输尿管开口周围膀胱黏膜预离断联合早期膀胱灌注化疗在上尿路尿路上皮癌根治术中的应用

doi:10.3877/cma.j.issn.1674-3253.2024.05.010

目的

探讨输尿管开口周围膀胱黏膜预离断联合早期膀胱灌注化疗在上尿路尿路上皮癌根治术中应用的安全性和有效性。

方法

整理并分析2021年1月至2023年8月复旦大学附属闵行医院收治的5例肾盂癌或输尿管癌患者的病例资料。该5例患者在行根治性肾输尿管切除术前，先行患侧输尿管开口周围膀胱黏膜预离断并于术中早期给予生理盐水50 ml+吉西他滨2.0 g膀胱灌注化疗。术后第7 d，拔除导尿管前再次给予生理盐水50 ml+吉西他滨2.0 g膀胱灌注化疗。所有患者术后每3个月行血常规、血生化、尿常规、尿液基细胞学和影像学（泌尿系统超声、CTU或MRU）检查，必要时行膀胱镜检查，以明确有无肿瘤复发、转移等情况发生。

结果

所有患者均顺利完成根治性肾输尿管切除术，术后恢复情况良好，无发热、血尿、漏尿、切口感染和切口疝等发生。5例患者随访时间为6～25个月。除1例肾盂癌合并输尿管癌的患者于术后第10个月时发现膀胱低度恶性潜能尿路上皮肿瘤外，其他4例患者随访期间未见肿瘤复发或转移。

结论

输尿管开口周围膀胱黏膜预离断技术，既保证了输尿管末段和开口的完整切除，又提高了手术效率，减少了并发症的发生。术中早期联合术后第7 d的两次生理盐水50 ml+吉西他滨2.0 g的膀胱灌注化疗方案，设计合理、操作简便、副反应小。

关键词: 上尿路尿路上皮癌, 根治性肾输尿管切除术, 预离断, 膀胱灌注化疗, 吉西他滨

Objective

To explore the safety and effectiveness of pre dissection of bladder mucosa around the ureteral opening combined with early bladder infusion chemotherapy during radical nephroureterectomy for upper urinary tract urothelial carcinoma.

Methods

The clinical data of 5 patients encountered from January 2021 to August 2023 with carcinoma of renal pelvis or ureteral carcinoma treated in Minhang Hospital Affiliated to Fudan University were reviewed. Before undergoing radical nephrectomy, these patients underwent pre dissection of the bladder mucosa around the ureter opening and bladder infusion chemotherapy by 50 ml physiological saline and 2.0 g gemcitabine. On the 7th day after surgery, before removing the catheter, 50 ml of physiological saline and 2.0 g of gemcitabine were administered for bladder infusion chemotherapy again. All patients underwent blood analysis, blood biochemistry, urine test, urine cytology, and imaging (urinary system ultrasound, CTU or MRU) examinations every 3 months after surgery. If necessary, cystoscopy will be performed to determine the occurrence of tumor recurrence, metastasis, and other conditions.

Results

All patients successfully completed the surgery, with good postoperative recovery and no occurrence of fever, hematuria, urinary leakage, incision infection, or incision hernia. The follow-up time of 5 patients was 6-25 months. Except for one patient with renal pelvis cancer and ureteral cancer who was diagnosed with low-grade malignant potential urothelial tumor of the bladder at the 10th month after surgery, the other four patients did not experience tumor recurrence or metastasis during follow-up.

Conclusions

By using the pre dissection technique of bladder mucosa around the ureteral opening, the complete resection of the distal ureter and ureteral opening is ensured, while improving surgical efficiency and reducing the occurrence of surgical complications. The performance of twice bladder infusion chemotherapy by physiological saline 50 ml+ gemcitabine 2.0 g in early intraoperative and on the 7th day after surgery is well-designed, easy to operate, and has minimal adverse reaction.

Key words: Upper tract urothelial carcinoma, Radical nephroureterectomy, Pre-dissection, Bladder infusion chemotherapy, Gemcitabine

表1 五例上尿路尿路上皮癌患者的临床资料

病例	性别	年龄(岁)	肿瘤位置	肿瘤长径（cm）	术前临床分期	术后病理分期	手术时间（min）	出血量（ml）	术后肌酐（μmol/L）	术后辅助治疗方案
1	男	65	右侧肾盂	2.5	T₂	T₂	217	36	121	GC方案化疗
2	男	77	左侧肾盂	5.0	T₃	T₃	250	110	187	替雷利珠单抗治疗
2	男	77	下段输尿管	1.2	T₃	T₃	250	110	187	替雷利珠单抗治疗
3	女	67	左侧输尿管上段	1.7	T₂	T₂	190	30	155	拒绝辅助治疗
4	男	65	右侧输尿管上段	2.3	T₂	T₃	195	38	125	GC方案化疗
5	女	68	左侧肾盂	4.8	T₃	T₃	198	40	123	GC方案化疗

表1 五例上尿路尿路上皮癌患者的临床资料

病例	性别	年龄(岁)	肿瘤位置	肿瘤长径（cm）	术前临床分期	术后病理分期	手术时间（min）	出血量（ml）	术后肌酐（μmol/L）	术后辅助治疗方案
1	男	65	右侧肾盂	2.5	T₂	T₂	217	36	121	GC方案化疗
2	男	77	左侧肾盂	5.0	T₃	T₃	250	110	187	替雷利珠单抗治疗
2	男	77	下段输尿管	1.2	T₃	T₃	250	110	187	替雷利珠单抗治疗
3	女	67	左侧输尿管上段	1.7	T₂	T₂	190	30	155	拒绝辅助治疗
4	男	65	右侧输尿管上段	2.3	T₂	T₃	195	38	125	GC方案化疗
5	女	68	左侧肾盂	4.8	T₃	T₃	198	40	123	GC方案化疗

图1 上尿路尿路上皮癌患者患侧输尿管开口旁1 cm处电切离断膀胱黏膜（黑色箭头为输尿管开口）

图2 环形离断输尿管开口周围的膀胱黏膜达深肌层，使输尿管末端及开口呈"乳头状"隆起于膀胱腔内（黑色箭头为输尿管开口）

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Preliminary study on the application of pre dissection of bladder mucosa around ureteral opening combined with early bladder infusion chemotherapy during radical nephroureterectomy for upper urinary tract urothelial carcinoma

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Preliminary study on the application of pre dissection of bladder mucosa around ureteral opening combined with early bladder infusion chemotherapy during radical nephroureterectomy for upper urinary tract urothelial carcinoma