肾移植术后膀胱癌患者的根治性膀胱切除术及原位尿流重建：临床结果及技术描述
Radical cystectomy and orthotopic urinary reconstruction in patients with bladder cancer after renal transplantation: clinical outcomes and description of technique.
作者信息
Moses K A, Bochner B H, Prabharasuth D, Sfakianos J P, Bernstein M, Herr H W, Dalbagni G
机构信息
Urology Service, Department of Surgery, Memorial Sloan-Kettering Cancer Center, New York, NY, USA.
出版信息
Transplant Proc. 2013 May;45(4):1661-6. doi: 10.1016/j.transproceed.2012.10.050.
OBJECTIVES
Radical cystectomy (RC) with pelvic lymph node dissection and urinary diversion is the standard treatment for muscle-invasive bladder cancer. In the setting of prior renal transplantation, surgical treatment remains the mainstay but is technically challenging. We report our patient outcomes in this unique population with a description of the technique.
METHODS
We identified five patients with a history of renal transplantation who underwent RC and orthotopic urinary diversion. Preoperative clinical and demographic features were compiled and disease-specific and functional outcomes were assessed. Intraoperative technical challenges and maneuvers for avoiding complications are highlighted.
RESULTS
Four patients were male and one was female, with a median age of 64 years. Gross hematuria was the most common sign at presentation. Clinical staging was T2, T2 with carcinoma in situ (CIS), high-grade (HG) Ta with CIS, T2 with squamous differentiation, and HG T1, and pathologic tumor stage was pTisN1, pT3N0, pTisN0, pT3N0, and pT0N0, respectively. One patient received a Studer-type diversion and four underwent Hautmann diversion. Median follow-up after cystectomy was 12.9 months. Graft ureteral identification was aided by the use of intravenous dye in all patients. Ipsilateral pelvic lymph node dissection was not possible in any patient. All patients are alive at follow-up, with two experiencing recurrence at 7.2 months and 66.8 months. No patient experienced a significant decrease in estimated creatinine clearance postoperatively. Postoperative daytime control was reported by all patients whereas two noted complete nighttime control.
CONCLUSIONS
RC with orthotopic diversion is a technically demanding procedure in patients with a history renal transplantation. Meticulous technique and careful attention to the altered anatomy are required for successful outcomes.
目的
根治性膀胱切除术（RC）联合盆腔淋巴结清扫及尿流改道是肌层浸润性膀胱癌的标准治疗方法。对于既往有肾移植史的患者，手术治疗仍是主要手段，但在技术上具有挑战性。我们报告了这一特殊人群的患者治疗结果，并描述了相关技术。
方法
我们确定了5例有肾移植史且接受了RC及原位尿流改道的患者。收集术前临床和人口统计学特征，并评估疾病特异性和功能结局。重点介绍术中技术挑战及避免并发症的操作。
结果
4例为男性，1例为女性，中位年龄64岁。肉眼血尿是最常见的表现。临床分期为T2、伴有原位癌（CIS）的T2、伴有CIS的高级别（HG）Ta、伴有鳞状分化的T2以及HG T1，病理肿瘤分期分别为pTisN1、pT3N0、pTisN0、pT3N0和pT0N0。1例患者接受了Studer式改道，4例接受了Hautmann改道。膀胱切除术后的中位随访时间为12.9个月。所有患者均通过静脉注射染料辅助识别移植输尿管。所有患者均无法进行同侧盆腔淋巴结清扫。所有患者在随访时均存活，2例分别在7.2个月和66.8个月出现复发。术后所有患者的估计肌酐清除率均未显著下降。所有患者均报告白天控尿良好，2例患者指出夜间完全控尿。
结论
对于有肾移植史的患者，原位改道的RC是一项技术要求很高的手术。为获得成功结局，需要精细的技术并密切关注解剖结构的改变。
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