王志超，周建甫，桂澤紅，謝旻君，王樹聲，向松濤

孤立腎腎結(jié)石并腎盂腎盞移行細(xì)胞癌漏診分析并文獻(xiàn)復(fù)習(xí)

王志超，周建甫，桂澤紅，謝旻君，王樹聲，向松濤

目的探討孤立腎腎結(jié)石并腎盂腎盞移行細(xì)胞癌的診治要點。方法對我院收治的孤立腎腎結(jié)石并腎盂腎盞移行細(xì)胞癌1例的臨床資料進行回顧性分析，并復(fù)習(xí)相關(guān)文獻(xiàn)。結(jié)果本例因右側(cè)腰部隱痛10余年，加重伴肉眼血尿1周入院。10年前診斷為右腎孤立腎腎結(jié)石，行右腎切開取石術(shù)。1年后結(jié)石復(fù)發(fā)，未診治。本次入院后行實驗室及影像學(xué)檢查，診斷為右腎孤立腎腎結(jié)石，于氣管插管全身麻醉下行經(jīng)皮腎穿刺碎石取石術(shù)，術(shù)中發(fā)現(xiàn)腎中盞單發(fā)基底寬1 cm的菜花樣腫物。術(shù)后病理報告：低級別非浸潤性尿路上皮移行細(xì)胞癌。與家屬商議后行經(jīng)皮腎鏡檢查并鈥激光消融止血治療，術(shù)中因無法止血，遂行孤立腎切除，術(shù)后定期行血液透析治療。隨訪7個月，肌酐波動于350～590 μmol/L，腰痛未復(fù)發(fā)。結(jié)論孤立腎腎結(jié)石并腎盂腎盞移行細(xì)胞癌臨床罕見，易漏診，且病情復(fù)雜，應(yīng)根據(jù)患者自身情況制定個體化治療方案。

腎腫瘤；腎結(jié)石；經(jīng)皮腎鏡取石術(shù)

孤立腎腎結(jié)石并腎盂腎盞移行細(xì)胞癌臨床罕見，早期腎盂腎盞腫瘤易被結(jié)石所引起的癥狀掩蓋，致誤漏診。我院近期收治孤立腎腎結(jié)石并腎盂腎盞移行細(xì)胞癌1例，病初將移行細(xì)胞癌漏診，現(xiàn)分析報告如下。

1 病例資料

男，55歲。因右側(cè)腰部隱痛10余年，加重伴肉眼血尿1周入院。有30年吸煙史。10年前因右側(cè)腰部隱痛，診斷為右腎結(jié)石、左腎先天性缺如，行右腎切開取石術(shù)，1年后結(jié)石復(fù)發(fā)，未系統(tǒng)診治。1周前右側(cè)腰痛復(fù)發(fā)且較前加重，伴肉眼血尿，遂以右側(cè)孤立腎腎結(jié)石收入院。查體：心肺檢查未見異常，右側(cè)腎區(qū)叩擊痛陽性。行靜脈腎盂造影顯示：右腎多發(fā)結(jié)石并大量積液，右腎排泄功能受損，左側(cè)尿路未見顯影。逆行腎盂造影示：右側(cè)輸尿管通暢，右腎多發(fā)結(jié)石并大量積液。泌尿系B超示：右腎多發(fā)結(jié)石并大量積液，左腎缺如。雙腎CT檢查示：左腎缺如，右腎多發(fā)結(jié)石，大小為(34～38)mm×(20～21)mm，伴右腎重度積液。查血白細(xì)胞10×109/L；肌酐212 μmol/L；尿白細(xì)胞6/ul。診斷為右腎孤立腎并多發(fā)結(jié)石。于氣管插管全身麻醉下行經(jīng)皮腎穿刺碎石取石術(shù)，術(shù)中取出結(jié)石，在腎中盞發(fā)現(xiàn)單發(fā)基底寬1 cm的菜花樣腫物，與家屬溝通后取腫物行活組織病理檢查(活檢)，留置腎造瘺管及雙J管。術(shù)后第1天腎造瘺管引流出鮮紅色血性液體，查血白細(xì)胞18×109/L，血紅蛋白88 g/L；肌酐725 μmol/L；B型腦鈉肽1250 pg/ml?？紤]心力衰竭(心衰)，予床邊血液透析及抗心衰治療。術(shù)后第3天病理報告示：低級別非浸潤性尿路上皮移行細(xì)胞癌。術(shù)后第5天轉(zhuǎn)重癥監(jiān)護病房行床邊血液透析，病情穩(wěn)定后與家屬溝通，同意行二期經(jīng)皮腎鏡檢查并鈥激光消融止血治療。術(shù)后第6天行經(jīng)皮腎鏡檢查并鈥激光消融止血，術(shù)中因無法止血，遂行孤立腎切除，術(shù)后定期行血液透析治療，病情平穩(wěn)出院。隨訪7個月，肌酐波動于350～590 μmol/L，腰痛未復(fù)發(fā)。

2 討論

2.1疾病概述 檢索維普及中國生物醫(yī)學(xué)數(shù)據(jù)庫2007—2016年文獻(xiàn)，尚未見孤立腎腎結(jié)石并腎盂腎盞移行細(xì)胞癌相關(guān)報道。上尿路移行細(xì)胞癌約占泌尿系移行上皮細(xì)胞腫瘤的5%[1]。常見的腎盂腫瘤包括移行細(xì)胞癌、鱗狀細(xì)胞癌、腺癌、囊腺癌等，其中移行細(xì)胞癌占90%，鱗狀細(xì)胞癌占10%，腺癌占1%[2-3]。腎結(jié)石并腎盂腫瘤占同期腎結(jié)石的0.91%，占同期腎盂腫瘤的21.71%[4]。腎盞憩室結(jié)石并腫瘤極為罕見，僅日本報道3例[5]。

目前腎盂腫瘤的發(fā)病原因尚未明確。吸煙是重要的危險因素之一，與上尿路腫瘤發(fā)生的相關(guān)系數(shù)達(dá)4.5，其他風(fēng)險因素包括家族史、某些化學(xué)藥品的職業(yè)暴露、X線輻射、飲濃咖啡、長期口服慢性鎮(zhèn)痛藥等[6-7]。泌尿系結(jié)石及感染與泌尿系腫瘤發(fā)病密切相關(guān)。Chow等[8]根據(jù)瑞典住院患者和癌癥登記的數(shù)據(jù)分析，發(fā)現(xiàn)上尿路結(jié)石患者發(fā)生腎盂或輸尿管腫瘤的概率顯著增加，結(jié)石并反復(fù)感染者發(fā)生腫瘤的概率是未感染者的2倍。有研究發(fā)現(xiàn)，結(jié)石導(dǎo)致的腎盂積液、反復(fù)感染、慢性炎癥等對腎盂黏膜的長期刺激是引起腎盂黏膜惡變的作用機制[9]。本例有30余年吸煙史，長達(dá)10余年的結(jié)石病史，長期腎盂積液是腎盂腫瘤發(fā)生的重要原因。

2.2治療 腎結(jié)石并腎盂腎盞腫瘤的治療較困難，多在行經(jīng)皮腎手術(shù)或腎切除時發(fā)現(xiàn)腫瘤，因而腫瘤的處理成為難點。目前關(guān)于是否保留腎臟臨床存在巨大爭議。對于對側(cè)腎功能正常的患者，主要治療方案為患側(cè)腎輸尿管切除術(shù)，可降低腫瘤局部復(fù)發(fā)的風(fēng)險，免除長期嚴(yán)密上尿路監(jiān)控[10]。然而，越來越多的研究傾向于保留腎臟。部分學(xué)者認(rèn)為低級別非浸潤性腫瘤，即使對側(cè)腎功能正常，亦可保留腎臟[10]。Goel等[11]對24例行經(jīng)皮腎鏡治療并長期隨訪的腎盂癌進行回顧性分析，發(fā)現(xiàn)多數(shù)低級別腎盂腫瘤保留腎臟是可行的，故對于腎盂單發(fā)低級別腫瘤，可優(yōu)先考慮內(nèi)鏡下切除。Palou等[12]報道34例采用經(jīng)皮腎鏡切除的上尿路移行細(xì)胞癌，平均隨訪51個月，病灶切除側(cè)復(fù)發(fā)率為41.2%，平均復(fù)發(fā)時間為24個月，認(rèn)為采用經(jīng)皮腎鏡治療腎臟尿路上皮腫瘤的長期療效肯定，可作為一種有效的治療方法，但腫瘤復(fù)發(fā)風(fēng)險較大，術(shù)后需長期嚴(yán)密隨訪。Forster等[13]通過文獻(xiàn)復(fù)習(xí)，發(fā)現(xiàn)鈥激光治療移行細(xì)胞癌已得到臨床廣泛認(rèn)可，尤其是經(jīng)皮腎鏡和輸尿管軟鏡的出現(xiàn)，更讓保留腎臟的微創(chuàng)鈥激光治療腎盂癌成為可能，但手術(shù)的成功與病例的選擇密切相關(guān)，術(shù)前需綜合分析腫瘤大小、分期、多灶性和患者的其他情況，如合并孤立腎、腎移植和患者意愿，且遠(yuǎn)期療效需患者及家屬具有良好的治療積極性和依從性。Moore等[14]認(rèn)為單發(fā)、低級別、直徑小于1.5 cm的腫瘤，內(nèi)鏡治療效果較好，但需堅持系統(tǒng)的輸尿管鏡隨訪，而內(nèi)鏡治療高級別腫瘤則屬于姑息性手術(shù)，需終生隨訪，定期灌注化療。

內(nèi)鏡治療后的腎盂灌注化療可能成為不適合行根治性手術(shù)患者的新選擇。Thalmann等[15]對37例共41側(cè)腎臟行經(jīng)皮腎鏡治療，其中25側(cè)腎盂原位癌行卡介苗灌注后治愈，16側(cè)Ta期甚至更高級別腎盂癌行微創(chuàng)切除后輔助性卡介苗灌注治療，平均中位生存期為42個月，無復(fù)發(fā)生存期21個月，無進展生存期34個月，其中14例死于腫瘤，11例死于其他病變，12例存活。Pak等[16]對57例腎功能不全或終末期腎病的上尿路移行細(xì)胞癌行保留腎臟的內(nèi)鏡治療，術(shù)后隨訪2年以上，發(fā)現(xiàn)該治療方式療效顯著，較行腎切除并透析治療的患者節(jié)省花費。

2.3漏診原因及防范措施 腎結(jié)石并腎盂腎盞尿路上皮移行細(xì)胞癌術(shù)前漏診并不少見[17]，且常以結(jié)石相關(guān)臨床表現(xiàn)就診，早期尿路上皮腫瘤表現(xiàn)不明顯。本例因血尿、腰痛就診，接診醫(yī)師診斷思維局限，簡單歸結(jié)為腎結(jié)石，加上影像學(xué)檢查難以對早期腎盂腎盞尿路上皮移行細(xì)胞癌做出明確診斷，尤其合并腎結(jié)石時，靜脈腎盂造影、B超及CT等檢查不能發(fā)現(xiàn)早期腎盂腎盞腫瘤[18-20]，致漏診。此外，CT對慢性纖維性增生及梗阻導(dǎo)致的炎性病變與腫瘤表現(xiàn)相似，合并結(jié)石時無法進行鑒別診斷[21]。本例常規(guī)行靜脈腎盂造影、逆行腎盂造影、CT等檢查均未發(fā)現(xiàn)腎盞腫瘤，加之術(shù)前未行相關(guān)細(xì)胞學(xué)檢查，亦是導(dǎo)致漏診的原因之一。

合并尿路結(jié)石時上皮細(xì)胞易發(fā)生各種不同形態(tài)變化，導(dǎo)致細(xì)胞學(xué)診斷率下降[22]，但尿脫落細(xì)胞學(xué)檢查仍是目前臨床診斷的參考指標(biāo)，推薦常規(guī)檢測。因結(jié)石并腫瘤術(shù)前難以明確診斷，有學(xué)者建議對所有行經(jīng)皮腎鏡碎石取石術(shù)的患者常規(guī)取尿路上皮組織進行活檢[23-26]。部分學(xué)者認(rèn)為上述舉措不值得推廣，若在經(jīng)皮腎鏡碎石取石術(shù)中發(fā)現(xiàn)可疑病變者，則必須取活檢或術(shù)中內(nèi)鏡下消融[3]。

提示臨床遇及腎結(jié)石并大量積液的患者，要考慮到腎盂腫瘤的可能，術(shù)前完善相關(guān)檢查，術(shù)中仔細(xì)探查各個腎盞，若發(fā)現(xiàn)腎盂可疑病變，及時取活檢及內(nèi)鏡下激光消融，改善預(yù)后，減少誤診誤治。

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Missed Diagnosis Analysis and a Literature Review of Solitary Kidney Patient with Renal Calculus Combined with Transitional Cell Carcinoma of Renal Pelvis and Calices

WANG Zhi-chao, ZHOU Jian-fu, GUI Ze-hong, XIE Min-jun， WANG Shu-sheng, XIANG Song-tao

( Department of Urinary Surgery, Guangdong Provincial Hospital of Traditional Chinese Medicine, Guangzhou 510105, China)

ObjectiveTo investigate key points of diagnosis and treatment for solitary kidney patients with renal calculus combined with transitional cell carcinoma of renal pelvis and calices.MethodsClinical data of 1 solitary kidney patient with renal calculus combined with transitional cell carcinoma of renal pelvis and calices was retrospectively analyzed, and related literature was reviewed.ResultsThe patient was admitted for right low back vague pain for more than 10 years and aggravation associated by macrohematuria for 1 week. The patient was diagnosed as having right kidney, solitary kidney and kidney stones 10 years ago, and underwent right kidney of nephrolithotomy. The calculus was recurred 1 year later without being treated. After admission, laboratory and iconography examinations were performed, and the diagnosis of solitary kidney combined with renal calculus was given. Right kidney of percutaneous nephrostolithotomy (PCNL) was performed under tracheal cannula and general anesthesia, and a cauliflower-like solitary neoplasm with 1 cm fundus width was discovered in middle kidney calices, and postoperatively pathological report showed low-grade noninfiltrating uroepithelium transitional cell carcinoma. After the family had agreed, percutaneous nephroscope examination and holmium laser tumor ablation hemostasis were given, but bleeding could not be stopped during operation, and then solitary nephrectomy was performed, and regular hemodialysis treatment was given after operation. With 7 months of follow-up, creatinine level fluctuated at 350-590μmol/L without recurrence of low back pain.ConclusionSolitary kidney patients with renal calculus combined with transitional cell carcinoma of renal pelvis and calices is rare in clinic, and therefore it is easily misdiagnosed. Individualized treatment should be given on the basis of patient's condition because of complex condition.

Kidney neoplasms; Kidney calculi; Percutaneous nephrolithotomy

R737.11；R692.4

A

1002-3429(2017)09-0027-03

10.3969/j.issn.1002-3429.2017.09.011

2017-05-03 修回時間：2017-06-05)

510105 廣州，廣東省中醫(yī)院泌尿外科

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