Gupta Narmada P, Kolla Surendra B, Seth A, Hemal Ashok K, Dogra Prem N, Kumar R
Department of Urology, All India Institute of Medical Sciences, New Delhi, India.
J Urol. 2007 Oct;178(4 Pt 1):1206-11; discussion 1211. doi: 10.1016/j.juro.2007.05.142. Epub 2007 Aug 14.
We present our experience with the perioperative, functional and oncological outcomes of radical cystectomy in patients with bladder cancer and obstructive uremia.
From 1998 to June 2006, 58 patients with bladder cancer, and concomitant obstructive uropathy and azotemia presented to our institution. Mean +/- SD serum creatinine at presentation was 9.2 +/- 4.5 mg% (range 2.4 to 16.5). Radical cystectomy, bilateral pelvic lymphadenectomy and urinary diversion were performed after stabilizing renal function with and without percutaneous nephrostomy in 28 and 8 patients, respectively. Various preoperative variables were evaluated for predicting long-term treatment failure and renal deterioration. Mean followup was 34 months.
Mean serum creatinine at surgery was 1.85 mg%. An ileal conduit was used in 32 patients and cutaneous ureterostomy was used in 4. One patient died of chest infection in the perioperative period. All patients had muscle invasive disease, while 15 had positive lymph nodes. At the mean followup 15 patients (41.6%) were free of disease and 21 had treatment failure. Of the factors evaluated pathological tumor stage, grade and lymph node involvement predicted the long-term oncological outcome, while serum creatinine greater than 2.5 mg% at surgery and ileal conduit diversion predicted long-term renal deterioration.
Patients with bladder cancer who have obstructive uremia usually present with locally advanced disease. Radical cystectomy is not associated with additional morbidity, provided that patients are adequately prepared before surgery by optimizing renal function. An adequate number of these patients achieve long-term disease-free survival after radical cystectomy. As the urinary diversion of choice, an ileal conduit appears to be safe in patients with serum creatinine less than 2.5 mg% at surgery.
我们介绍了膀胱癌合并梗阻性尿毒症患者行根治性膀胱切除术的围手术期、功能和肿瘤学结果。
1998年至2006年6月，58例膀胱癌合并梗阻性尿路病和氮质血症患者就诊于我院。就诊时平均±标准差血清肌酐为9.2±4.5mg%（范围2.4至16.5）。分别在28例和8例患者中，通过经皮肾造瘘稳定肾功能后或未行该操作的情况下，进行了根治性膀胱切除术、双侧盆腔淋巴结清扫术和尿流改道。评估了各种术前变量以预测长期治疗失败和肾功能恶化。平均随访34个月。
手术时平均血清肌酐为1.85mg%。32例患者采用回肠膀胱术，4例采用皮肤输尿管造口术。1例患者在围手术期死于肺部感染。所有患者均为肌层浸润性疾病，其中15例有阳性淋巴结。在平均随访时，15例患者（41.6%）无疾病，21例有治疗失败。在评估的因素中，病理肿瘤分期、分级和淋巴结受累预测了长期肿瘤学结果，而手术时血清肌酐大于2.5mg%和回肠膀胱术改道预测了长期肾功能恶化。
患有梗阻性尿毒症的膀胱癌患者通常表现为局部晚期疾病。如果患者在手术前通过优化肾功能得到充分准备，根治性膀胱切除术不会增加额外的发病率。相当数量的这些患者在根治性膀胱切除术后实现了长期无病生存。作为首选的尿流改道方式，回肠膀胱术对于手术时血清肌酐低于2.5mg%的患者似乎是安全的。
