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目的:探讨完全腹腔镜下根治性肾输尿管切除(肾输尿管全长切除+膀胱袖套装切除)联合区域淋巴切除术治疗上尿路泌尿上皮癌的安全性和临床效果。方法:2008年1月~2013年12月,我院对29例肾盂输尿管癌行经腹腔途径完全腹腔镜肾输尿管全长切除+膀胱袖套状切除术,并行区域淋巴清扫术。男16例,女13例,年龄37~84岁,平均69.2岁。其中肾盂癌20例,输尿管癌9例(上段5例,中段4例)。左侧13例,右侧16例。术后均予吡柔比星30mg膀胱灌注化疗,每周1次,共8次,2例术前发现膀胱癌者灌注疗程为2年。随访4~41个月,平均23.2个月。结果:所有手术均获成功,无中转开放手术。手术时间95~220min,平均140min。术中估计出血量60~400ml,平均210ml。术后引流管放置5~14d。术后第2~7天,4例出现乳糜漏,持续3~12d,均为左侧。早期2例出现不全性小肠梗阻,经中药灌肠等处理后好转,在缝合盆底腹膜后未再出现不全性肠梗阻。未观察到其他严重并发症。住院时间7~14d,平均9.6d。术后病理诊断均为尿路上皮癌,平均切除淋巴结6枚。淋巴结阳性率27.6%(8/29),T1、T2、T3、T4分期的淋巴结阳性率分别是0(0/3)、15.4%(2/13)、36.4%(4/11),100%(2/2)。不同病理分级G1、G2、G3淋巴结阳性率分别为0(0/2)、27.3%(3/11)、31.3%(5/16)。而术前影像学检查仅5例提示淋巴结转移。淋巴结阴性者有2例患者分别于术后9个月、18个月发现膀胱肿瘤,行电切。8例淋巴结阳性患者中,1例接受放化疗,术后9个月仍出现对侧淋巴结转移,之后死于肺转移。其余未行放化疗,1例于术后13个月出现肝转移,1例术后12个月发现膀胱肿瘤,另外5例随访时间短,未发现复发转移。其余病例未发现局部复发或远处转移。未发现切口转移。结论:选择合适的病例,完全腹腔镜根治性肾输尿管切除术治疗肾盂输尿管癌在技术上是安全可行的。区域淋巴清扫能准确进行肿瘤分期,同时切除了常规检查未发现的转移淋巴结,改善了患者的预后。
Objective: To investigate the safety and clinical efficacy of radical laparoscopic radical nephroureterectomy (total ureter length excision + bladder sleeve cuff removal) combined with regional lymphadectomy in the treatment of upper urinary tract urothelial carcinoma. Methods: From January 2008 to December 2013, 29 cases of renal pelvis and ureteropelvic cancer underwent laparoscopic radical nephroureterectomy combined with cuff cuff resection via regional laparoscopic lymphadenectomy. There were 16 males and 13 females, aged 37-84 years, with an average of 69.2 years. Including renal pelvis cancer in 20 cases, ureteral carcinoma in 9 cases (upper section in 5 cases, middle section in 4 cases). Left in 13 cases, right in 16 cases. Postoperative intraperitoneal injection of pirarubicin 30mg chemotherapy, once a week, a total of 8 times, 2 cases of bladder cancer were found preoperative infusion therapy for 2 years. Follow-up 4 to 41 months, an average of 23.2 months. Results: All surgeries were successful without open surgery. Surgery time 95 ~ 220min, an average of 140min. Intraoperative blood loss was estimated 60 ~ 400ml, an average of 210ml. Postoperative drainage tube placed 5 ~ 14d. 2 to 7 days after surgery, 4 cases of chyle leakage occurred, lasting 3 ~ 12d, are on the left. Early 2 cases of incomplete intestinal obstruction, the Chinese medicine enema and other improvements after suture pelvic peritoneum no longer appeared incomplete intestinal obstruction. No other serious complications were observed. Hospitalization time 7 ~ 14d, an average of 9.6d. Postoperative pathological diagnosis of urothelial carcinoma, the average removal of lymph nodes 6. The positive rate of lymph nodes was 27.6% (8/29). The positive rates of lymph nodes in T1, T2, T3 and T4 stages were 0 (0/3), 15.4% (2/13), 36.4% (4/11) (2/2). The positive rates of G1, G2 and G3 in different pathological grades were 0 (0/2), 27.3% (3/11) and 31.3% (5/16) respectively. Preoperative imaging examination only 5 cases suggest lymph node metastasis. Two patients with negative lymph nodes were found to have bladder tumor at 9 months and 18 months after surgery, respectively. Of the 8 patients with lymph node positive, 1 received radiotherapy and chemotherapy, contralateral lymph node metastasis still occurred 9 months after the operation, and then died of lung metastasis. The remaining patients did not receive radiotherapy and chemotherapy. One case had liver metastasis at 13 months after operation, one case had bladder tumor at 12 months after operation, and the other 5 cases had short follow-up time. No recurrence and metastasis was found. The remaining cases did not find local recurrence or distant metastasis. No incision metastasis was found. Conclusion: Choosing the right case, complete laparoscopic radical nephroureterectomy in the treatment of ureteropelvic cancer is technically safe and feasible. Regional lymphadenectomy can accurately tumor staging, at the same time removed the conventional examination of lymph node metastasis was not found to improve the prognosis of patients.