术均成功.32次自体肾、输尿管的病理检查结果均为移行细胞癌,包括单纯肾盂肿瘤4次,单纯输尿管肿瘤9次,合并肾盂、输尿管肿瘤19次.23次肾盂肿瘤的分级为1级8例,2级11例,3级4例;28次输尿管肿瘤的分级为1级6例,2级10例,3级12例.术后随访(26.8±25.1)个月,1例出现肺部转移后死亡;1例发生腰背部软组织转移性移行细胞癌,局部切除;其他患者未发现肿瘤复发及转移.结论 肾移植后自体上尿路移行细胞癌的常见表现为血尿合并自体肾积水,该肿瘤侵袭性较强,对于膀胱及一侧自体上尿路同时存在移行细胞癌者,应行对侧自体肾上尿路预防性切除术.

Abstract：

Objective To investigate the clinical features of bilateral native pelvic and ureteral transitional cell carcinoma (TCC) in renal transplant patients. Methods A retrospective analysis was carried out on 16 patients with bilateral native pelvic and ureteral TCC after kidney transplantation.The mean time between transplantation and diagnosis of upper urinary TCC was 56. 2 ± 33. 0 months.Two patients were suffered from bilateral upper urinary TCC at the same time. The mean interval between 2 upper urinary tract operations of the remaining 14 cases was 8. 6 ± 6. 7 months. Hematuria and hydronephrosis of native kidneys were the main symptoms and targets in checkup. Intravesical chemotherapy was postoperatively given. Results All operations were performed successfully. All specimens obtained from the operations were pathologically diagnosed as TCC. The TCC location involved pure native pelvis (n = 4), pure native ureter (n = 9), and pelvis combined with ureter (n = 19). Pelvic TCC pathological grades included grade 1 in 8 cases, grade 2 in 11 cases, and grade 3 in 4 cases; Ureteral TCC grades included grade 1 in 6 cases, grade 2 in 10 cases, and grade 3 in 12 cases.Patients were followed up for 26. 8 ± 25. 1 months. One patient died of lung metastasis. (One case of lumbar soft tissue transfer was given local excision. The remaining patients had no recurrence and metastasis. Conclusion Renal transplant patients with hematuria and native renal hydronephrosis should be highly vigilant of the occurrence of upper urinary tract TCC. TCC after renal transplantation is invasive. Prophylactic contralateral nephroureterectomy should be performed on the recipients having TCC at the bladder and one side of native upper urinary tract.