孤立肾肾结石并肾盂肾盏移行细胞癌漏诊分析并文献复习

王志超，周建甫，桂泽红，谢旻君，王树声，向松涛

孤立肾肾结石并肾盂肾盏移行细胞癌漏诊分析并文献复习

王志超，周建甫，桂泽红，谢旻君，王树声，向松涛

目的探讨孤立肾肾结石并肾盂肾盏移行细胞癌的诊治要点。方法对我院收治的孤立肾肾结石并肾盂肾盏移行细胞癌1例的临床资料进行回顾性分析，并复习相关文献。结果本例因右侧腰部隐痛10余年，加重伴肉眼血尿1周入院。10年前诊断为右肾孤立肾肾结石，行右肾切开取石术。1年后结石复发，未诊治。本次入院后行实验室及影像学检查，诊断为右肾孤立肾肾结石，于气管插管全身麻醉下行经皮肾穿刺碎石取石术，术中发现肾中盏单发基底宽1 cm的菜花样肿物。术后病理报告：低级别非浸润性尿路上皮移行细胞癌。与家属商议后行经皮肾镜检查并钬激光消融止血治疗，术中因无法止血，遂行孤立肾切除，术后定期行血液透析治疗。随访7个月，肌酐波动于350～590 μmol/L，腰痛未复发。结论孤立肾肾结石并肾盂肾盏移行细胞癌临床罕见，易漏诊，且病情复杂，应根据患者自身情况制定个体化治疗方案。

肾肿瘤；肾结石；经皮肾镜取石术

孤立肾肾结石并肾盂肾盏移行细胞癌临床罕见，早期肾盂肾盏肿瘤易被结石所引起的症状掩盖，致误漏诊。我院近期收治孤立肾肾结石并肾盂肾盏移行细胞癌1例，病初将移行细胞癌漏诊，现分析报告如下。

1 病例资料

男，55岁。因右侧腰部隐痛10余年，加重伴肉眼血尿1周入院。有30年吸烟史。10年前因右侧腰部隐痛，诊断为右肾结石、左肾先天性缺如，行右肾切开取石术，1年后结石复发，未系统诊治。1周前右侧腰痛复发且较前加重，伴肉眼血尿，遂以右侧孤立肾肾结石收入院。查体：心肺检查未见异常，右侧肾区叩击痛阳性。行静脉肾盂造影显示：右肾多发结石并大量积液，右肾排泄功能受损，左侧尿路未见显影。逆行肾盂造影示：右侧输尿管通畅，右肾多发结石并大量积液。泌尿系B超示：右肾多发结石并大量积液，左肾缺如。双肾CT检查示：左肾缺如，右肾多发结石，大小为(34～38)mm×(20～21)mm，伴右肾重度积液。查血白细胞10×109/L；肌酐212 μmol/L；尿白细胞6/ul。诊断为右肾孤立肾并多发结石。于气管插管全身麻醉下行经皮肾穿刺碎石取石术，术中取出结石，在肾中盏发现单发基底宽1 cm的菜花样肿物，与家属沟通后取肿物行活组织病理检查(活检)，留置肾造瘘管及双J管。术后第1天肾造瘘管引流出鲜红色血性液体，查血白细胞18×109/L，血红蛋白88 g/L；肌酐725 μmol/L；B型脑钠肽1250 pg/ml。考虑心力衰竭(心衰)，予床边血液透析及抗心衰治疗。术后第3天病理报告示：低级别非浸润性尿路上皮移行细胞癌。术后第5天转重症监护病房行床边血液透析，病情稳定后与家属沟通，同意行二期经皮肾镜检查并钬激光消融止血治疗。术后第6天行经皮肾镜检查并钬激光消融止血，术中因无法止血，遂行孤立肾切除，术后定期行血液透析治疗，病情平稳出院。随访7个月，肌酐波动于350～590 μmol/L，腰痛未复发。

2 讨论

2.1疾病概述 检索维普及中国生物医学数据库2007—2016年文献，尚未见孤立肾肾结石并肾盂肾盏移行细胞癌相关报道。上尿路移行细胞癌约占泌尿系移行上皮细胞肿瘤的5%[1]。常见的肾盂肿瘤包括移行细胞癌、鳞状细胞癌、腺癌、囊腺癌等，其中移行细胞癌占90%，鳞状细胞癌占10%，腺癌占1%[2-3]。肾结石并肾盂肿瘤占同期肾结石的0.91%，占同期肾盂肿瘤的21.71%[4]。肾盏憩室结石并肿瘤极为罕见，仅日本报道3例[5]。

目前肾盂肿瘤的发病原因尚未明确。吸烟是重要的危险因素之一，与上尿路肿瘤发生的相关系数达4.5，其他风险因素包括家族史、某些化学药品的职业暴露、X线辐射、饮浓咖啡、长期口服慢性镇痛药等[6-7]。泌尿系结石及感染与泌尿系肿瘤发病密切相关。Chow等[8]根据瑞典住院患者和癌症登记的数据分析，发现上尿路结石患者发生肾盂或输尿管肿瘤的概率显著增加，结石并反复感染者发生肿瘤的概率是未感染者的2倍。有研究发现，结石导致的肾盂积液、反复感染、慢性炎症等对肾盂黏膜的长期刺激是引起肾盂黏膜恶变的作用机制[9]。本例有30余年吸烟史，长达10余年的结石病史，长期肾盂积液是肾盂肿瘤发生的重要原因。

2.2治疗 肾结石并肾盂肾盏肿瘤的治疗较困难，多在行经皮肾手术或肾切除时发现肿瘤，因而肿瘤的处理成为难点。目前关于是否保留肾脏临床存在巨大争议。对于对侧肾功能正常的患者，主要治疗方案为患侧肾输尿管切除术，可降低肿瘤局部复发的风险，免除长期严密上尿路监控[10]。然而，越来越多的研究倾向于保留肾脏。部分学者认为低级别非浸润性肿瘤，即使对侧肾功能正常，亦可保留肾脏[10]。Goel等[11]对24例行经皮肾镜治疗并长期随访的肾盂癌进行回顾性分析，发现多数低级别肾盂肿瘤保留肾脏是可行的，故对于肾盂单发低级别肿瘤，可优先考虑内镜下切除。Palou等[12]报道34例采用经皮肾镜切除的上尿路移行细胞癌，平均随访51个月，病灶切除侧复发率为41.2%，平均复发时间为24个月，认为采用经皮肾镜治疗肾脏尿路上皮肿瘤的长期疗效肯定，可作为一种有效的治疗方法，但肿瘤复发风险较大，术后需长期严密随访。Forster等[13]通过文献复习，发现钬激光治疗移行细胞癌已得到临床广泛认可，尤其是经皮肾镜和输尿管软镜的出现，更让保留肾脏的微创钬激光治疗肾盂癌成为可能，但手术的成功与病例的选择密切相关，术前需综合分析肿瘤大小、分期、多灶性和患者的其他情况，如合并孤立肾、肾移植和患者意愿，且远期疗效需患者及家属具有良好的治疗积极性和依从性。Moore等[14]认为单发、低级别、直径小于1.5 cm的肿瘤，内镜治疗效果较好，但需坚持系统的输尿管镜随访，而内镜治疗高级别肿瘤则属于姑息性手术，需终生随访，定期灌注化疗。

内镜治疗后的肾盂灌注化疗可能成为不适合行根治性手术患者的新选择。Thalmann等[15]对37例共41侧肾脏行经皮肾镜治疗，其中25侧肾盂原位癌行卡介苗灌注后治愈，16侧Ta期甚至更高级别肾盂癌行微创切除后辅助性卡介苗灌注治疗，平均中位生存期为42个月，无复发生存期21个月，无进展生存期34个月，其中14例死于肿瘤，11例死于其他病变，12例存活。Pak等[16]对57例肾功能不全或终末期肾病的上尿路移行细胞癌行保留肾脏的内镜治疗，术后随访2年以上，发现该治疗方式疗效显著，较行肾切除并透析治疗的患者节省花费。

2.3漏诊原因及防范措施 肾结石并肾盂肾盏尿路上皮移行细胞癌术前漏诊并不少见[17]，且常以结石相关临床表现就诊，早期尿路上皮肿瘤表现不明显。本例因血尿、腰痛就诊，接诊医师诊断思维局限，简单归结为肾结石，加上影像学检查难以对早期肾盂肾盏尿路上皮移行细胞癌做出明确诊断，尤其合并肾结石时，静脉肾盂造影、B超及CT等检查不能发现早期肾盂肾盏肿瘤[18-20]，致漏诊。此外，CT对慢性纤维性增生及梗阻导致的炎性病变与肿瘤表现相似，合并结石时无法进行鉴别诊断[21]。本例常规行静脉肾盂造影、逆行肾盂造影、CT等检查均未发现肾盏肿瘤，加之术前未行相关细胞学检查，亦是导致漏诊的原因之一。

合并尿路结石时上皮细胞易发生各种不同形态变化，导致细胞学诊断率下降[22]，但尿脱落细胞学检查仍是目前临床诊断的参考指标，推荐常规检测。因结石并肿瘤术前难以明确诊断，有学者建议对所有行经皮肾镜碎石取石术的患者常规取尿路上皮组织进行活检[23-26]。部分学者认为上述举措不值得推广，若在经皮肾镜碎石取石术中发现可疑病变者，则必须取活检或术中内镜下消融[3]。

提示临床遇及肾结石并大量积液的患者，要考虑到肾盂肿瘤的可能，术前完善相关检查，术中仔细探查各个肾盏，若发现肾盂可疑病变，及时取活检及内镜下激光消融，改善预后，减少误诊误治。

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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 修回时间：2017-06-05)

510105 广州，广东省中医院泌尿外科

向松涛，E-mail：tonyxst@163.com