膀胱癌术后再发上尿路肿瘤临床分析（附11例报告）

膀胱癌是泌尿系肿瘤中最常见的恶性肿瘤之一，上尿路肿瘤术后膀胱癌再发率为15％-40％，但膀胱癌术后再发上尿路癌的发生率文献报道不一。我院自1996—2006年共收治膀胱癌316例，术后再发上尿路癌11例，行根治性患侧上尿路全切术10例，输尿管部分切除＋膀胱部分切除＋输尿管膀胱吻合术1例，现报告如下。     

耻骨前尿道全切术

膀胱癌是泌尿系统最常见的肿瘤之一。由于尿路上皮癌具有多中心发生特点,膀胱癌患者行根治性膀胱全切术后尿道复发的概率为5％-10％。既往主张在膀胱全切术同时行预防性尿道切除,近年来随着原位膀胱技术的发展,目前仅限于肿瘤累及后尿道或膀胱颈口时行预防性尿道切除。尿道切除术传统上多采用经会阴途径,2010年6月-2016年7月,我们对8例男性膀胱癌患者行根治性膀胱切除术的同时行耻骨前尿道全切术,现报道如下。     

腹腔镜及开放根治性肾输尿管膀胱切除术治疗上尿路肿瘤合并膀胱癌8例报告

目的探讨腹腔镜和开放根治性肾输尿管膀胱切除术治疗上尿路肿瘤合并膀胱癌患者的可行性和安全性。方法收集我院2004年6月至2009年3月期间收治的8例单侧上尿路肿瘤并浸润性膀胱癌行根治性肾输尿管膀胱切除术及尿流改道手术患者的临床资料并进行随访分析。结果本组8例。男7例,女1例,平均年龄56岁。术前经膀胱镜、输尿管镜、B超和CT等检查证实为单侧上尿路肿瘤并浸润性膀胱癌,其中4例左肾盂癌和2例右肾盂癌合并膀胱癌,2例为左输尿管癌合并膀胱癌。2例行腹腔镜肾输尿管膀胱切除术及回肠膀胱术,平均手术时间470min,术中平均出血量275ml,均无输血,术后肠功能恢复时间为2d,下床活动时间为4d。6例患者行开放肾输尿管膀胱全切除术,其中4例行回肠膀胱术,另2例行输尿管造口术,平均手术时间366min,平均出血量767ml,平均输血量485ml,术后肠功能恢复时间为3.3d,下床活动时间平均为6.7d。8例患者术后均未出现并发症。术后病理结果 7例为尿路上皮癌,上尿路肿瘤分期分级为T2～4N0～1M0G2,膀胱癌为T2～3N0M0G3,另1例为左肾盂鳞癌T4N1M0合并膀胱鳞癌T3N0M0。术后平均随访24.6个月,鳞癌患者术后18个月因肿瘤广泛转移死亡,余7例患者无瘤生存至今。结论单侧上尿路肿瘤合并膀胱癌可行Ⅰ期根治性肾输尿管膀胱切除术,腹腔镜下行该手术是可行及安全的,较开放手术创伤小,出血少,恢复快。     

腹腔镜根治性全膀胱切除回肠新膀胱术治疗浸润性膀胱癌（附30例报告）

目的 探讨腹腔镜下根治性全膀胱切除原位回肠新膀胱术的手术方法及临床疗效.方法 收集2007年5月至2011年10月应用腹腔镜下根治性全膀胱切除原位回肠新膀胱术的浸润性膀胱癌患者30例.对其临床资料进行回顾性分析和总结.结果 所有手术均获得成功,无中转开放,手术时间180～360 min（平均240 min）,术中出血量150～450mL（平均220 mL）.术后4～8d恢复肠道正常蠕动功能,随访时间6～60个月,中位随访时间26个月.30例术后均能恢复较满意的控尿功能,平均膀胱容量约398mL,平均夜尿1～3次;1例出现夜间遗尿;2例出现尿漏;膀胱镜检查无尿道肿瘤复发;2例死于原发病转移.其余患者术后随访6个月血生化指标均正常,B超检查未见上尿路扩张积水.结论 腹腔镜下根治性全膀胱切除原位回肠新膀胱术具有创伤小、出血少、盆腔淋巴结清扫彻底、术后恢复快、术后控尿满意等优点,是治疗浸润性膀胱癌的一种理想手术方式.     

腹腔镜根治性全膀胱切除回肠新膀胱术治疗浸润性膀胱癌（附30例病例报告）

目的 探讨腹腔镜下根治性全膀胱切除原位回肠新膀胱术的手术方法及临床疗效。方法 收集2007年5月至2011年10月应用腹腔镜下根治性全膀胱切除原位回肠新膀胱术的浸润性膀胱癌患者30例。对其临床资料进行回顾性分析和总结。结果 所有手术均获得成功,无中转开放,手术时间180～360 min(平均240 min),术中出血量150～450 ml(平均220 m1)。术后4～8d恢复肠道正常蠕动功能,随访时间6～60个月,中位随访时间26个月。30例术后均能恢复较满意的控尿功能,平均膀胱容量约398ml,平均夜尿1～3次;1例出现夜间遗尿; 2例出现尿漏;膀胱镜检查无尿道肿瘤复发;2例死于原发病转移。其余患者术后随访6个月血生化指标均正常,B超检查未见上尿路扩张积水。结论 腹腔镜下根治性全膀胱切除原位回肠新膀胱术具有创伤小、出血少、盆腔淋巴结清扫彻底、术后恢复快．术后控尿满意等优点,是治疗浸润性膀胱癌的一种理想手术方式。     

后腹腔镜联合经尿道电切镜术后继发膀胱癌的危险因素分析

目的研究后腹腔镜联合经尿道电切镜治疗上尿路上皮癌术后继发膀胱癌的危险因素。方法回顾性分析2003年3月至2015年3月青岛大学医学院附属烟台毓璜顶医院252例不合并膀胱癌的上尿路上皮癌患者,手术方式为经尿道电切镜电切患侧输尿管口周围约1.5 cm范围膀胱壁至膀胱外脂肪组织,电凝输尿管口,然后行后腹腔镜根治性肾输尿管切除术(RL-RNU),随访时间5~113个月,中位随访时间为62个月。结果 252例患者中,32例(12.7%)继发膀胱癌,年龄65岁患者膀胱癌发病风险较年龄≤65岁患者明显升高,且肿瘤同时位于肾盂和输尿管的患者术后继发膀胱癌的风险明显升高(P0.01),差异有统计学意义。而性别、是否合并肾积水、肿瘤的分级、分期以及切缘是否阳性并没有增加术后继发膀胱癌的风险(P0.05)。结论对于采用后腹腔镜联合经尿道电切镜治疗上尿路上皮癌的患者,继发膀胱癌的危险因素主要为高龄和肿瘤位置。     

单次与多次膀胱灌注化疗对上尿路尿路上皮癌术后复发膀胱癌的影响

目的研究单次与多次膀胱灌注化疗对上尿路尿路上皮癌术后复发膀胱癌的影响。方法研究对象为2017年1月至2019年1月入院的46例上尿路尿路上皮癌术后患者,按照化疗方案划分为对照组(23例)与研究组(23例)两组,对照组选用单次膀胱灌注化疗,研究组选用多次膀胱灌注化疗,比较两组术后不良反应发生率、腹膜后肿瘤复发率及膀胱癌发生率。结果对照组术后出现1例膀胱刺激征,不良反应发生率为4.35%;研究组术后出现1例少量血尿,1例下尿路刺激征,不良反应发生率为8.70%,两组术后不良反应发生率差异无统计学意义(P>0.05)。对照组术后1例患者复发腹膜后肿瘤,发生率为4.35%;研究组术后无1例患者复发腹膜后肿瘤,两组术后腹膜后肿瘤复发率差异无统计学意义(P>0.05)。对照组术后发生9例膀胱癌,发生率为39.13%;研究组术后发生2例膀胱癌,发生率为8.70%,研究组术后膀胱癌发生率明显低于对照组(P<0.05)。结论多次膀胱灌注化疗可有效降低上尿路尿路上皮癌术后患者的膀胱癌发生率,对于预防膀胱癌具有积极作用,值得推广应用。     

保留膀胱治疗后完全机器人辅助腹腔镜根治性膀胱切除术+原位回肠膀胱1例报告

患者, 男, 56岁。因膀胱癌反复复发于2021年11月29日入院。患者因膀胱癌既往有开放膀胱部分切除术史、同步放化疗治疗史、4次经尿道膀胱肿瘤切除术史。本次入院CT检查示膀胱左侧壁膀胱癌, 肿瘤分期T3期;继发左肾积水。全麻下行机器人辅助腹腔镜根治性膀胱切除术+完全腹腔内原位回肠新膀胱。手术顺利, 患者恢复良好, 术后7 d出院。术后病理诊断为膀胱高级别尿路上皮癌, 病理分期T2b期, 伴左侧盆腔淋巴结转移。术后3个月复查, 患者无复发表现, 新膀胱功能良好, 日间可完全控尿, 肠道和肾功能恢复好。目前正在接受吉西他滨联合顺铂辅助化疗。对于有手术史和放疗史的膀胱癌患者, 根治性膀胱切除术+原位回肠膀胱的手术难度高, 术者丰富的腹腔镜手术经验和机器人辅助手术的精细化特点是完成此类手术的重要前提。     

腹腔镜根治性膀胱切除术患者早期活动等级及影响因素研究

目的了解腹腔镜行根治性膀胱切除术患者术后早期活动现状及影响因素,为术后早期活动的开展提供参考。方法对92例膀胱癌腹腔镜下根治性膀胱切除术患者,评估术后24h内活动情况,分析早期活动等级的影响因素。结果 71.7%的患者术后早期处于低活动等级水平,其中50.0%处于卧床休息状态;合并症、术前活动水平是根治性膀胱切除术患者术后早期活动等级的主要影响因素(P0.05,P0.01)。结论根治性膀胱切除术患者术后早期活动水平较低,需对患者进行个性化评估和干预,尤其关注术前活动水平和合并症情况。     

全尿路上皮癌1例

<正>患者,男,66岁。既往2010年11月在我院因左侧肾盂癌、膀胱癌(术前泌尿系CT检查提示左侧肾盂癌,膀胱占位病变;膀胱镜检取病变组织做病理检查为高级别乳头状尿路上皮癌),行左侧肾输尿管切除、膀胱袖套式切除术(术后病理检查为肾盂、输尿管、膀胱高级别乳头状尿路上皮癌)。2012年2月因膀胱癌复发行根治性膀胱全切、去带乙状结肠原位新膀胱术(术前及术后病理检查为     

经尿道膀胱肿瘤电切变性术的疗效

目的评估经尿道膀胱肿瘤电切变性术(TURD-Bt)的疗效和安全性。方法采用TURD-Bt治疗56例膀胱肿瘤,与32例行经尿道膀胱肿瘤电切术(TUR-Bt)进行对照研究。有和无肿瘤进展因素患者分别比较。结果随访时间TURD-Bt组(48.55±23.74)月,对照组(56.28±17.61)月。无肿瘤进展因素患者,TURD-Bt组无肿瘤复发,14例均生存;对照组3例(37.50%)复发,5例(62.5%)生存。有肿瘤进展因素患者,TURD-Bt组8例(19.05%)肿瘤复发,32例(76.19%)生存,肿瘤死亡3例(7.14%);TUR-Bt组18例(75.00%)复发(P0.05),12例(50.00%)生存(P0.01),8例(33.33%)肿瘤死亡(P0.05)。TURD-Bt组无特殊并发症发生。结论 TURD-Bt术可彻底切除和凝固变性膀胱肿瘤,疗效显著提高。手术安全可靠,操作过程预期可控制。对没有淋巴和远处转移的膀胱肿瘤,TURD-Bt可替代根治性TUR-Bt,保留膀胱。     

Hydronephrosis as a prognostic marker in bladder cancer in a cystectomy-only series

OBJECTIVES: Hydronephrosis in patients with bladder cancer is caused by tumour at the ureteral orifice, secondary ureteral tumours, intramural or extravesical tumour infiltration, or compression of the ureter. This study investigated the prognostic impact of hydronephrosis in bladder cancer. METHODS: A series of 788 patients were treated with radical cystectomy with curative intent for transitional cell carcinoma of the bladder without neoadjuvant/adjuvant radiotherapy/chemotherapy between January 1986 and September 2003. All patients had a complete follow-up until death or until the study's end date. Survival rates were calculated using the Kaplan-Meier method. A multivariate analysis with a Cox regression model was performed with respect to potential influencing factors. RESULTS: A total of 108 patients (13.7%) had unilateral and 25 patients (3.2%) had bilateral hydronephrosis. The rate of organ-confined tumours was significantly higher in patients without hydronephrosis (67.9% vs. 37.6%; p<0.001). Forty-three (32.3%) of the 133 hydronephrotic patients had a tumour involving the ureteral orifice. In this group the rate of organ-confined tumours was significantly higher than in the other patients with hydronephrosis (53.5% vs. 30.0%; p=0.009). In the multivariate analysis, preoperative hydronephrosis was determined as an independent prognostic marker for recurrence-free survival besides the pT classification and lymph node status (p=0.0015). The etiology of hydronephrosis did not affect the tumour-specific survival. CONCLUSIONS: Hydronephrosis at the time of diagnosis of bladder cancer is associated with a high probability of advanced tumours. It is an independent prognostic factor for recurrence-free survival.     

淋巴结转移率对胃癌患者预后的评估价值

目的 探讨淋巴结转移率（rN）对胃癌根治术患者预后的评估价值.方法 回顾性分析1980-2006年间中国医科大学附属第一医院肿瘤外科收治的接受根治性手术的710例胃癌患者的临床资料.按淋巴结捡取数目将710例患者分为少于15枚组（327例）和15枚以上（含15枚）组（383例）.按淋巴结转移率进行rN分期;按淋巴结转移数量进行pN分期.分别采用Logrank检验和Cox比例风险模型来进行单因素和多因素预后分析.结果 少于15枚组和15枚以上组胃癌患者中位生存时间分别为74个月（95％ CI：55.6～92.4个月）和96个月（95％ CI：77.8～119.2个月）,差异无统计学意义（P＞0.05）.多因素预后分析显示,rN分期既是少于15枚组（P＜0.01,RR=1.225,95％ CI：1.102～1.362）,又是15枚以上组（P＜0.01,RR=1.421,95％ CI：1.269～1.592）胃癌患者的独立预后因素;而pN分期仅仅是少于15枚组胃癌患者的独立预后因素（P＜0.01,RR=1.475,95％ CI：1.168～1.863）.采用rN分期系统,相同分期的两组胃癌患者生存时间的差异均无统计学意义（P＞0.05）;而采用pN分期系统,在pN1期患者中少于15枚组患者生存时间明显短于15枚以上组（P＜0.01）.结论 淋巴结转移率是影响胃癌预后的独立因素.在判断胃癌预后中,按淋巴结转移率的rN分期不受检出淋巴结数目的限制,较pN分期系统更为可靠.     

Prognostic significance of vascular invasion in patients with bladder cancer who underwent radical cystectomy

BACKGROUND: The objective of this study was to determine whether vascular invasion (i.e. lymphatic and blood vessel invasion) could be a useful prognostic predictor in patients with locally invasive transitional cell carcinoma (TCC) of the bladder who underwent radical cystectomy. METHODS: This series included 114 consecutive patients undergoing radical cystectomy for primary TCC of the bladder between November 1989 and July 2003. Several clinicopathological characteristics of these patients were analyzed, focusing on the association between vascular invasion and disease recurrence after radical cystectomy. RESULTS: Lymphatic and blood vessel invasions were detected in 55 (48.2%) and 33 (29.8%) specimens, respectively. Lymphatic invasion was significantly associated with pathological stage, tumor grade, lymph node metastasis, blood vessel invasion and disease recurrence, whereas blood vessel invasion was significantly related to pathological stage, lymph node metastasis, lymphatic invasion and disease recurrence. Recurrence-free survival in patients with lymphatic invasion was significantly lower than that in those without lymphatic invasion, and a similar significant difference in recurrence-free survival was observed between patients with and without blood vessel invasion. However, multivariate analysis using the Cox proportional hazards model showed that only pathological stage and lymph node metastasis could be used as independent predictors for disease recurrence after radical cystectomy. CONCLUSIONS: Despite a significant association between several prognostic parameters, vascular invasion was not an independent predictor of disease recurrence; therefore, if there are other conventional parameters available, there might not be any additional advantage to considering the presence of vascular invasion when predicting the prognosis of patients undergoing radical cystectomy for TCC of the bladder.     

Clinicopathological Features of Recurrence after Radical Cystectomy for Patients with Transitional Cell Carcinoma of the Bladder

Background: The objective of this study was to investigate the clinicopathological features of recurrent transitional cell carcinoma (TCC) of the bladder in patients who had previously undergone radical cystectomy. Materials and methods: This study included 124 patients who underwent radical cystectomy for transitional cell carcinoma (TCC) of the bladder in our institution. Several clinicopathological factors were analyzed to characterize differences between patients with and without disease recurrence, and determined predictive factors for disease recurrence using multivariate analysis. We further analyzed prognostic parameters that affect survival after disease recurrence was diagnosed. Results: Of the 124 patients, 24 (19.5%) developed recurrence, and the median time to recurrence was 9.5 months (range, 1–44 months). The 5-year recurrence-free survival in these 124 patients was 75.6%. The incidence of disease recurrence was significantly associated with gender, pathological stage, lymph node metastasis, lymphatic invasion and blood vessel invasion. Multivariate analysis identified gender, pathological stage and lymph node metastasis as independent predictors of disease recurrence following radical cystectomy. After disease recurrence, the 1-year cancer-specific survival of the 24 patients was 16.7%; that is, 23 of the 24 patients had died of progressive recurrent diseases, while the remaining 1 who survived had developed recurrence in the upper urinary tract. Conclusions: These findings suggest that careful follow-up should be performed after radical cystectomy for TCC of the bladder considering gender, pathological stage and nodal involvement; however, once recurrent disease develops, the prognosis of such patients is extremely poor. Therefore, it would be potentially important to establish a multimodal therapeutic approach targeting recurrent TCC of the bladder.     

病理N3期胃癌310例预后分析

目的探讨UICC第7版TNM分期标准中病理N3（pN3）期胃癌患者的预后特征及预后影响因素。方法回顾性分析2000年1月至2006年12月间天津医科大学附属肿瘤医院收治的实施胃癌根治术或扩大根治术的310例pN3期胃癌患者的临床病理和随访资料,分别采用Logrank检验和Cox比例风险模型进行单因素和多因素预后分析。结果310例患者均获随访,随访时间为2～103（平均35．7）月,术后5年生存率为14．6％。其中pN3a期201例,pN3b期109例,5年生存率分别为16．8％和10．3％,差异有统计学意义（P=0．013）。单因素预后分析显示,肿瘤部位、Borrmann分型、pT分期、pN分期、淋巴结转移率及手术方式与患者预后有关（均P〈0．05）。多因素分析显示,浸润深度、手术方式及淋巴结转移率是影响预后的独立危险因素（均P〈0．01）,而pN分期并不是独立的预后影响因素（P=0．658）。按浸润深度对患者进行分层分析显示,对于210例pT4a期患者,pN3a和pN3b亚组5年生存率分别为16．1％和12．8％,差异有统计学意义（P=0．001）;但对于88例pT4b期患者,pN3a和pN,b亚组5年生存率的差异则无统计学意义（8．6％比3．1％,P=0．137）。结论pM期胃癌患者预后较差,肿瘤浸润深度和不同手术方式是影响其预后的重要因素,淋巴结转移率对判断pM期胃癌预后有重要意义。第7版TNM分期中pN3分期能较好反映患者的预后情况。     

胃切除方式对胃中部癌患者预后的影响

目的探讨胃切除方式对胃中部癌患者预后的影响。方法回顾性分析1998年1月至2005年12月间福建医科大学附属协和医院收治的222例胃中部癌患者的临床资料,其中行开腹远端胃大部切除术66例（DG组）,行开腹全胃切除术患者156例（TG组）,比较两组患者术后5年的生存率。结果DG组和TG组术后5年生存率分别为63．9％和49．8％,差异具有统计学意义（P〈0．05）。但相比之下,TG组患者肿瘤更大、分期更晚、肿瘤位于小弯侧者居多（均P〈0．01）。按TNM分期进行分层预后分析显示,相同病期的两组患者术后5年生存率的差异均无统计学意义（均P〉0．05）。无论是以4cm、5cm还是6cm作为近切缘截点,不同近切缘距离患者5年生存率的差异均无统计学意义（均P〉0．05）。多因素预后分析显示,浸润深度、淋巴结转移和TNM分期是独立预后影响因素（均P〈0．05）;而胃切除方式并不是独立预后因素（P〉0．05）。结论胃中部癌患者如果能够达到根治手术的要求,其预后不受胃切除方式的影响,行远端胃大部切除术是可行的。     

Superiority of ratio based lymph node staging for bladder cancer

PURPOSE: The current study evaluated lymph node staging and the outcome in patients with lymph node positive bladder cancer after radical cystectomy. MATERIALS AND METHODS: A total of 162 patients with lymph node positive bladder cancer were followed a median of 7.5 years after radical cystectomy and pelvic lymph node dissection for survival and local recurrence. Lymph node disease was stratified by pN stage, the number of positive lymph nodes and the number of positive lymph nodes in relation to the number removed (ratio based pN stage). RESULTS: A median of 13 lymph nodes (range 2 to 32) was examined, showing an average of 3.3 positive lymph nodes per specimen. An increased number of lymph nodes correlated with the identification of lymph node positive cases. The ratio of the number of positive-to-total number of lymph nodes removed better defined surgical outcome than conventional lymph node staging. CONCLUSIONS: Ratio based lymph node staging, which reflects the number of lymph nodes examined and the quality of lymph node dissection, was a significant prognostic variable for survival and local control in patients with lymph node positive bladder cancer after radical cystectomy.     

乙酰肝素酶、CD222在膀胱癌中的表达及其临床意义

目的探讨膀胱癌中乙酰肝素酶和CD222的表达水平及其与膀胱癌发生、发展、转移及预后的关系。方法应用免疫组化SP法研究95例膀胱癌标本中乙酰肝素酶和CD222的表达水平。采用x2检验、Kaplan-Meier法、Logrank检验等统计学方法分析乙酰肝素酶、CD222的表达水平与膀胱癌临床病理特征及5年生存率的关系。结果乙酰肝素酶在膀胱癌中阳性表达65例（68．42％）,其表达率与膀胱癌患者的肿瘤直径、病理分级、病理学分期、淋巴结转移等情况明显相关（P〈0．05）。CD222在膀胱癌中阳性表达58例（61．05％）,其表达率与膀胱癌患者的肿瘤病理分级、病理学分期、淋巴结转移等情况明显相关（P〈0．05）。乙酰肝素酶和CD222的表达呈正相关（P〈0．05）。生存曲线分析显示乙酰肝素酶阳性表达组患者的5年生存率明显低于阴性表达组。CD222阳性表达组患者与其阴性组相比5年生存率无明显差异（P〉0．05）。乙酰肝素酶、CD222共表达阳性组与其阴性组比较,5年生存率有统计学意义（P〈0．05）。结论乙酰肝素酶及CD222在膀胱尿路上皮癌中的表达与肿瘤的发生、发展、转移和预后相关。其中乙酰肝素酶及CD222的共表达对膀胱癌生存预后的预测更具参考价值。     

胃癌患者近远期预后影响因素的COX模型分析

目的探讨影响胃癌预后的主要因素。方法选择中山市人民医院普外三科2005年12月至2008年12月收治的160例胃癌患者,采用COX回归模型,将患者的临床资料和随访情况作为分析因子计算生存率,多因素回归分析预后影响因素。结果总随访率93.75%（150/160）,截至2013年1月存活53例,总1、3、5年累计生存率分别为66.70%、50.67%、38.67%。单因素分析表明胃癌预后与手术方式、肿瘤大体分型、组织分型、浸润深度、淋巴结转移情况及TNM分期有关（P〈0.05）。COX多因素分析结果显示手术方式、肿瘤大体分型、组织分型、浸润深度、淋巴结转移情况及TNM分期是胃癌预后的独立预后因素（P〈0.05）。Borrmman分型与远期预后相关,而与近期预后无关。综合治疗与近期预后有关,与远期预后无关。结论手术方式、肿瘤大体分型、组织分型、浸润深度、淋巴结转移情况及TNM分期是胃癌预后的独立预后因素。