Montanari Emanuele, Del Nero Alberto, Bernardini Paolo, Mangiarotti Barbara, Confalonieri Silvia, Grisotto Massimo, Cordima Giovanni
Clinica Urologica III, Università degli Studi di Milano, Ospedale San Paolo, Milan, Italy.
Arch Ital Urol Androl. 2005 Dec;77(4):211-4.
Nephroureterectomy with the excision of the ipsilateral ureteral orifice and bladder cuff has been considered the standard treatment of the urinary upper transitional cell carcinoma. With the advent of sophisticated techniques for the endo-urologic management of many benign urologic diseases of the upper tract, there has been growing enthusiasm for the application of these same techniques in the management of upper tract TCC, which is also supported by recent advances in the development of small calibre telescopes with improved optics and the development of small calibre adjunctive instruments and laser fibers. A large number of cases published in the literature has confirmed the safety and efficacy of percutaneous treatment in selected patients with upper tract TCC of low grade and stage. Between 1997 and 2005 we treated 62 pts (37 pelvic transitional cell carcinoma and 25 ureteral). 4 pts (5 renal units: 4 T1G2 and 1 TaG1) underwent percutaneous resection for a tumor in a solitary kidney (2 cases), one case for bilateral neoplasm, and in the other case the lesion was unilateral with chronic renal failure. After preoperative evaluation, (excretory urography, computerized tomography and ureteroscopy with biopsy to confirm the low stage and grade of the lesion) the tumor was resected using an Amplatz sheat of 26-30 Fr and a 24 Fr resectoscope to keep a low intra-caliceal pressure. The tumor base was biopsied and fulgurated After 48 h, contrastography to assure integrity of the urinary system was performed and Mitomycin C was infused over 24 h. Second-look nephroscopy with multiple biopsies was performed in all cases 7 days later and 8 Ch nephrostomy was placed. If the biopsies resulted negative the patient was submitted to 6 weekly endocavitary instillation of BCG through the nephrostomy tube. All pts at a mean follow up of 71 months were tumor free. One patient presented a bladder relapse after 83 months. No complication of percutaneous resection was observed. The endocavitary instillations were well tolerated. In our experience the percutaneous approach is safe and useful in neoplastic lesions of low grade and stage and should be considered as first line therapy in selected patients. Adjuvant topical therapy appears efficacious and some complications may be avoided by maintaining low intracavitary pressures during administration.
肾输尿管切除术加同侧输尿管口及膀胱袖口切除术一直被视为上尿路移行细胞癌的标准治疗方法。随着用于上尿路许多良性泌尿系统疾病的腔内泌尿外科治疗技术的出现，人们越来越热衷于将这些相同技术应用于上尿路移行细胞癌的治疗，小口径望远镜光学性能的改进以及小口径辅助器械和激光纤维的发展也为这种应用提供了支持。文献中发表的大量病例证实了经皮治疗对选定的低级别和低分期上尿路移行细胞癌患者的安全性和有效性。1997年至2005年间，我们治疗了62例患者（37例盆腔移行细胞癌和25例输尿管移行细胞癌）。4例患者（5个肾单位：4例T1G2和1例TaG1）因孤立肾肿瘤（2例）、双侧肿瘤（1例）以及1例单侧病变合并慢性肾衰竭接受了经皮切除术。经过术前评估（排泄性尿路造影、计算机断层扫描和输尿管镜检查并活检以确认病变的低分期和低级别），使用26 - 30F的Amplatz鞘和24F的电切镜切除肿瘤，以保持肾盏内低压。对肿瘤基底部进行活检并电凝。48小时后，进行造影以确保泌尿系统的完整性，并在24小时内注入丝裂霉素C。7天后对所有病例进行二次肾镜检查并多次活检，同时放置8F肾造瘘管。如果活检结果为阴性，则通过肾造瘘管对患者进行每周6次的卡介苗腔内灌注。所有患者平均随访71个月，均无肿瘤复发。1例患者在83个月后出现膀胱复发。未观察到经皮切除术的并发症。腔内灌注耐受性良好。根据我们的经验，经皮治疗方法对于低级别和低分期的肿瘤性病变是安全且有用的，在选定的患者中应被视为一线治疗方法。辅助局部治疗似乎有效，并且在给药过程中通过保持低腔内压力可以避免一些并发症。
