复杂上尿路癌的多镜联合治疗

目的探讨孤立肾、慢性肾功能不全时肾盂内或双输尿管内复杂上皮癌患者多镜联合治疗的可行性。方法3例均以间断无痛性全程肉眼血尿入院,通过尿脱落细胞学、IVU、CT、膀胱镜、输尿管镜等检查确诊为尿路上皮癌。例1为左侧重复肾、双输尿管畸形,重复肾上肾盂内、双侧3个输尿管内均为上尿路癌,采用经皮肾镜和输尿管镜联合行左侧重复肾上肾盂、双侧3条输尿管内肿物切除术;例2为肾功能不全、右肾萎缩,发生左侧肾盂、膀胱癌,行膀胱镜肿瘤电切及输尿管镜、经皮肾镜联合左肾盂癌局部切除术;例3为左侧肾盂癌根治术后3年,右孤立肾再发肾盂癌,经输尿管镜及经皮肾镜行右肾盂癌切除术。3例均成功保留肾脏。结果术后病理检查均为尿路上皮癌。早期经肾造瘘灌注化疗1~2次,之后常规膀胱化疗,分别随访13、14、15个月,B超及CT检查无肿瘤复发及死亡。例3孤立肾患者术后2天、2周时经肾造瘘化疗,术后1个月拔出输尿管支架管,于第2日夹闭肾造瘘管,出现发热,输尿管镜检查考虑输尿管狭窄明显,留置支架管,以后定期更换,1周后拔除肾造瘘管。结论对于孤独肾、对侧肾无功能、肾功能不全、年龄大、伴有禁忌证的内科疾患的复杂上尿路癌患者,采用输尿管镜、经皮肾镜联合治疗是可行和安全有效的,但需要术后严格的随访和检查。

Multiple Endoscopy for Epithelioma of the Upper Urinary Tract

Objective To explore the feasibility of multiple endoscopy in the treatment of patients with epithelioma in the renal pelvis or bilateral ureters complicated with chronic renal insufficiency or solitary kidney.Methods Three patients complaining of continuous painless gross hematuria were admitted to our hospital.Epithelioma was diagnosed by means of exfoliocytology,IVU,CT,cystoscopy,and ureteroscopy.Case 1 showed left duplex kidneys,bilateral ureteral deformity,epitheliomas in both the pelvises of the duplex kidneys and the three ureters.Percutaneous nephroscopy combined with ureteroscopy were carried out to resect the tumors.In Case 2,renal insufficiency and right renal atrophy were revealed,epitheliomas were found in the left renal pelvis and bladder;thus,cystoscopy and ureteroscopy combined with percutaneous nephroscopy were performed for resection of the tumors.Case 3 was a recurrent case of renal epithelioma in the left solitary kidney,whose left kidney was cut three years ago for the same cause.For this case,ureteroscopy and percutaneous nephroscopy were used to remove the tumor.In all the three cases,the kidney of the diseased side was preserved successfully.Results After the operations,epithelioma was confirmed pathologically in the patients.The patients then received nephrostomy for chemotherapy infusion followed by intrabladder chemotherapy.The three cases were followed up for 13,14,and 15 months respectively,during which no tumor recurrence was detected by B-ultrasonography and CT scan nor death occurred.The Case 3 with solitary kidney received nephrostomy twice for chemotherapy on day 2 and week 2 respectively after the surgery,upon the chemotherapy.In this patient,the ureteral stent was withdrawn in one month postoperation,the renal fistula was then clipped in the following day,which reduced fever.Afterwards,ureteroscopic examination showed ureteral stenosis,the stent was therefore re-placed and changed regularly. Conclusions Ureteroscopy combined with percutaneous nephroscopy is feasible and safe for patients with epithelioma in the urinary tract complicated with solitary kidney,renal insufficiency,or non-functional contralateral kidney.Strict follow-up after the surgery should be implemented.