输尿管软镜下钬激光切除术治疗肾盂癌6例报道及文献复习

目的：探讨输尿管软镜钬激光切除术治疗肾盂癌的应用价值，并总结治疗过程中的相关经验。方法：回顾性分析北京大学第三医院2015年1月至2017年1月输尿管软镜治疗6例肾盂癌患者的临床资料，手术均由同一名医师操作。患者于全身麻醉下行输尿管软镜钬激光肾盂肿瘤切除术，采用200 μm钬激光传导光纤，设置功率为0.5~1.5 J，10~20 Hz，能量10~30 W。采用窄带成像技术寻找肿瘤，并检查切除是否满意。术后4~6周常规行二次输尿管软镜探查，对可疑病变部位行汽化烧灼。术后每6个月行输尿管软镜复查，同时行彩色多普勒超声、CT尿路造影（computed tomography urography，CTU）或磁共振水成像（magnetic resonance urography，MRU）检查，复查手术前连续3天每天进行尿液细胞学检查，检测尿路上皮肿瘤标记物［如尿液核基质蛋白22 (nuclear matrix protein 22，NMP22)］。术后组织病理为高危尿路上皮癌且肾功能正常的患者，给予全身辅助化疗6个周期。结果：6例患者均顺利完成手术，手术时间45~115 min，平均77.5 min，失血量5~20 mL，术后住院2~5 d，平均3 d，术后随访13~34个月，平均22个月， 2例肿瘤复发。例5和例6两患者术后行全身辅助化疗，例5患者的组织病理为高级别尿路上皮癌，术后给予6个周期的全身化疗，化疗期间（术后4个月）患者出现局部复发，再次手术后1年未见复发；例6患者组织病理为低级别尿路上皮癌，但右肾上盏、下盏多发肿瘤，术后予6个周期的全身化疗，随访13个月未见复发。结论：输尿管软镜钬激光切除术治疗肾盂癌的手术技术相对安全，适合孤立肾、肾功能不全等特殊病例以及低危的尿路上皮肿瘤患者，但其复发率较高，需严格掌握适应证。选择行内镜下切除术的高危尿路上皮癌患者，术后应积极予吉西他滨与顺铂（gemcitabine and cisplatin, GC）方案的全身辅助化疗，采用内镜治疗和全身辅助化疗联合的方法提高尿路上皮癌患者的总体生存率。全身化疗联合内镜手术有可能成为治疗上尿路尿路上皮癌的新治疗手段。

Transurethral flexible ureteroscopic holmium laser resection for tumors of renal pelvis: 6 cases report and literature review

Objective： To summarize the experience of flexible ureteroscopic holmium laser resection in treatment of renal pelvic carcinoma and to evaluate its value in treatment of renal pelvic carcinoma. Methods: The clinical data of 6 patients with renal pelvic carcinoma treated in Peking University Third Hospital from January 2015 to January 2017 were retrospectively analyzed. The 6 patients were treated by the same experienced urologist and by flexible ureteroscopic holmium laser resection of renal pelvic tumors under general anesthesia. Regarding the intensity of the holmium laser, 10-30 W was generally used with settings of 0.5-1.5 J and 10-20 Hz. In general, a 200 μm end-firing holmium laser fiber was used. Narrow-band imaging (NBI) technique was applicated to search for tumors and check whether the excision was satisfactory. Routine “second flexible ureteroscopy” was performed after 4-6 weeks, and suspected lesions were referred for a biopy, then vaporized and cauterized. The ureteroscopy was examined every 6 months after operation, and color Doppler ultrasound, computed tomography urography (CTU) or magnetic resonance urography (MRU) were performed at the same time. The urine tumor cells were examined for 3 days before the operation, and the urine tumor markers, such as urinary nuclear matrix protein 22 (NMP22) were tested. For cases with high-risk urothelial carcinoma and normal renal function, and 6 cycles of systemic adjuvant chemotherapy were performed after operation. Results: All of the cases were successfully treated. The data were as follows: the operation time 77.5 min (45-115 min), the blood loss 10 mL (5-20 mL), and hospital stay after surgery 3 days (2-5 days). After 13-34 months’ follow-up, two patients had recurrent tumor recurrence and underwent resection operation. Two patients received systemic adjuvant chemotherapy after operation. Case 5 was histopathologically high grade urothelial carcinoma, and 6 cycles of systemic chemotherapy were given after operation. Local recurrence occurred during chemotherapy, and then endoscopic operation was performed, and no recurrence occurred in the follow-up for 12 months after reoperation. In case 6, the pathology was low grade urothelial carcinoma, but the case was multiple tumors in the right renal calyx and the lower calyx. Then 6 cycles of systemic chemotherapy were given, and no recurrence was found in the follow-up for 13 months. Conclusion: Transurethral flexible ureteroscopic holmium laser resection is relatively safe for the treatment of renal pelvic carcinoma. It is suitable for special cases of solitary kidney and renal dysfunction, as well as for patients with low risk urinary tract epithelial tumors, but the recurrence rate is high, and the indications need to be strictly controlled. Patients with high-risk urothelial carcinoma who underwent endoscopic resection are advised to receive systemic adjuvant gemcitabine and cisplatin (GC) regimen after surgery, in order to increase the overall survival rate. Systemic chemotherapy combined with endoscopic operation may become a new treatment for upper tract urothelial carcinoma (UTUC).