后腹腔镜联合膀胱电切镜治疗上尿路移行细胞癌

目的 介绍后腹腔镜行肾输尿管全长及膀胱袖状电切治疗上尿路移行细胞癌的经验.方法 经后腹腔镜施行肾输尿管全长及膀胱袖状切除术32例.其中输尿管肿瘤20例,肾盂肿瘤12例.肿瘤位于右侧17例,左侧15例.2例输尿管肿瘤合并膀胱肿瘤.经尿道电切镜距输尿管口约0.5 cm环形切透膀胱全层,对输尿管末端电灼彻底封闭输尿管开口.输尿管末端电切结束退出电切镜后留置尿管.采用腰部3个穿刺套管针入路,行根治性肾切除,输尿管尽量向下游离,下腹部行5～9 cm切口,取出.肾标本,然后行下端输尿管及膀胱袖状切除.结果 31例手术顺利,1例术前有经皮肾镜术史,术中发生十二指肠瘘,手术中转开放修补十二指肠,术后恢复顺利.手术时间2.0～6.5 h,平均3.5 h.出血量25～1 500 ml,平均163 ml.术后随访2～36个月.29例患者无瘤存活;1例患者术后2个月发生膀胱、盆腔转移,目前带瘤存活;1例患者术后2年发生膀胱肿瘤,电切后无瘤存活;1例患者术后第3个月死于心脏疾病.结论 经后腹腔镜手术治疗肾盂和输尿管肿瘤,切口明显小于开放手术,术后恢复快.用电切镜环状切除输尿管末端可完整切除输尿管.     

后腹腔镜下肾输尿管全长切除加经尿道膀胱袖状切除治疗上尿路上皮癌

目的：探讨后腹腔镜下肾输尿管全长切除加经尿道膀胱袖状切除术治疗上尿路上皮癌的临床效果。方法：上尿路上皮癌患者68例,男23例,女45例,平均年龄63（43-78）岁。肾盂癌55例,输尿管上段肿瘤4例,输尿管下段肿瘤9例。其中输尿管下段肿瘤合并膀胱肿瘤1例。经尿道膀胱镜患侧输尿管逆行插入输尿管导管引流肾盂尿,用电切镜针状电极距输尿管口周围约0．5cm环形切透膀胱壁,分离出输尿管开口及膀胱壁内段。拔除输尿管导管,电凝输尿管开口,使开口封闭,减少肿瘤细胞种植机会。采用腰部3个穿刺套管针人路,行后腹腔镜下根治性肾切除,输尿管尽量向下游离,如果是肾盂癌或输尿管上段肿瘤,用腹腔镜分离钳可以将下段输尿管提拉出来,扩大套管切口,将肾输尿管全长完整取出,避免了下腹部开放切口;如果是下段输尿管肿瘤,则需下腹部行5-7cm切口,先取出。肾标本,再行输尿管下段切除术。结果：68例手术顺利。手术时间平均120（90-240）min,术中出血量平均60（40-500）ml,1例需输血。术后引流管留置时间平均4（3-7）d,导尿管留置时间平均8（7-15）d。拔除尿管后均行B超检查无膀胱漏尿。术后病理报告均为尿路上皮癌。65例患者获随访平均18（3-38）个月。58例患者无瘤生存,3例死于心脑血管及肺部疾病。4例术后患膀胱肿瘤而行电切治疗。结论：后腹腔镜下肾输尿管全长切除加经尿道膀胱袖状切除治疗上尿路上皮癌,手术安全易行,用电切镜环状切除输尿管开口及膀胱壁内段可完整切除输尿管,对输尿管开口进行电凝封闭可减少肿瘤细胞种植。对肾盂癌及上段输尿管肿瘤患者可避免行下腹部开放切口的输尿管下段切除术,有效减少创伤,疗效可靠,无肿瘤种植转移。     

后腹腔镜双侧一期肾输尿管全长切除术——肾移植术后原上尿路移行细胞癌8例报告

目的探讨肾移植术后发现原肾肾盂癌和(或)输尿管癌一期行后腹腔镜双侧肾输尿管全长切除术的安全性与可行性。方法 2006年4月~2009年11月对8例肾移植术后发现原肾肾盂癌和(或)输尿管癌行腹腔镜下双侧一期肾输尿管全长切除。先取左侧卧位,后腹腔镜下游离右侧肾及输尿管,输尿管远端用钛夹夹闭;改为右侧卧位后同法处理左侧肾及输尿管;然后取截石位,经尿道用电切镜袖状切除双侧输尿管膀胱膀胱壁内段;最后取下腹正中6 cm切口取出标本。结果 8例均行后腹腔镜双侧肾输尿管全长切除联合经尿道膀胱袖状切除,其中1例因膀胱内发现肿物同时行经尿道膀胱电切术,无中转开腹。手术时间(346.9±105.4)min(230~574 min);术中出血量(162.5±102.6)ml(100~400 ml),均无输血;住院时间(18.3±5.7)d(12~49 d)。病理报告均为尿路上皮癌,其中2例为双侧病变,此2例中有1例合并膀胱癌。8例随访(22.6±14.2)月(6~49个月),其中1年6例,均存活,1例膀胱癌复发相继行电切、膀胱部分切除治疗。结论肾移植术后原肾肾盂癌或输尿管癌一期行后腹腔镜双侧肾输尿管全长切除术是一种安全可行的治疗方式。     

后腹腔镜联合经尿道输尿管口电切术治疗肾盂输尿管肿瘤(附17例报告)

目的:评估后腹腔镜联合经尿道输尿管口电切术治疗肾盂、输尿管肿瘤的临床疗效。方法:2008年10月至2013年1月为17例肾盂或输尿管移行细胞癌患者行后腹腔镜根治性肾输尿管切除术,其中肾盂癌11例,输尿管癌6例。经尿道袖状电切患侧输尿管口周围1 cm范围膀胱壁,采用后腹腔镜切除肾及全长输尿管,完整取出切除的肾输尿管。术后常规吡柔比星膀胱灌注。结果:手术时间平均(186.9±30.2)min;术中出血量平均(110.1±38.6)ml;术中、术后未发生明显并发症。术后随访3～51个月,1例发生膀胱移行细胞癌。结论:后腹腔镜联合经尿道电切镜治疗肾盂癌、输尿管癌具有手术损伤小、康复快等优点,且不增加肿瘤种植风险,临床应用前景良好。     

后腹腔镜下肾输尿管全长及膀胱袖状切除术35例报告

目的 介绍后腹腔镜下行肾、输尿管全长及膀胱袖状切除的体会。方法 经后腹腔镜施行肾输尿管全长及袖状膀胱切除术35例。男14例，女21例。年龄49～82岁，平均67岁。输尿管肿瘤20例，肾盂肿瘤15例。肿瘤位于右侧19例，左侧16例。其中输尿管肿瘤合并膀胱肿瘤者2例，先后发生双侧输尿管肿瘤并膀胱肿瘤者1例。经尿道用针状电极距输尿管口约0．5am环行切透膀胱。采用腰部3个穿刺套管针入路，行根治性肾切除，输尿管尽量向下游离，下腹部行5～9cm切口，取出肾标本，然后行下段输尿管及部分膀胱袖状切除。结果 35例手术顺利，手术时间1．5～6．0h，平均3．1h。出血量20～1600ml，平均166ml。4例需输血。术后20～32h下床活动。术后病理报告为移行细胞癌30例，输尿管低分化腺癌2例，输尿管鳞状细胞癌1例，输尿管平滑肌肉瘤1例，黄色肉芽肿性肾盂肾炎1例。1例术前为尿毒症透析患者，术后并发十二指肠漏，术后第3天放置引流管引流十二指肠漏出液，术后2个月死于心力衰竭。术后常规行膀胱灌注，预防肿瘤复发。平均住院时间11d。随访1～32个月，平均14个月，33例患者无瘤生存，1例术后3个月发生盆腔转移，目前带瘤存活。膀胱肿瘤均未见复发。结论 经后腹腔镜手术治疗肾盂和输尿管肿瘤，切口明显小于开放手术，术后恢复快。用电切镜环状切除输尿管末端可完整切除输尿管。     

后腹腔镜肾输尿管全长与膀胱袖状切除术的三种术式比较（附110例报告）

目的：探讨后腹腔镜肾输尿管全长与膀胱袖状切除的最佳手术方式.方法：对110例肾盂或输尿管癌伴膀胱癌患者采用三种不同术式行肾输尿管全长及膀胱袖状切除术：A术式即后腹腔镜肾输尿管全长切除＋下腹部切口膀胱壁内段袖状切除术,共行32例 B术式即后腹腔镜肾输尿管全长切除＋经尿道电切膀胱袖状切除＋经腹部切口取肾术,共行19例 C术式即经尿道电切膀胱袖状切除＋后腹腔镜肾输尿管全长切除＋经腹部切口取肾术,共行59例.结果：手术经过均顺利.三种术式的手术时间、术中出血量、平均住院时间差异无统计学意义.围手术期死亡3例.出院后获定期随访58例,随访8～85个月,平均38.3个月,46例失访.因肿瘤转移死亡4例,因气胸、脑血管病死亡各1例.三种术式术后早期并发症、对侧病变、膀胱痛复发情况差异无统计学意义 但C术式术后死亡及转移例数较少.结论：肾盂或输尿管癌伴膀胱癌者可优先选择经尿道电切膀胱袖状切除＋后腹腔镜肾输尿管全长切除＋经腹部切口取肾术,而仅有肾盂或输尿管癌者可考虑行后腹腔镜肾输尿管全长切除＋下腹部切口膀胱壁内段袖状切除术.     

联合应用多种内腔镜一期诊断和治疗早期肾盂癌（附8例报告）

目的：探讨多种内腔镜在早期肾盂癌诊断和治疗中的联合应用价值。方法：8例肾盂癌患者运用输尿管软硬镜或经皮。肾镜诊断,并一期采用后腹腔镜联合经尿道输尿管切开,行肾输尿管全长切除及膀胱输尿管开口袖套状切除。术后病理诊断为G,5例,G2 3例,T1N0M0 5例,T2N0M0 3例。结果：8例均顺利完成手术,手术时间平均150min,术中出血量平均120ml。导尿管留置时间为7天左右,术后2～4天下床活动。均无漏尿、切口感染等并发症。仅1例因淋巴漏,皮管引流至术后2周拔除。随访6～18个月,患者均无瘤生存,未见肿瘤复发、转移及切口肿瘤种植。结论：通过联合应用多种内腔镜,可以在明显提高肾盂癌的诊断率的基础上,一期完成腹腔镜肾盂癌根治性切除,最大限度地减少患者手术创伤和手术并发症。     

肾盂恶性肿瘤（附31例报告）

报告３１例肾盂恶性肿瘤，其中移行上皮细胞癌２７例，移行上皮及鳞状上皮混合性癌３例，腺癌１例。静脉尿路造影（ＩＶＵ）和ＣＴ为主要诊断方法。肾、输尿管全长及膀胱袖状切除可预防肾盂肿瘤的种植。术后定期复查膀胱镜和灌注化疗药物十分必要。     

经腹腹腔镜技术治疗上尿路尿路上皮癌52例报告

目的:探讨经腹腹腔镜技术行肾、输尿管全长切除在肾盂输尿管癌根治术中的应用价值。方法:52例肾盂癌、输尿管癌患者应用经腹腹腔镜技术行肾、输尿管全长切除术。手术采用健侧卧位70°,采用腹部3孔或4孔法先行根治性切除肾脏,更换器械操作通道,向下完全分离全长输尿管及输尿管膀胱壁段,全长切除输尿管后缝合膀胱切口。结果:手术均获成功,无中转开放病例,手术时间90～165min,平均(113.4±18.2)min,术中出血量30～200ml,平均(69.2±27.3)ml,无尿漏及其他并发症发生,术后1周拔出尿管。结论:经腹腹腔镜肾、输尿管全长切除术具有视野好、空间大,出血少,术中无需转换体位及再行切口,创伤小,是治疗肾盂癌、输尿管癌的较好选择,具有推广应用价值。     

腹腔镜联合尿道电切镜行肾输尿管切除并膀胱袖状切除术治疗上尿路肿瘤

目的:总结腹膜后腹腔镜联合尿道电切镜行肾输尿管切除并膀胱袖状切除术治疗上尿路移行细胞癌的临床经验.方法:回顾分析9例肾盂癌、8例输尿管癌患者的临床资料.术中先用电切镜经尿道袖状分离输尿管管口及壁内段,再切除肾、输尿管,并记录相关指标,术后常规用丝裂霉素或吡柔比星灌注膀胱.结果:16例手术顺利完成,1例因右肾切除时损伤下...     

后腹腔镜联合尿道电切镜根治性肾输尿管切除治疗上尿路肿瘤3例

目的探讨后腹腔镜联合尿道电切镜根治性肾输尿管切除治疗上尿路移行细胞癌的临床疗效。方法对2例肾盂癌、1例输尿管上段移行细胞癌先采用尿道电切镜行患侧输尿管口膀胱黏膜袖套状切除,而后行后腹腔镜根治性肾输尿管全切术。结果3例手术均获成功,平均手术时间190min,术中出血平均50mL,患者均于术后36~48h下床活动,术后住院时间9~11d(平均10d),术中、术后无严重并发症。结论后腹腔镜联合尿道电切镜根治性肾输尿管切除治疗上尿路肿瘤是一种安全、有效的微创手术方法,实用性较强,具有良好的应用前景。     

上尿路移行细胞癌的诊断与治疗（附39例报告）

目的探讨上尿路移行细胞癌的诊治方法。方法回顾性分析39例上尿路移行细胞癌患者的临床表现及诊治方法。结果39例患者均行手术治疗,术后病理检查证实29例为肾盂移行细胞癌,10例为输尿管移行细胞癌。通过B超、静脉尿路造影（IVU）、逆行肾盂造影、CT、尿脱落细胞学及输尿管镜等检查,术前诊断符合率为92.3%（36/39）。35例患者获得随访6个月-12年,6例术后出现膀胱移行细胞癌,5例死于肿瘤进展。结论B超、IVU、CT可作为上尿路肿瘤的常规检查,IVU显影不佳时逆行肾盂造影可作补充,输尿管镜配合组织活检准确性极高。根治性肾输尿管切除术效果较好,术后应行膀胱灌注治疗及定期膀胱镜检查。     

70°斜卧位腹腔镜治疗上尿路移行细胞癌

目的 探讨70°斜卧位经腹入路腹腔镜治疗上尿路移行细胞癌的临床效果.方法 2004年5月至2007年1月联合尿道电切镜、70°斜卧位经腹入路腹腔镜肾输尿管切除治疗上尿路移行细胞癌(TCC)31例,同时采用钛夹夹闭输尿管或输尿管肿瘤两端,下腹斜形切口取出标本.结果 31例手术均成功,无术中转开放;平均手术时间140 min,平均出血量80 ml,平均住院时间8 d,无尿漏、肠瘘等并发症发生.结论 70°斜卧位经腹入路腹腔镜肾输尿管全长切除术具有手术操作空间大、肾蒂血管处理简单、手术风险小、创伤轻、术后恢复快等优点,值得临床推广应用;但其对肿瘤播散、复发等的影响还需要长期的观察随访.     

70 degrees recumbent position transperitoneal laparoscopy for treatment of upper urinary tract transitional cell carcinoma

OBJECTIVE: To study the effect of 70 degrees recumbent position transperitoneal laparoscopy for treatment of upper urinary tract transitional cell carcinoma (TCC). METHODS: From May 2004 to January 2007, 70 degrees recumbent position transperitoneal laparoscopy combined with urethral resectoscope was used to treat 31 cases of upper urinary tract transitional cell carcinoma. At the same time titanium clip to occlude the two extremities of ureter tumor was used, extracting specimen by oblique incision of lower quadrant. RESULTS: All operations were finished successfully, no one was turned to open surgery; mean operation time was 140 min, mean blood loss 80 ml, mean hospital stay time 8 d, without complications of urine leakage and intestinal fistula and so on. CONCLUSIONS: 70 degrees recumbent position transperitoneal laparoscopy for resection of whole kidney and ureter is worth of general clinical application because it could provide large space for operation, simplify the treatment of renal pedicle vessels, decrease operation risk, reduce operation trauma and offer early recovery. But its effect on tumor spread and recurrence will still need long term follow-up.     

后腹腔镜联合经尿道电切镜治疗上尿路移行细胞癌(附83例报告)

目的 探讨后腹腔镜联合经尿道电切镜治疗上尿路移行细胞癌的效果和安全性. 方法 2003年3月～2006年7月,我院采用后腹腔镜联合经尿道电切镜治疗83例上尿路移行细胞癌.经尿道袖状电切患侧输尿管口周围1.5 cm范围膀胱壁达膀胱外脂肪组织,采用后腹腔镜切除肾及全长输尿管.术后留置导尿管7 d.11例术后辅助放疗. 结果 83例手术均成功.手术时间115～205 min,平均156 min.术中出血50～150 ml,平均80 ml.无术中并发症.术后住院7～11 d,平均8.5 d.病理报告：82例上尿路移行细胞癌,1例肾盂上皮中～重度不典型增生.术后随访3～38个月,平均10.8月.术后12个月内行膀胱镜检查发现膀胱肿瘤6例,其中5例行经尿道膀胱肿瘤电切,1例行腹腔镜根治性膀胱全切术、左侧输尿管皮肤造口术.2例肾盂肿瘤（pT3 G3和pT2 G3）于术后3个月肝转移.2例输尿管中段肿瘤（pT3 G3和pT3 G2～3）术后6个月原位复发并肺转移.1例输尿管下段肿瘤（pT3 G3）术后6个月骨转移.失访1例.其余71例均未发现肿瘤复发、切口转移及远处转移. 结论 对于上尿路移行细胞癌,采用后腹腔镜联合经尿道电切镜行肾、输尿管全切及膀胱袖套状切除具有创伤小、安全、恢复快等优点,值得临床推广应用.     

腹腔镜肾输尿管全长切除术及膀胱袖状切除术治疗上尿路移行细胞癌

目的:评价腹腔镜经腹腔径路行肾输尿管全长切除术及膀胱袖状切除术治疗上尿路移行细胞癌的有效性及安全性。方法:对6例上尿路移行细胞癌患者行腹腔镜经腹腔径路肾切除术,经同侧下腹斜切口、袖状切除输尿管并完整取出标本。结果:6例手术均获成功,无中转开放手术,手术时间200～320min,平均250min,术中出血100～300ml,均未输血,住院8～12d,平均9d,术后常规膀胱灌注丝裂霉素,随访2～14个月,均无复发或转移。结论:腹腔镜肾输尿管全长切除术是治疗上尿路移行细胞癌安全有效的微创手术,具有痛苦小、康复快等优点。     

Laparoscopic nephroureterectomy for upper tract transitional cell cancer: the Washington University experience

PURPOSE: Laparoscopic nephroureterectomy has only recently been done to treat patients with upper tract transitional cell carcinoma. We retrospectively evaluated our experience with and long-term followup of laparoscopic nephroureterectomy, compared our results to those of contemporary series of open nephroureterectomy and reviewed the literature. MATERIALS AND METHODS: We reviewed the charts of and followed up by telephone 25 patients who underwent laparoscopic nephroureterectomy between May 1991 and June 1998, and 17 who underwent open nephroureterectomy between March 1990 and January 1997. Demographic, perioperative and followup data were compared. We performed a MEDLINE search and reviewed the literature on laparoscopic nephroureterectomy for upper tract transitional cell carcinoma. RESULTS: Laparoscopic nephroureterectomy required twice the operating time of open nephroureterectomy (7.7 versus 3.9 hours). However, patients who underwent the laparoscopic procedure had a 74% decrease in analgesia requirements (37 versus 144 mg. morphine sulfate equivalent), a 63% shorter hospital stay (3.6 versus 9.6 days) and a 72% more rapid convalescence (2.8 versus 10 weeks). Subsequent bladder transitional cell carcinoma and overall cancer specific survival were similar at a mean followup of 2 years. There was no sign of trocar site or peritoneal seeding after laparoscopic nephroureterectomy. CONCLUSIONS: Although laparoscopic nephroureterectomy is a longer operation, it has the same efficacy and is better tolerated by patients than open nephroureterectomy for upper tract transitional cell carcinoma. As operating time decreases due to surgeon experience and the recent development of hand assisted laparoscopy, laparoscopic nephroureterectomy may soon become the procedure of choice for the ablative management of upper tract transitional cell carcinoma.     

Ureteroscopic management of upper tract transitional cell carcinoma in patients with normal contralateral kidneys

PURPOSE: The standard treatment for upper tract transitional cell carcinoma in patients with a normal contralateral kidney is nephroureterectomy with a bladder cuff or segmental ureterectomy. We evaluate whether ureteroscopic tumor resection with vigilant surveillance is a safe alternative in select patients. MATERIALS AND METHODS: Patients with isolated upper tract filling defects on an excretory urogram and a normal contralateral kidney were diagnosed ureteroscopically with papillary low intermediate grade appearing transitional cell carcinoma. Biopsies of the lesions were obtained, and the tumors were treated with laser ablation or electrofulguration in the same sitting. Patients with cytopathological results of high grade transitional cell carcinoma underwent nephroureterectomy. Surveillance consisted of ureteroscopy every 3 months until tumor-free and ureteroscopy every 6 months thereafter. RESULTS: Between 1989 and 1998, 23 patients with normal creatinine (mean 1.0, range 0.7 to 1.6) underwent ureteroscopic resection of unilateral upper tract transitional cell carcinoma. On initial biopsy 22 tumors were grade 1 or 2 and 1 was grade 2 to 3. After the primary tumor was treated 8 (35%) patients remained tumor-free and 15 (65%) had multiple recurrences, which were treated ureteroscopically. Mean followup was 35 months (range 8 to 103 months). All 23 patients are alive without evidence of disease progression. At last followup 4 patients (17%) had persistent disease, 4 (17%) elected to undergo nephroureterectomy and 15 (65%) are free of ipsilateral disease for a mean duration of 17 months (range 6 to 77). CONCLUSIONS: Ureteroscopic treatment of focal low intermediate grade superficial upper tract transitional cell carcinoma is a safe alternative to nephroureterectomy in select patients when vigilant ureteroscopic followup is used.