全腹膜外途径膀胱瓣肾盂吻合自体肾移植术在上尿路尿路上皮癌治疗中的应用

doi:10.19723/j.issn.1671-167X.2019.04.029

摘要/Abstract

摘要：

目的:探讨全腹膜外途径膀胱瓣肾盂吻合自体肾移植术治疗上尿路尿路上皮癌的可行性及有效性,总结自体肾移植术在上尿路尿路上皮癌治疗中的应用经验。方法:报道1例行全腹膜外途径膀胱瓣肾盂吻合自体肾移植术治疗上尿路尿路上皮癌的病例,并对相关文献进行回顾总结。本例患者为64岁男性,1年前因右输尿管癌行根治性右肾输尿管切除术,现诊断左输尿管癌(G2,高级别)。为保留患者肾功能,同时考虑到常用保留肾单位手术的局限性,本中心创新性地为该患者行全腹膜外途径腹腔镜左肾切取、左输尿管切除、自体肾移植、膀胱瓣肾盂吻合术。结果:手术过程顺利,无围术期并发症。术后1周肾功能即恢复至术前水平,随访期内肾功能正常,术后3个月行膀胱镜检查未见局部肿瘤复发征象。结论:全腹膜外途径膀胱瓣肾盂吻合自体肾移植术是治疗上尿路尿路上皮癌可行、有效的方法。本创新性术式较以往术式有一定优势,全腹膜外途径手术具有创伤小、并发症少、恢复时间短等优势,且不增加肾热缺血时间;膀胱瓣肾盂吻合具有便于随访、发现早期病变及利于局部治疗等优势。通过本例特点分析及文献回顾,我们认为自体肾移植术对孤立肾上尿路尿路上皮癌或双侧上尿路尿路上皮癌患者来说,是一种可供选择的治疗方式,其具有保留肾功能且能完全切除肿瘤等优点,但目前自体肾移植术治疗上尿路尿路上皮癌缺乏长期随访和大样本研究,对术后肾功能及肿瘤复发的远期评估仍待完善。

关键词: 尿路上皮癌, 肾, 移植, 自体, 全腹膜外腹腔镜, 吻合术, 外科

Abstract:

Objective: To evaluate the feasibility and effectiveness of the totally extraperitoneal renal autotransplantation with boari flap-pelvis anastomosis in the treatment of upper urinary tract urothelial carcinoma (UTUC), and to review the experience of renal autotransplantation for UTUC treatment. Me-thods: One case of applying the totally extraperitoneal renal autotransplantation with boari flap-pelvis anastomosis to the UTUC treatment was reported, and related literature was reviewed. The patient was a sixty-four-year old man who received right radical nephroureterectomy for right ureteral carcinoma 1 year before and diagnosed as left ureteral carcinoma(G2, high grade) this time. In order to preserve his renal function and avoid the shortness of common kidney-sparing surgery, a totally extraperitoneal procedure, including retroperitoneoscopic nephrectomy, ureterectomy, renal autotransplantation and Boari flap-pelvis anastomosis, was performed to the patient.Results: The operation was completed successfully without perioperative complications. The renal function recovered to preoperative level within 1 week. No deterioration of renal function during the follow-up and no tumor recurrence was observed under cystoscopy at the 3-month postoperative consult.Conclusion: The totally extraperitoneal renal autotransplantation with Boari flap-pelvis anastomosis is a feasible and effective treatment for UTUC. The innovative procedure has several advantages compared to the former ones. The extraperitoneal procedure results in significantly less pain, shorter hospital stay, decreased overall time to recovery and lower bowel complications risk without warm ischemia time extension. Meanwhile, the Boari flap-pelvis anastomosis simplifies the follow-up protocols and creates an easy route for cystoscopy and topical therapy. From the systematic clinical analysis, as well as the related literature review, it’s been concluded that the renal autotransplantation can be a reasonable option for the patients who have UTUC in solitary kidney or have bilateral UTUC. This type of treatment possesses advantages of preservation of renal function and total resection of malignant lesions. But long-term data and large cohort study on renal function or tumor recurrence are still absent which will be necessary to confirm the advantages of this approach.

Key words: Urothelial carcinoma, Kidney, Transplantation, autologous, Totally extraperitoneal laparoscopy, Anastomosis, surgical

中图分类号:

R737.13

程嗣达,李万强,穆莉,丁光璞,张博,谌诚,应泽伟,杨昆霖,郝瀚,李学松,周利群. 全腹膜外途径膀胱瓣肾盂吻合自体肾移植术在上尿路尿路上皮癌治疗中的应用[J]. 北京大学学报（医学版）, 2019, 51(4): 758-763.

Si-da CHENG,Wan-qiang LI,Li MU,Guang-pu DING,Bo ZHANG,Cheng SHEN,Ze-wei YING,Kun-lin YANG,Han HAO,Xue-song LI,Li-qun ZHOU. Application of totally extraperitoneal renal autotransplantation with Boari flap-pelvis anastomosis in upper urinary tract urothelial carcinomas treatment[J]. Journal of Peking University(Health Sciences), 2019, 51(4): 758-763.

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Study	Year	Case	Approach	Procedure	Follow-up/ months	Renal function	Tumor recurrence
Pettersson, et al^[9]	1984	8	Open	Nephroureterectomy,extracorporeal total ureterectomy, renal autotransplantation by Gibson incision and pyelocystostomy	14-53	Normal in 7 cases	3/8
Gill, et al^[13]	2000	1	Retroperitoneal laparoscopy	Nephroureterectomy,extracorporeal ureterectomy, renal autotransplantation by Gibson incision and pyeloureterostomy	6	Normal	0
Jarrett, et al^[14]	2001	1	Transperitoneal laparoscopy	Nephrectomy, intracorporeal ureterectomy and renal autotransplan-tation by extraperitoneal incision	6	Normal	0
Kang, et al^[15]	2004	1	Open	Nephroureterectomy,extracorporeal total ureterectomy,renal autotransplantation by Gibson incision and pyelocystostomy	70	Normal	1/1
Holmang, et al^[10]	2005	23	Not reported	Not reported	84-240	Not reported	10/23
Iida, et al^[16]	2009	1	Retroperitoneal laparoscopy	Nephroureterectomy,extracorporeal ureterectomy, renal autotransplantation by Gibson incision and pyeloureterostomy	20	Normal	0
Cheng, et al^[11]	2014	12	Retroperitoneal laparoscopy	Hand-assisted nephroureterectomy, extracorporeal total ureterectomy, renal autotransplantation by Gibson incision and pyelocystostomy	3-24	Normal	3/12
Bourgi, et al^[17]	2018	2	Not reported	Not reported	30 (average)	Normal	0