【作者】 赵国华；

【导师】 洪宝发；

【作者基本信息】 中国人民解放军军医进修学院 ， 泌尿外科， 2010， 硕士

【摘要】 目的探讨肾移植患者并发尿路上皮癌的诊断及治疗要点。方法回顾性分析1977-2009年8月间接受免疫抑制治疗(至少半年)的2159例肾移植患者中发生尿路上皮癌的共42例病例。所有42例病例均采用手术治疗,9例行开放的肾根治性切除联合经尿道膀胱袖套状切除,11例行后腹腔镜肾根治性切除联合经尿道膀胱袖套状切除术,22例患者行膀胱肿瘤电切。术后常规膀胱灌注化疗药物如吡柔比星或丝裂霉素等防止复发,并定期随访。根据患者是否服用马兜铃酸成分中药,移植前透析时间等因素行相关性卡方检验。结果在2159例肾移植患者中,发生尿路上皮癌42例,发病率为1.9%。全部42例患者病例资料完整,所有患者均经术后病理证实为尿路上皮癌。35例(83.3%)患者因血尿就诊；7例(16.7%)患者体检时发现病情,其中包括2例无尿的患者。所有患者均接受手术治疗,术后辅以化疗及放疗。9例患者行开放的肾根治性切除联合经尿道膀胱袖套状切除,其中2例术后行床旁血滤；11例行后腹腔镜肾根治性切除联合经尿道膀胱袖套状切除术,住院时间13-19天;22例行经尿道膀胱肿瘤电切,住院天数0-10天。4例患者术后因广泛转移死亡。病理结果：均为泌尿系统尿路上皮癌,纯膀胱癌22例,肾盂癌12例,’肾盂输尿管膀胱癌2例,输尿管癌6例。病理结果均为泌尿系统尿路上皮癌,病理分级：Ⅰ级4例,Ⅱ级34例,Ⅲ级4例。其中有2例并存肾盂腺癌与输尿管癌及膀胱尿路上皮癌。切口愈合时间7-15天,围手术期均未见切口感染、出血、腹腔积液、肠梗阻、肠麻痹、淋巴屡、褥疮或坠积性肺炎等并发症。术后均应用丝裂霉素膀胧灌注化疗。目前随访时间为1-45个月(17.3±11.65),其中4例死亡。复发肾盂癌2人4例次,均行根治性切除术；膀胱尿路上皮癌行TURBt术后的膀胱癌患者,1例于7个月后转移至肾盂、输尿管,行肾、输尿管根治性切除术,另有7人13例次复发,复发后病理为输尿管尿路上皮癌Ⅲ级为3人,恶性程度增加死亡病例中3例为马兜铃酸肾病,最长慢性肾功能衰竭病史11年,平均5.6年。结论对于肾移植术后患者,特别是存在马兜铃酸类似中药成份服药史及马兜铃酸致间质性肾炎的患者,于复查时应加强泌尿系统的常规检查,如尿常规、尿脱落细胞病理检查以及泌尿系B超等；对于出现血尿、腰痛等症状的患者必要时可行膀胱镜、MRI等检查,争取尽早发现病情,以便及时治疗。对具备手术条件的肾移植术后的尿路上皮癌患者尽量选择微创治疗。及时监测患者肾功能及血药浓度,力争不影响移植肾脏功能的情况下,尽量减少免疫抑制药物用量。更多还原

【Abstract】 Objective To analyse the characters of clinical pathology of urinary malignancies in patients with renal transplantation.Methods A retrospective study was performed on 2159 renal allografts under at least 0.5 year immunosuppression from 1978-2009. All of the cases were operated.Results 42 cases of uroepithelial tumors were found in 2159 cases undergoing renal transplantation with the incidence being 1.9%.42 cases had intact medical history and all of the cases were demonstrated pathologically.35 cases(83.3%) were diagnosed on account of hematuria,7 cases (16.7%)were diagnosed by medical examination including 2 anuric patients. all of the patients accepted operations, additional therapies including chemical or radiological.9 cases accepted patent operation of radical nephrectomy and transurethral cuffing cystectomy, length of stay was 17-25 days; 11 cases accepted retroperitoneoscopic radical nephrectomy and transurethral cuffing cystectomy, length of stay was 13-19 days;22 cases haved TURBT, length of stay was 0-10 days;4 cases died of wide metastasis.Conclusions Patients with renal transplantation should pay more attention on urological routine examinations,the operations with less trauma should be choosed, at the same time, the dosage of immunosuppressants was reduced to maintain normal function of the graft.更多还原