【作者】 王杰；

【导师】 李宏岩；

【作者基本信息】 吉林大学 ， 外科学（专业学位）， 2022， 硕士

【摘要】 目的:探究我院不同位置的上尿路上皮癌(病理分期≤T2)患者行后腹腔镜下肾输尿管根治性切除术中其中常见的2种输尿管末端处理方式(腹部小切口行膀胱袖套状切除与经尿道电切输尿管开口)的疗效及肿瘤安全性的优劣,为临床手术诊疗方式的选择提供相关参考。方法:通过对在2018年1月至2021年1月期间由我科收治的病理分期≤T2的98例不同位置的上尿路上皮癌患者的临床资料进行回顾性分析,并参考输尿管影像学分段以骶髂关节上缘为分界线,将上尿路上皮癌分为上段上尿路肿瘤(即骶髂关节上缘以上包括肾盂肿瘤)组(48例)和下段上尿路肿瘤(骶髂关节上缘以下)组(50例)。同时依据手术方式的不同,两组中又细分为腹部切口组和电切组。在上段上尿路肿瘤组或下段上尿路肿瘤组中在对腹部切口组和电切组患者的术前资料如性别、BMI、肿瘤大小、术后病理分期等进行统计学分析,两组患者术前统计无明显差异,其后对比分析电切组和腹部切口组的手术时长、术后留置引流管时间、术后留置导尿管时间、术后排气时间,术后出院时间、及术后6个月内肿瘤复发情况等结果,对术式的疗效及术后短期肿瘤安全性等进行评估,从而对不同位置的上尿路上皮癌根治术中输尿管末端处理方式的选择提供参考意见。结果:四组患者均顺利完成手术,无术中中转开放手术,围手术期间无休克、死亡等严重并发症。所有患者均顺利出院,且术后出院前均完成术后膀胱灌注,出院时患者已摘除全身引流管及导尿管,切口愈合良好,且拔除尿管后无尿失禁等相关不适,出院后继续按膀胱灌注方案(至少为期一年)进行定期灌注及膀胱镜检查,并进行为期半年的随访。通过查阅患者病历资料、追踪复诊信息及电话随访等对患者术中及术后相关资料进行对比,在上段输尿管肿瘤组中:A组手术时间131.21±20.21min,B组手术时间:172.39±29.54min,两组数据比较后P<0.001,具有明显统计学差异。术中失血量示:A组:102.40±35.27mL,B组:158.70±33.48mL,P<0.05,存在统计学差异;对术后排气时间进行比较:A组排气时间中位数为2天;B组排气时间的中位数为3天,P<0.001,存在明显统计学差异;下段输尿管肿瘤组中;C组手术时间133.18±19.49min,D组手术时间:193.18±42.27min,两组数据比较后P<0.05,具有统计学差异。术中失血量示:C组:118.18±17.90mL,D组:194.29±17.89mL,P<0.05,存在统计学差异;对术后排气时间进行比较:C组排气时间的中位数为2天,D组排气时间的中位数为3天,P<005,存在统计学意义;A组和B组,C组和D组各自做比较,其在比较结果显示:在患者术后住院时、术后拔除尿管时间、术后引流管留置时间及术后随访半年内肿瘤复发等方面无统计学意义(P>0.05)。结论:对于病理分期≤T2期的上尿路上皮癌,无论肿瘤位置位于何处,电切组和腹部切口组有着相同的肿瘤学安全性,其两者在术后膀胱肿瘤复发率未见明显异常,且其术后两者在住院时间、全身引流管及导尿管摘除时间等未见明显异常。但电切组较腹部切口组具有手术时间更短,术中出血量更少、术后排气时间更早等优点,因此对于病理分期≤T2的上尿路上皮癌而言,肿瘤位置并不影响在后腹腔镜中对于输尿管末端处理方式的选择,在后腹腔镜UTUC根治术中对输尿管末端处理方式上经尿道输尿管口电切术较腹部切口行膀胱袖套状切除术更值得推荐。更多还原

【Abstract】 Objective: To explore the therapeutic efficacy and tumor safety of two common ureteral end treatment methods(bladder sleeve resection through small abdominal incision and transurethral resection of ureteral opening)in retroperitoneal laparoscopic radical nephrectomy for patients with upper urinary tract epithelial cancer(pathological stage ≤ T2)in our hospital,so as to provide relevant reference for the selection of clinical surgical diagnosis and treatment methods..Methods: The clinical data of 98 patients with upper urinary tract epithelial cancer with pathological stage ≤ T2 treated by our department from January 2018 to January 2021 were retrospectively analyzed,and the upper edge of sacroiliac joint was taken as the dividing line with reference to ureteral imaging,Upper urothelial carcinoma was divided into upper urothelial tumor(above the upper edge of sacroiliac joint,including renal pelvis tumor)group(48 cases)and lower upper urothelial tumor(below the upper edge of sacroiliac joint)(50 cases).At the same time,according to the different surgical methods,the two groups were subdivided into abdominal incision group and electric resection group.In the upper urinary tract tumor group or the lower upper urinary tract tumor group,the preoperative data such as gender,BMI,tumor size and postoperative pathological stage of the patients in the abdominal incision group and the electro-resection group were statistically analyzed.There was no significant difference in the preoperative statistics between the two groups.Then,the operation time,postoperative indwelling drainage tube time,postoperative indwelling catheter time,postoperative discharge time and tumor recurrence within 6months after operation,to evaluate the efficacy of the operation and the safety of short-term tumor after operation,so as to provide reference for the selection of ureteral end treatment in radical resection of upper urinary tract epithelial cancer at different positions.Results: All the patients in the four groups successfully completed the operation without conversion to open surgery.There were no severe complications such as shock and death during the perioperative period.All patients were discharged smoothly,and the postoperative bladder perfusion was completed before discharge.At discharge,the patient had removed the whole-body drainage tube and catheter,the incision healed well,and there was no urinary incontinence and other related discomfort after removing the catheter.After discharge,the patients continued to perform regular perfusion and cystoscopy according to the bladder perfusion scheme(for at least one year),and were followed up for half a year.In the upper ureteral tumor group,the operation time of group A was 131.21 ± 20.21 min,and that of group B was 172.39 ± 29.54 min.There was significant statistical difference between the two groups(P<0.001).Intraoperative blood loss was 102.40 ± 35.27 ml in group A and158.70 ± 33.48 ml in group B,P<0.05;Comparison of postoperative exhaust time:the median exhaust time in group A was 2 days;The median exhaust time in group B was 3 days,P<0.05;Lower ureteral tumor group;The operation time in group C was133.18 ± 19.49 min and that in group D was 193.18 ± 42.27 min,P < 0.05.Intraoperative blood loss was 118.18 ± 17.90 ml in group C and 194.29 ± 17.89 ml in group D,P<0.05;The median time of postoperative exhaust was 2 days in group C and 3 days in group D,P<0.05;Group A and group B,group C and group D were compared respectively.The comparison results showed that there was no statistical significance in the following aspects: the time of postoperative hospitalization,the time of postoperative catheter removal,the time of postoperative drainage tube retention and postoperative exhaust,and the tumor recurrence within half a year of postoperative follow-up(P>0.05).Conclusion: For upper urinary tract epithelial carcinoma with pathological stage≤ T2,no matter where the tumor is located,the electric resection group and the abdominal incision group have the same oncological safety.There is no obvious abnormality in the probability of postoperative bladder tumor recurrence.and there is no obvious abnormality in the length of hospital,the removal time of systemic drainage tube and urinary catheter,and the short-term postoperative recurrence rate in the bladder.However,compared with the abdominal incision group,the electric resection group has the advantages of shorter operation time,less intraoperative bleeding and earlier postoperative exhaust time.Therefore,for the upper urinary tract epithelial carcinoma with pathological stage ≤ T2,the tumor location does not affect the choice of ureteral end treatment in retroperitoneal laparoscopy,In retroperitoneal laparoscopic radical surgery for UTUC,transurethral resection of ureteral orifice is more recommended than bladder sleeve resection through abdominal incision.更多还原