孤立腎腎結石并腎盂腎盞移行細胞癌漏診分析并文獻復習

王志超，周建甫，桂澤紅，謝旻君，王樹聲，向松濤

孤立腎腎結石并腎盂腎盞移行細胞癌漏診分析并文獻復習

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石并腎盂腎盞移行細胞癌的診治要點。方法對我院收治的孤立腎腎結石并腎盂腎盞移行細胞癌1例的臨床資料進行回顧性分析，并復習相關文獻。結果本例因右側腰部隱痛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石，行右腎切開取石術。1年后結石復發，未診治。本次入院后行實驗室及影像學檢查，診斷為右腎孤立腎腎結石，于氣管插管全身麻醉下行經皮腎穿刺碎石取石術，術中發現腎中盞單發基底寬1 cm的菜花樣腫物。術后病理報告：低級別非浸潤性尿路上皮移行細胞癌。與家屬商議后行經皮腎鏡檢查并鈥激光消融止血治療，術中因無法止血，遂行孤立腎切除，術后定期行血液透析治療。隨訪7個月，肌酐波動于350～590 μmol/L，腰痛未復發。結論孤立腎腎結石并腎盂腎盞移行細胞癌臨床罕見，易漏診，且病情復雜，應根據患者自身情況制定個體化治療方案。

腎腫瘤；腎結石；經皮腎鏡取石術

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

1 病例資料

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

2 討論

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

目前腎盂腫瘤的發病原因尚未明確。吸煙是重要的危險因素之一，與上尿路腫瘤發生的相關系數達4.5，其他風險因素包括家族史、某些化學藥品的職業暴露、X線輻射、飲濃咖啡、長期口服慢性鎮痛藥等[6-7]。泌尿系結石及感染與泌尿系腫瘤發病密切相關。Chow等[8]根據瑞典住院患者和癌癥登記的數據分析，發現上尿路結石患者發生腎盂或輸尿管腫瘤的概率顯著增加，結石并反復感染者發生腫瘤的概率是未感染者的2倍。有研究發現，結石導致的腎盂積液、反復感染、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10余年的結石病史，長期腎盂積液是腎盂腫瘤發生的重要原因。

2.2治療 腎結石并腎盂腎盞腫瘤的治療較困難，多在行經皮腎手術或腎切除時發現腫瘤，因而腫瘤的處理成為難點。目前關于是否保留腎臟臨床存在巨大爭議。對于對側腎功能正常的患者，主要治療方案為患側腎輸尿管切除術，可降低腫瘤局部復發的風險，免除長期嚴密上尿路監控[10]。然而，越來越多的研究傾向于保留腎臟。部分學者認為低級別非浸潤性腫瘤，即使對側腎功能正常，亦可保留腎臟[10]。Goel等[11]對24例行經皮腎鏡治療并長期隨訪的腎盂癌進行回顧性分析，發現多數低級別腎盂腫瘤保留腎臟是可行的，故對于腎盂單發低級別腫瘤，可優先考慮內鏡下切除。Palou等[12]報道34例采用經皮腎鏡切除的上尿路移行細胞癌，平均隨訪51個月，病灶切除側復發率為41.2%，平均復發時間為24個月，認為采用經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，但腫瘤復發風險較大，術后需長期嚴密隨訪。Forster等[13]通過文獻復習，發現鈥激光治療移行細胞癌已得到臨床廣泛認可，尤其是經皮腎鏡和輸尿管軟鏡的出現，更讓保留腎臟的微創鈥激光治療腎盂癌成為可能，但手術的成功與病例的選擇密切相關，術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]認為單發、低級別、直徑小于1.5 cm的腫瘤，內鏡治療效果較好，但需堅持系統的輸尿管鏡隨訪，而內鏡治療高級別腫瘤則屬于姑息性手術，需終生隨訪，定期灌注化療。

內鏡治療后的腎盂灌注化療可能成為不適合行根治性手術患者的新選擇。Thalmann等[15]對37例共41側腎臟行經皮腎鏡治療，其中25側腎盂原位癌行卡介苗灌注后治愈，16側Ta期甚至更高級別腎盂癌行微創切除后輔助性卡介苗灌注治療，平均中位生存期為42個月，無復發生存期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胞癌行保留腎臟的內鏡治療，術后隨訪2年以上，發現該治療方式療效顯著，較行腎切除并透析治療的患者節省花費。

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

合并尿路結石時上皮細胞易發生各種不同形態變化，導致細胞學診斷率下降[22]，但尿脫落細胞學檢查仍是目前臨床診斷的參考指標，推薦常規檢測。因結石并腫瘤術前難以明確診斷，有學者建議對所有行經皮腎鏡碎石取石術的患者常規取尿路上皮組織進行活檢[23-26]。部分學者認為上述舉措不值得推廣，若在經皮腎鏡碎石取石術中發現可疑病變者，則必須取活檢或術中內鏡下消融[3]。

提示臨床遇及腎結石并大量積液的患者，要考慮到腎盂腫瘤的可能，術前完善相關檢查，術中仔細探查各個腎盞，若發現腎盂可疑病變，及時取活檢及內鏡下激光消融，改善預后，減少誤診誤治。

[1] Wein A J, Kavoussi L R, Novick A C,etal. Campbell-Walsh Urology[M].Philadelphia: Elsevier Science Health Science, 2007:1970-1974.

[2] 陳俊星,丘少鵬,鄭克立,等.31例腎結石并發腎盂腫瘤診治體會[J].中國臨床醫學,2002,9(4):424-425.

[3] Zuckerman J M, Passman C, Assimos D G. Transitional cell carcinoma within a calyceal diverticulum associated with stone disease[J].Rev Urol, 2010,12(1):52-55.

[4] Spires S E, Banks E R, Cibull M L,etal. Adeocarcinoma of renal pelvis[J].Arch Pathol Lab Med, 1993,117(11):1156-1160.

[5] Gowing N F C. Tumors of the kidney, renal pelvis, and ureter[J].Armed Forces Institute of Pathology, 1975,148(2):1041.

[6] Ross R K, Paganini-Hill A, Landolph J,etal. Analgesics, cigarette smoking, and other risk factors for cancer of the renal pelvis and ureter[J].Cancer Res, 1989,49(4):1045-1048.

[7] 馬強,劉殿成,于江,等.腎盂癌漏診一例報告[J].臨床誤診誤治,2016,29(3):51-53.

[8] Chow W H, Lindblad P, Gridley G,etal. Risk of urinary tract cancers following kidney or ureter stones[J].J Natl Cancer Inst, 1997,89(19):1453-1457.

[9] Kaur G, Naik V R, Rahman M N. Mucinous adenocarcinoma of the renal pelvis associated with lithiasis and chronic gout[J].Singapore Med J, 2004,45(3):125-126.

[10] Gerber G S, Lyon E S. Endourological management of upper tract urothelial tumors[J].J Urol, 1993,150(1):2-7.

[11] Goel M C, Mahendra V, Roberts J G. Percutaneous management of renal pelvic urothelial tumors: long-term followup[J].J Urol, 2003,169(3):925-929.

[12] Palou J, Piovesan L F, Huguet J,etal. Percutaneous nephroscopic management of upper urinary tract transitional cell carcinoma: recurrence and long-term followup[J].J Urol, 2004,172(1):66-69.

[13] Forster J A, Palit V, Browning A J,etal. Endoscopic management of upper tract transitional cell carcinoma[J].Indian J Urol, 2010,26(2):177-182.

[14] Moore K, Khastgir J, Ghei M. Endoscopic management of upper tract urothelial carcinoma[J].Adv Urol, 2009:620604.

[15] Thalmann G N, Markwalder R, Walter B,etal. Long-term experience with bacillus Calmette-Guerin therapy of upper urinary tract transitional cell carcinoma in patients not eligible for surgery[J].J Urol, 2002,168(4):1381-1385.

[16] Pak R W, Moskowitz E J, Bagley D H. What is the cost of maintaining a kidney in upper-tract transitional-cell carcinoma? An objective analysis of cost and survival[J].J Endourol, 2009,23(3):341-346.

[17] Shah H N, Jain P, Chibber P J. Laparoscopic nephrectomy for giant staghorn calculus with non-functioning kidneys: is associated unsuspected urothelial carcinoma responsible for conversion? Report of 2 cases[J].BMC Urol, 2006,6:1.

[18] Blacher E J, Johnson D E, Abdul-Karim F W,etal. Squamous cell carcinoma of renal pelvis[J].Urology, 1985,25(2):124-126.

[19] 崔麗麗,侯新燕,王建華,等.超聲造影在腎盂腫瘤診斷中的臨床應用[J].中國臨床醫生,2013,41(9):47-49.

[20] 黃寧結,沈浩霖,楊舒萍.SonoVue超聲造影在腎盂癌診斷中的應用[J].海南醫學院學報,2010,16(7):931-933.

[21] Cholankeril J V, Freundlich R, Ketyer S,etal. Computed tomography in urothelial tumors of renal pelvis and related filling defects[J].J Comput Tomogr, 1986,10(3):263-272.

[22] Sangisetty K V, Randrup E R. Congenital giant hydronephrosis with unsuspected transitional cell carcinoma[J].Urology, 1985,26(4):400-401.

[23] Ozdamar A S, Ozkurkcugil C, Gultekin Y,etal. Should we get routine urothelial biopsies in every stone surgery[J].Int Urol Nephrol, 1997,29(4):415-420.

[24] 郭躍先,趙萬里.長期腎結石并發腎盂癌肉瘤一例[J].臨床誤診誤治,2008,21(2):96-97.

[25] Gokalp A, Günes H A, Gültekin E Y,etal. Renal pelvic biopsies of renal calculi patients[J].Br J Clin Pract, 1989,43(8):297-299.

[26] Katz R, Gofrit O N, Golijanin D,etal. Urothelial cancer of the renal pelvis in percutaneous nephrolithotomy patients[J].Urol Int, 2005,75(1):17-20.

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，廣東省中醫院泌尿外科

向松濤，E-mail：tonyxst@163.com