后腹腔镜联合经尿道输尿管口电切治疗上尿路尿路上皮癌

目的探讨后腹腔镜联合经尿道输尿管口电切行上尿路尿路上皮癌（upper urinary tract urothelial carcinoma,UUT—UC）根治性切除术的疗效。方法2009年4月～2012年1月,对21例UUT—UC采用后腹腔镜联合经尿道输尿管口电切行肾、输尿管、膀胱袖状切除术。先经尿道行输尿管口电切使输尿管与膀胱完全脱离,后腹腔镜下行肾及上段输尿管的游离和切除,取标本同时游离中下段输尿管以完成全程输尿管的切除。结果21例手术均成功,手术时间80～150min,平均110min,术中出血量60～180ml,平均100ml;无严重并发症发生。术后住院8～14d,平均9．5d。病理检查均为UUT—UC,其中肾盂癌15例,输尿管癌6例,20例T1-2N0M0,1例T3N0M0。21例随访4～36个月,平均20个月,均未见肿瘤复发及转移。结论后腹腔镜手术联合经尿道输尿管口电切治疗低级别肾盂癌和上段输尿管癌安全、有效。     

经脐单孔腹腔镜肾输尿管全长切除术8例分析

目的观察经脐单孔腹腔镜肾输尿管全长切除术治疗肾盂癌或输尿管癌的安全性及可行性。方法回顾性分析2011年4～10月在本院入住的肾盂癌或输尿管癌行经脐单孔腹腔镜肾输尿管全长切除术8例患者的临床资料。术中先行经尿道电切法分离壁内段输尿管。后采用脐周患侧弧形切口,用自制＂两环一套法＂建立单孔腹腔镜通道,行经脐单孔腹腔镜肾输尿管全长切除术。结果全部手术顺利,手术平均时间（179±18）min,单孔腹腔镜部分平均手术时间（146±17）min,术中平均出血量为（80±51）mL。全部患者术中未输血、无术中并发症发生、无中转开放手术。患者术后72h内排气。3～5d拔除引流管。术后1周拔除导尿管。术后住院天数为8～11d。随访3～9月,均未见肿瘤复发和转移。结论经脐单孔腹腔镜肾输尿管全长切除术安全可行,美容效果比传统腹腔镜更好。自制＂两环一套法＂建立单孔腹腔镜通道制作简单,操作方便,成本低,能够完成单孔腹腔镜肾输尿管全长切除术。     

完全腹腔镜肾盂输尿管癌根治术治疗上尿路肿瘤32例报告

目的探讨完全腹腔镜肾盂输尿管癌根治术治疗上尿路肿瘤的疗效。方法 2007年11月～2011年3月行完全腹腔镜肾盂输尿管癌根治术32例。70°～90°健侧卧位,建立人工气腹,于脐缘、平脐腋前线、锁骨中线肋缘下和脐与耻骨联合连线中点置入trocar,先在肾周筋膜外切除肾脏后,向下游离输尿管至膀胱壁段,膀胱充水后打开膀胱,吸净液体,观察双侧输尿管开口,袖状切除患侧输尿管,3-0可吸收线连续缝合膀胱切口,2-0可吸收线间断加固肌肉层,腰部取5～7 cm切口取出标本。结果 32例手术均获成功,无中转开放手术。手术时间80～150 min,平均100 min。术中出血量80～200 ml,平均150 ml。引流量50～150 ml/d,平均100 ml/d,术后24～48 h拔除引流管。术中、术后无明显手术并发症。住院时间7～14 d,平均9 d。32例病理诊断均为尿路上皮癌。32例随访4～40个月,平均23.2月,1例术后1年死于肺转移,其余均无瘤生存。结论完全腹腔镜肾盂输尿管癌根治术具有创伤小、术后恢复快的优点,是一种安全、有效的治疗方法。     

耻骨上辅助经脐单孔腹腔镜上尿路全切除术（附8例报告）

目的：探讨耻骨上辅助经脐单孔腹腔镜（SA—LESS）上尿路全切除术的可行性、有效性和技术要点。方法：对2例肾盂癌,2例输尿管癌,1例肾盂癌合并输尿管癌,2例肾结核,1例巨输尿管症并积脓、肾萎缩患者施行SA—LESS上尿路全切除术。患者全麻,取健侧70°卧位,于脐缘内侧置人两个Trocar,自患侧耻骨联合上方置人一个Trocar,分别置入远端可弯曲腹腔镜及操作器械。先游离患侧输尿管下段,予Hem—0—lok夹闭;向上游离肾脏并离断。肾动静脉,切除肾脏;向下行袖套状切除输尿管末端周围膀胱壁,缝合膀胱切口;标本装袋,延长耻骨上切口取出。结果：8例手术均顺利完成。中位手术时间165（115～220）min,术中中位失血量140（50～200）ml。均未输血,术中未出现肠管、实质性器官和大血管损伤等并发症。均于术后第1天下床活动,第2～3天拔除腹腔和盆腔引流管,第6～7天拔除导尿管（肿瘤患者行膀胱灌注后）,第8天出院。结论：SA-LESS上尿路全切除术安全可行,术后恢复快,住院时间短,美容优势明显,值得临床应用。     

后腹腔镜加下腹部斜行小切口治疗上尿路尿路上皮癌的临床研究

目的：探讨后腹腔镜加下腹部斜行小切口行上尿路尿路上皮癌根治性切除术的方法,并对本手术方式的临床疗效及并发症进行评价。方法：回顾性分析18例后腹腔镜加下腹部斜行小切口上尿路尿路上皮癌根治性切除术患者的临床资料,并对其临床结果进行总结。结果：手术均获成功。平均手术时间为（120．8±24．5）min,术中出血量（63．3±19．7）ml;术后肠功能恢复时间平均为（26±10）h;术后平均住院时间为（7．0±2．3）天;术中及术后未发生明显并发症。随访2～30个月,均未见肿瘤复发及转移。结论：后腹腔镜联合下腹部斜行小切口肾盂、输尿管癌根治术是一种安全有效的微创治疗方法,与传统的开放手术相比,疗效相当,但同时具有手术时间短、创伤小、出血量少、恢复快、术后并发症少等优点,可作为。肾盂、输尿管尿路上皮癌的首选治疗方法。     

改良体位经腹完全腹腔镜肾输尿管全长切除术20例报告

目的:谈讨改良体位经腹完全腹腔镜肾输尿管全长切除术在上尿路尿路上皮癌(UTUC)微创治疗方面的技术优势。方法:收集2017年1月～2018年6月在我院接受该术式20例患者的临床资料。先取30°健侧斜卧位并向患侧旋转手术床约15°头低脚高位。脐上2 cm正中放置观察通道,脐下2 cm左右侧腹直肌外缘放置操作通道,患侧麦氏点放置辅助通道,采用经膀胱途径完成袖套状切除。将手术床放平并向健侧旋转40°,形成70°斜卧位,患侧肋缘下锁骨中线处建立新操作通道,其余通道不变,完成根治性肾切除,术中同时完成盆腔或腹膜后淋巴清扫。术后给予局部灌注或全身化疗。结果:手术时间(178.2±29.0) min,术中出血量(155.4±46.6)mL,2例予以输血。3例术后出现淋巴漏,1例出现乳糜漏,给予持续负压引流后好转。无出血、感染、肠梗阻、漏尿发生。病理提示2例肿瘤侵犯局部淋巴结,所有标本输尿管切缘阴性。远期2例发生盆腔淋巴结转移,1例发生纵膈转移。结论:改良体位下经腹途径LRNU术操作简便、创伤小、并发症发生率低且控瘤效果满意,是一种适宜推广的UTUC微创处理新方法。     

经尿道输尿管开口环切加肾输尿管全长切除术九例报告

肾盂输尿管癌传统手术方式是肾输尿管全长及输尿管口周围膀胱壁瓣切除 ,但需同时取腰部和腹部切口 ,手术创伤较大。 2 0 0 0年 6月至 2 0 0 1年 2月 ,我们对 9例肾盂输尿管癌患者采用先经尿道输尿管开口环形切开 ,再经腰部作肾输尿管全长切除术 ,效果满意。现报告如下。材料与方法　本组 9例。男 7例 ,女 2例。年龄 5 1～ 72岁 ,平均 6 1岁。输尿管癌 3例 ,上、中、下段各 1例 ,肾盂癌5例 ,肾盂癌合并输尿管癌 1例。右侧 5例 ,左侧 4例。手术方式 :先用电切镜沿输尿管口周围环形切开直至显露膀胱周围脂肪组织 ,再取腰部切口 ,游离肾脏至肾门…     

经腹入路一站式腹腔镜肾脏-输尿管-膀胱袖状切除术治疗上尿路尿路上皮癌的临床研究

目的:探讨完全腹腔镜下经腹入路一站式肾脏-输尿管-膀胱袖状切除术治疗上尿路尿路上皮癌(UTUC)的手术技巧和临床效果。方法:2015年2月～2018年5月我院通过影像学检查或输尿管镜活检确诊的17例UTUC患者行完全腹腔镜下经腹入路一站式肾脏-输尿管-膀胱袖状切除手术。采取健侧60°卧位,放置5个Trocar,先行患侧根治性肾切除,然后沿输尿管向下游离至输尿管膀胱入口处,再将输尿管开口周围膀胱壁作袖状切除,缝闭膀胱切口。结果:17例手术均获成功,无中转开放,手术时间110～150min,平均125min;术中出血80～200ml,平均120ml;术后住院6～14d,平均8d;术后漏尿1例,引流后自愈。术后随访6～45个月,其中术后漏尿患者于术后9个月发现对侧输尿管口周围尿路上皮癌复发,行经尿道膀胱肿瘤电切术(TURBt),随访至今未见复发;失访3例,其余病例未见术中术后并发症,未见肿瘤复发及转移。结论:经腹入路一站式腹腔镜肾脏-输尿管-膀胱袖状切除术治疗UTUC安全可行,术中无需变换体位就能完成从肾脏到输尿管全段和膀胱袖状切除,是一种值得推广的手术方法。     

经腹腹腔镜肾切除术治疗成人巨大肾积水26例报告

目的:探讨经腹腹腔镜肾切除术治疗成人巨大肾积水的临床疗效、安全性及手术技巧。方法:回顾分析2012年5月至2015年7月采用经腹入路为26例巨大肾积水患者行腹腔镜肾切除术的临床资料,其中男17例,女9例;19~61岁,平均(42.0±6.7)岁。肾盂输尿管交界处狭窄13例,输尿管结石10例,输尿管膀胱连接部梗阻3例。左侧15例,右侧11例。通过改进手术方法,观察手术时间、术中出血量、术后住院时间、并发症及手术效果。结果:26例手术均获成功,无中转开放手术及严重并发症发生。肾积水量平均(4 800±1 860)ml,手术时间平均(76±19)min,术中出血量平均(55±27)ml,术后平均住院(6.4±1.3)d。结论:成人巨大肾积水行腹腔镜肾切除术是安全、可行的,通过一定的技巧改进有助于手术的顺利进行,值得推广。     

后腹腔镜加下腹小切口术治疗上尿路肿瘤(附18例报告)

目的探讨腹腔镜对肾盂或输尿管癌等上尿路肿瘤根治性切除术的手术方法,对加用下腹小切口术式的临床效果进行评价。方法回顾性分析18例行后腹腔镜加下腹部小切口肾盂癌或输尿管癌根治性切除术患者的临床资料及手术方法。结果手术均获成功,无一例中转开放;平均手术时间为120～176min,术中平均出血量110～200ml;术后肠功能恢复时间平均为26～48h,手术后30～48h下床活动;术后平均住院时间为6～8d。术中、术后未发生明显并发症。随访2～36个月均未见肿瘤复发及转移。结论后腹腔镜加下腹部小切口行肾盂癌和输尿管癌根治术是一种安全有效的微创方法,与传统开放手术和其他术式相比,具有手术时间短、出血少、恢复快、术后并发症少等优点。     

Robot-assisted laparoscopic nephroureterectomy for upper tract urothelial carcinoma (UT-UC)

Upper tract urothelial carcinoma (UT-UC), including tumors evolving from the renal pelvis and ureter, accounts for around 5% of all UCs and 10% of all renal tumor cases. In Taiwan, the incidence of UT-UC is higher than the western countries especially in the female and patients at renal replacement therapy. The standard care of UT-UC is nephroureterectomy with bladder cuff excision. In the past decades, minimally invasive surgery is proved to achieve comparable oncological results as conventional open procedure. Though laparoscopic nephroureterectomy with bladder cuff excision including pure laparoscopic or hand-assisted technique have been very common practice in Taiwan, several institutes have the early experience of robot-assisted nephroureterectomy which is believed to provide 3-D visualization with magnification, better surgical exposure, and safer watertight suture of the cystostomy. In this review, we review the published reports of robot-assisted nephroureterectomy with bladder cuff excision.     

一体位完全腹腔镜下治疗上尿路移行上皮癌

目的探讨一体位完全腹腔镜下治疗上尿路移行上皮癌的手术方法及临床效果。 方法选取2016年1月至2017年6月至烟台毓璜顶医院就诊的89例上尿路移行上皮癌患者为研究对象,采用前瞻性临床对照研究方法,按照随机数字表法将患者分为实验组与对照组。实验组（n=45）手术方式选择一体位完全腹腔镜下上尿路移行上皮癌根治术,对照组（n=44）采用后腹腔镜联合下腹部斜行小切口治疗上尿路移行上皮癌。对比两组患者的围手术期相关指标及肿瘤复发情况的差异,分析一体位完全腹腔镜下治疗上尿路移行上皮癌的临床效果。 结果实验组与对照组均顺利完成手术,术中均无中转开放,围术期均未出现明显的并发症。实验组患者的平均手术时间（96.6±8.6） min、术中出血量（39.6±4.2） ml、术后首次下床活动时间（7.5±1.0） h以及平均住院时间（7.0±1.1） d与对照组患者相比（147.5±9.2） min,（46.5±4.6） ml,（11.4±1.8） h,（9.9±1.5） d,其差异有统计学意义（P<0.05）,而两组患者的肿瘤分期、肿瘤分级、胃肠功能恢复时间、随访时间及术后肿瘤复发情况的差异无统计学意义（P>0.05）。 结论一体位完全腹腔镜下治疗上尿路移行上皮癌较传统术式具有手术时间短、术中出血量少、术后首次下床活动时间早等优势,可缩短患者的住院时间,加速患者康复,是切实可行的术式,值得临床推广应用。     

腹腔镜治疗上尿路尿路上皮癌的热点及进展

腹腔镜手术在上尿路尿路上皮癌的治疗中的应用越来越广泛。为明确腹腔镜手术的治疗效果,本文对相关文献进行了检索及总结,从目前研究结果来看,腹腔镜下肾盂输尿管癌根治术的治疗效果与开放手术相当,尤其是对早期上尿路尿路上皮癌(如pTa、pT1、pT2)。另外,输尿管末端的处理方法有多种。目前尚缺乏相关的对比研究来比较各种方法的优劣,最大限度地遵循肿瘤治疗原则是评判这些方法优劣的重要依据。     

Transperitoneal laparoscopic nephroureterectomy for native upper tract urothelial carcinoma in renal transplant recipients

Purpose

To analyze the safety and clinical outcome of laparoscopic nephroureterectomy (LNUT) for native upper tract urothelial carcinoma (UC) in renal transplant (RT) recipients.

Methods

We conducted a retrospective analysis of 956 RT recipients from January 2003 to December 2010 to evaluate the benefit of LNUT for patients who were diagnosed with de novo UC after renal transplantation.

Results

Women predominated (10/11, 91 %) in the 11 patients with upper tract UC who underwent LNUT. Five patients underwent LNUT ipsilateral to the transplanted kidney, 4 patients underwent contralateral LNUT, and 2 patients underwent bilateral LNUT. Nine were operated with LNUT combining resection of bladder cuff, 2 with right ureteral cancer underwent open ureterectomy with bladder cuff due to severe adhesions attached to the lesion. The mean surgical duration was 184.2 min (105–305), the mean blood loss was 182.3 ml (20–500), and the mean hospitalization time was 6.7 days (5–9). The mean levels of preoperative and postoperative serum creatinine were 0.99 mg/dl (0.78–1.16) and 1.01 mg/dl (0.89–1.18), respectively. No intraoperative complications occurred. One patient died of multiple metastases at 13 months after LNUT. The mean follow-up of the remaining 10 patients after diagnosis was 21.7 months (3–48). Two patients had recurrent bladder cancer and underwent transurethral resection of the tumor. Eight patients showed no evidence of disease during the follow-up.

Conclusions

LNUT is a safe and effective approach with low morbidity in transplant recipients, and this therapy provides less trauma, quicker recovery, and acceptable oncological outcomes.     

Pure laparoscopic complete excision of distal ureter with a bladder cuff for upper tract urothelial carcinoma

PURPOSE: In laparoscopic nephroureterectomy for upper tract urothelial carcinoma techniques for removing the lower ureter with a bladder cuff have been a matter of debate. We have developed a pure laparoscopic technique for the complete resection of the lower ureter with a bladder cuff. MATERIALS AND METHODS: Laparoscopic nephroureterectomy was performed in ten patients with upper tract urothelial carcinoma using this technique. After a working space was made retroperitoneally, the ureter was ligated at the distal site of the tumor. Retracting the ureter cranially, a stay suture was placed at an anterior point on the bladder and the bladder opened. With the patient placed in a lateral position, there was no urine leakage from the opened bladder. The ureteral orifice was confirmed laparoscopically. Incising around the ureteral orifice, the distal ureter was detached with the bladder cuff. The opened bladder wall was closed with running stitches. RESULTS: This method was technically successful in these ten cases with minimal bleeding and average operative time of 87 min. The margins of the bladder cuff were all negative and the average follow-up period of 19 months revealed only one (10%) bladder tumor recurrence. CONCLUSIONS: The ligation of the distal part of the ureter and the complete excision of the ipsilateral orifice and a bladder cuff under laparoscopic vision could reduce bladder tumor recurrence. Although this is a limited study with a small sample, the observation of low rates of bladder tumor recurrence after 19 months warrants further study.     

Primary upper tract urothelial carcinoma with thyroid-like features

Abstract:   We present a unique case of primary urothelial carcinoma with both histological and immunohistochemical features similar to thyroid papillary carcinoma. Following surgical resection of the primary tumor and localized metastatic lymphadenectomy, the patient was treated with a course of adjuvant chemotherapy. No evidence of primary thyroid carcinoma was noted. The patient was without recurrence after a 6 month follow-up.     

Salvage topical therapy for upper tract urothelial carcinoma

Purpose

Topical therapy (TT) for upper tract urothelial carcinoma (UTUC) has been explored as a kidney sparing approach to treat carcinoma in situ (CIS) and as adjuvant for endoscopically treated Ta/T1 tumors. In bladder cancer, data support use of salvage TT for repeat induction. We investigate the outcomes of salvage TT for UTUC in patients ineligible for or refusing nephroureterectomy.

Methods

A single-center retrospective review on patients receiving salvage TT via percutaneous nephrostomy tube or cystoscopically placed ureteral catheters was performed. Primary outcome was response to therapy based on International Bladder Cancer Group criteria.

Results

51 patients with 58 renal units (RUs) received TT. Of these, 17 patients with 18 RUs received the second-line TT, with a median follow-up of 36.5 months (IQR 24.5–67 months). 44% (8/18) received salvage TT for refractory disease and 56% (10/18) as reinduction. 5 RUs with CIS were unresponsive to initial TT and went on to receive salvage TT, of which 20% (1/5) responded. 13 RUs recurred or relapsed following initial TT and received salvage TT for papillary tumors, with 62% (8/13) responding.

Conclusion

Our data provide preliminary clinical rationale for the second-line TT for refractory and recurrent, endoscopically managed papillary UTUC in patients ineligible for or refusing nephroureterectomy. However, refractory upper tract CIS appears to have poor response to salvage TT.

     

A polymeric paste-drug formulation for local treatment of upper tract urothelial carcinoma

BackgroundIntravesical instillation of chemo- or immunotherapy is commonly used in bladder cancer. Upper tract urothelial carcinoma (UTUC) shares similar pathological features, but current formulations are not suitable for direct instillation to the upper urinary tract.ObjectiveTo evaluate in vivo applicability, characteristics and toxicity of ST-UC, a mucoadhesive polymeric paste formulation of gemcitabine, for upper urinary tract instillation.Material and methodsThree pigs received 10 ml of ST-UC (100 mg/ml gemcitabine) retrogradely into 1 renal pelvis for pharmacokinetic studies. Four days later, a second injection into the contralateral renal pelvis was followed by serial euthanasia of the pigs and nephroureterectomy after 1, 3, and 6 hours. Adverse effects were monitored. Urine, serum, and tissue gemcitabine concentrations were measured, along with histologic examination of the upper urinary tract.ResultsRetrograde instillation of ST-UC was well tolerated with mild, completely receding hydronephrosis. Urine gemcitabine concentrations were highest in the first 3-hour collection interval. Hundred percent of gemcitabine was recovered in the urine within 24 hours. Serum peak concentrations (c_max) of gemcitabine were low at 5.5 µg/ml compared to the 10 to 30 µg/ml levels observed after a single intravenous dose of 1,000 mg/m² gemcitabine. The formulation was still traceable after one hour and gemcitabine tissue concentrations are supportive of this extended drug exposure. No major histopathological changes were observed. The main limitation of this study is the lack of antitumor activity data.ConclusionThis preclinical evaluation of ST-UC demonstrated feasible instillation in the renal pelvis, no significant safety concerns, and sustained release of gemcitabine.     

Molecular aspects of upper tract urothelial carcinoma

ObjectivesPrimary upper tract urothelial carcinoma (UTUC) is a relatively rare tumor with up to 60% of cases being muscle invasive at presentation. In this article we review the molecular biology of UTUC, an understanding of which may help to address some of the dilemmas surrounding the diagnosis and treatment of this disease and ultimately lead to the introduction of personalized treatment plans.MethodsThe literature search on the molecular aspects of UTUC was performed using the National Library of Medicine database.ResultsUTUC and urothelial carcinomas of the bladder share many common biological pathways. UTUC are more commonly associated with conditions such as Balkan Endemic Nephropathy and Hereditary Non Polyposis Colon Cancer (HNPCC), the molecular basis of which is now being understood. A large number of potential biomarkers have been studied to help identify robust prognostic markers in UTUC.ConclusionAdvances in our understanding of the biology of UTUC is may in the future help to identify novel druggable targets, clinically applicable biomarkers and guide treatment of the rare but lethal condition.