外 科 部
泌 尿 外 科 工 作 手 冊
臺中榮民總醫院
中 華 民 國 1 0 6 年 0 3 月 0 1 日 修 訂
泌 尿 外 科 工 作 手 冊
目 錄
壹. 泌尿外科之常規作業及特殊檢查 P３
貳. 泌尿道內視鏡檢查之注意事項 P４－７
參. 泌尿道外傷之處理 P８－１２
肆. 攝護腺肥大之診治 P１３－１４
伍. 泌尿道結石之診治 P１５－１９
陸. 性功能失調之診治 P２０－２１
柒. 泌尿道腫瘤之診治 P２２－４３
捌. 腹腔鏡手術概論 P４４－４６
玖. 腎臟移植概論 P４７－５０
壹拾. 機器人手臂概論 P５１－５４
壹、 泌尿外科之常規作業及特殊檢查
雖然泌尿科的病人之病情範圍很高，包括一般泌尿道感染、結石、尿路阻塞、腫 瘤及功能性的疾病，因此對於病情的描述以及需要的檢查作業則可分成兩大類：
一、常規作業及檢查
1. 病史：
A. 與本科有關之症狀：
Urination: Frequency, urgency, Nacturia, Hestancy, Initial or terminal dripping, urine retention, stress incontinence, Incontinence, bladder distention
Hematuria: Initial, total or terminal, gross hematuria, microscopic hematuria
Flank pain: Colic or dull pain, Intermittend or continuous, Radiation to gorin or tecticular area
Pain of scrotum and its content
Perineal pain – suggest prostatitis or perianal disease Urethral pain – related or not related urination
Sexual function: Normal regular, erectial dysfunction, poor or inadequate rigidity, premature ejeculation, unable ejeculation
Other symptoms: pneumoturia, hemospermia, milky urine a chyuria, hemochyuria, pyuria
B. Constitutional symptoms:
Chill, fever, weight loww, fatque, vomiting, cold sweating, anorexia, hypertention
2. Occupation:
Include present and past occupation especially relate to GU cancer 3. Family history:
Cancer, stone disease, BPH, Hypertension Personal History:
Smoking: amount durations
Eq: 1½ PPD from 1960-1995 4. Medication:
Past de present and past occupation especially relate to GU cancer
貳、 泌尿道內視鏡檢查之注意事項
腎臟鏡
一、腎臟鏡之型式：rigid 與 flexible。
二、適應症(indications)
1. 結石 – 腎結石與輸尿管上端之結石。
2. 腫瘤 – 單一腎臟之早期低惡性腫瘤切除。
三、經皮腎臟造廔碎石術(Percutaneous Nephrolithotomy) 1. 腎臟皮膚造廔(Nephrostomy)
病人採臥姿，在超音波或 X 光透視下進行穿刺，穿刺針進入腎盞(calyx) 後，以 Gcride-wire 穿過穿刺針，置入腎盂(renal pelvis)，再擴張廔管。
廔管之擴張方式有數種，如 Balloon，Amplatz dilators，Metal coaxial dilators，Optic visuld field 與 Otis dilation 等，視個人習慣而定。此步驟 可分 one stage 或 two stage，結石之取出可一次完成或分數次完成，視 結石大小與數目而定。廔管進入位置之選擇：依結石之位置決定 lower calyx – 腎結石在 lower 與 upper calyx，renal pelvis。
middle calyx – 結石在 middle calyx，renal pelvis，U-P-J 與 upper ureter。
Upper calyx – (通常需穿過胸膜，除非需要，少使用) – 結石在 upper calyx 而 infundibulum 狹窄，無法從 lower calyx 操作。
2. 經皮腎臟造廔碎石術之適應症：indications A. 腎結石造成症狀 – 疼痛，血尿。
B. 阻塞。
C. 感染。
3. 經皮腎臟造廔碎石術之禁忌症：(contra-indications) A. un-correctable coagulation disorders
B. extreme obesity C. severe kyphoscoliosis D. very mobile kidney
E. small or bifid intra-renal collecting systems F. high lying kidney
4. 術前病人面談：
A. 手術之併發症。
B. 結石取出失敗之可能性。
C. 結石可能需分數次取出。
5. 結石之摘除：
PCNL 術前需置導尿管，ureteral catheter 亦可考慮置放，防止碎結石從 腎盂掉入輸尿管。輸尿管上端之結石可設法推回腎盂再取出。PCNL 一 般可不需用 X 光透視，但有時可借助來確定結石之位置或有無殘餘結 石。小於一公分之結石，可直接用網子或夾子(Stone basket or stone
forceps)將結石取出。較大結石，則需用 E.H.L.(electro-hydraulic lithotripsy) 或超音波碎石(ultra-sonic litho-tripsy)。
6. 結石取出後皮腎廔管之引流
Nephrostomy tube，safety catheter 與 safety guide wire。
目的：
A. drain the collecting system。
B. provide tamponade of the tract。
C. preserve access to the kidney。
術後 24 小時內，小便需仔細量，若小便量很少，病人合併患側腎臟漲 痛，需考慮下列原因：
A. clots in renal pelvis。
B. over-inflation of balloon causing obstruction of pelvis。
C. extra-vasation of urine caused by renal pelvis perforation。
D. mal-positioned catheter outside of renal pelvis。
E. blockage of drain holes against wall of renal pelvis。
F. kinking of nephrostomy tube。
G. kinking of drainage tube。
導尿管於無血尿時即可拔除，Nephrostomy tube 與 safety catheter 需 antegrade pyelogram 確定無殘餘結石、阻塞、腎盂無漏尿方可拔除。
7. Complications：
acute：
A. hemorrhage。
B. perforation-avulsion。
C. urinoma。
D. retroperitoneal hematoma。
E. fever。
F. infection。
G. Pulmonary complications (e.g atelectasis ， pneumonia ， pneumo-hydrothorax)。
H. systemic absorption of fluid or air。
I. failure to retrieve stone or stone fragments。
J. mal-position of nephrostomy tube or loss of tract acess。
K. contrast media reaction。
L. abdominal organ puncture。
M. temporary U-P junction or ureteral obstruction。
Chronic：
A. delayed hemorrhage (e.g A-V fistula，pseudoaneurysm，vessel erosion by tube)。
B. peri-renal abscess。
C. renal mal-function。
D. accelerated recurrent stone formation。
E. infundibulum，U-P junction or ureteral stricture。
輸尿管鏡
一、 輸尿管鏡之型式：rigid 與 flexible。
二、 適應症(indications) 1. 輸尿管結石。
2. 腫瘤之診斷與切除。
A. 診斷：
a. 靜脈腎盂攝影懷疑有輸尿管或腎盂腫瘤。
b. 單側輸尿管有不明原因之血尿。
c. 單側輸尿管尿液細胞學檢查有惡性細胞。
B. 治療 – 早期、低惡性度輸尿管與腎盂之腫瘤切除。
3. 輸尿管導管之置放 – 當有輸尿管廔管而輸尿管極度扭曲時，可利用輸 尿管鏡來放導尿管做尿液引流。
4. 輸尿管內異物取出。
三、 術前病人之評估：
1. 過去病史：
A. 患 者 有 無 做 過 骨 盆 腔 手 術 ， 如 radical prostatectomy ， radical hysterectomy 等，ureter 會與 retroperitoneum 沾粘使輸尿管鏡不易操 作。
B. 曾做過輸尿管取石術(ureterolithotomy)，可能使輸尿管結疤或狹窄不 利輸尿管鏡操作。
C. 做過膀胱輸尿管鏡吻合手術之輸尿管不易擴張。
2. X 光片之評估：
A. 靜脈腎盂攝影確定石頭之位置、大小、阻塞程度。
B. 確定結石末端輸尿管有無狹窄或極端扭曲，可於術前從輸尿管末端 注入少量顯影劑。
C. 術前需照腹部 X 光，確定結石位置有無改變。
3. 手術時病人之姿勢：
A. standard Lithotomy position – 中段與末端輸尿管結石。
B. steep reverse Trendelenberg position：在腰肌 f(psoa’s muscle)上端之輸 尿管結石，因輸尿管往後傾斜結石易往腎盂移位，可考慮採用此姿
勢。
4. 術前病人需告訴輸尿管鏡取石術可能之併發症與失敗之可能。
四、 輸尿管開口之擴張：
方式：
1. dilation with successively larger ureteral catheters。
2. passage of conical metal bougies。
3. balloon dilating catheters。
4. passage of olive-shaped metal bongies。
五、 輸尿管結石之取出：
小結石(< 5mm) – 用網子或夾子取出(basket or forceps) 大結石(>5mm) – a. ultra-sonic lithotripsy. b. E.H.L.
六、 輸尿管鏡取石術失敗之原因：
1. 輸尿管鏡無法進入輸尿管或放至結石處：
A. bladder neck obstruction 與 immobility，如前列腺肥大。
B. 結石末端輸尿管阻塞或極度扭曲。
2. 結石往近端移位。
七、 輸尿管鏡術之併發症<5%。
1. mucosal injury。
2. ureteral perforation。
3. ureteral bleeding。
4. extra-vasation。
5. stricture。
6. infection。
參、 泌尿系統外傷之處理
急診病患約 10% 合併有不等程度之泌尿系統損傷，因此對急診病人的處理除 先行穩定病情，止血，治療休克外亦應同時檢查泌尿系統有無受傷。
一、 詳細的病史詢問:
發生意外的機轉，種類，身體受傷部偉，何種凶器，鈍傷或穿剌傷。
二、 受傷部位的檢視:
上腹部，胸部下，上背部 -- 腎臟受傷，骨盤骨折，外生殖器，下腹部 -- 膀 胱或尿道受傷，槍傷，刃傷，則視入口位置而異。
三、 理學及檢臉室檢查:
腹部具反彈痛或壓痛。尿逍口有無流血，有無血尿，瘀血或血腫之部位，有 無貧血、休克。
四、
1. 例行 X 光攝影：胸部及腹部 X 光 -- 注意有無肋骨、腰椎骨、骨盆骨折，
後腹腔posa’s line 有無消失，腎臟大小，位置角度有無改變。
2. 特殊 X 光攝影：先注意尿道口有無出血情形，如有而且骨盆骨或恥骨骨 析時，或會陰部跨傷(straddle injury)情形，應懷疑膀胱破裂或尿道斷裂傷，
應先作逆行性膀胱道攝影(Retrograde.Cystourethrogram)，切勿逕行插置導 尿管。無尿道或膀胱受傷時，應於病人情況穩定下接受靜脈腎臟腎盂攝影 (I.V.P.)，以確定血尿是否源出於腎臟或輸尿管部份。當發現腎臟無法顯 影時，應接受 renal Anterigraphy，以確定腎動脈有無受傷，腎臟實質是否 撕裂。當考慮到腹腔內臟器(肝，脾)合併受傷或後腹腔血腫時可以電腻斷 層攝影掃描檢查。
§腎臟受傷(Renal trauma)
以腹部、腰部或上背部之鈍挫傷佔大部份(80-85%)，機車車禍、打架、跌倒或 激烈運動是常見之機轉。高速碰撞車禍是造成腎動脈受傷的主要原因。腰部或 上腹部之槍傷、刀傷除了合併腹腔內臟的受傷外也會造成腎臟受傷。
病理分類:
一、Minor renal trauma (85%)
-- Renal parenchyma contusion or Bruising, subcapsular hematoma, superficial cortical laceration.
二、Major renal trauma (15%)
-- Deep corticomedullary laceration may extend to collecting system.
三、Vascular injury (l%)
-- 此類病人 30%，不會發生血尿。
治療：
一、 病人情況緊急時，應先矯正出血性休克，但亦需同時評估其他相關鄰近臟 器組織損傷。
二、 一般之 minor renal injury 採取非手術之保守性療法處理，但約 15%有持續 性後腹腔出血，或腎臟血管受傷或腎臟實質壞死情形應考慮手術方法治 療。
三、 關於槍傷、刃傷或一些穿透傷，因 80%可能合併其他內臟受傷，必頇手 術探查治療。
§輸尿管受傷(Ureter trauma) 原因:
一、 大腸惡性腫瘤或婦科惡性惡性腫瘤之骨盆腔手術，因黏連或浸潤程度利害 手術時可能傷及輸尿管。
二、 對輸尿管結石之內視鏡操作時，可能引起穿孔或撕裂傷。
三、 刀傷、槍傷及其他穿剌傷亦均可能傷及輸尿管。
臨床症狀:
一、 發燒。
二、 腰痛或下腹痛。
三、 腸麻痺、噁心、嘔吐。
四、 輸尿管陰道淒管，輸尿管皮膚廔管。
五、 腎水腫等阻塞性症狀。
診斷:
一、 I.V.P.。
二、 Retrograde pyelography。
三、 Ultrasonogram 視有無 hydroureter。
治療:
一、 發生損傷時，如能及早發現，馬上治療，通常預後良好，合併症很少。受 傷發生後 10 天至 14 天之內發現而且無發炎，化膿，及其他併發症時可立 即手術治療。
二、 發現時間較久時，或合併其他併發症時，應先作 percutaneous Nephrostomy 引流，防止腎機能變壞，俟日後再作進一步手術治療。
對於 1. low ureter injury 可施行:
A. reimplantation into Urinary Bladder, With posa’s hitch procedure.
B. primary ureteroureteiostomy.
C. Boari Bladder flap.
D. Transureteroureterostomy.
2. upper ureter injury:
A. primary ureteroureterostomy.
B. Auto transplantation of Kidney.
C. Bowel replacement of Ureter.
3. Mid ureter injury:
A. primary ureteroureterostomy.
B. transureteroureterostomy..
§膀胱受傷(Bladder trauma) 原因:
一、 約 15%的骨盆骨折之病人，合併有膀胱或尿道受傷。
二、 婦科或骨盆腔手術，或疝氣修補手術。
三、 經尿道之內視鏡手術。
1. 腹腔外膀胱破裂(Extraperitoneal bladder 即 perforation)：發生於膀胱未滿脹 時的骨盆骨折或下腹部鈍傷可能引起骨盆腔深部膿瘍發生。
2. 腹腔內膀胱破裂(Intraperitoneal bladder perforation)：相同之外傷發生於膀 胱滿脹時，會引起腹膜炎。
診斷: A.X 光攝影
-- plain abdominal film.
-- Cystography 包括 filling film 及 drainage film.
B.一般而言，膀胱鏡沒有幫助，因為出血利害或血塊 使檢查無法進行。
治療: A.緊急情況時，先處理出血，矯正休克，穩定病情。
B.內科支持性療法 -- 對比較輕微的受傷，導尿管置放後，觀察。
C.手術治療 -- 剖腹探查，修補膀胱破洞，需小心檢視
腹腔內有無其他合併受傷，視後需置放 extraperitoneal suprapubic cystostomy 至少 10 天，俟傷口癒合，情況穩定後再行拔除。
§尿道受傷(Urethral trauma)
常見於男性骨盆骨骨折或跨傷(straddle injury)或尿道狹窄而接受不當之 instrumentation 引起。
程度:
一、contused 二、lacerated 三、transected
位置可為:
一、posterior urethra -- 包括 prostatic 及 membranous part.
二、Anterior urethra -- 包括 bulbous 及 Pendulous Part.
(A) 後尿道受傷(posterior urethra trauma)，常見於 membranous urethra 穿過 urogenital diaphragm 處而此處為尿道外括約肌部位，因其前端固定於恥骨 下緣，骨盆骨折時膜狀尿道會從攝護腺膜狀尿道之交換處斷裂，引起攝護 腺周圍及膀胱周圍的血腫，使攝護腺與膀胱向上移位。
臨床表徵:
一、骨盆骨骨折。
二、下腹痛，無法解小便。
三、尿道口流血 -- 此時切不可插置導尿管而應立即作
urethrography，以避免使尿道斷裂傷由部份撕裂演變成完全斷裂，同時造 成骨盆底血腫發生利害之發炎情形。
四、會陰部或恥骨部份有挫傷之跡象。
五、合併出血性貧血或休克。
治療:
一、緊急時先處理出血性休克，穩定病情。
二、Delay urethral reconstruction -- 先以 suprapubic cystostomy 置放，等 3 個月 之後血腫溶解消失之後，向上移位之攝護腺復位後再作尿道重整手術。
三、Immediate urethral realignment -- interlocking procedure.,但
因出血利害，有時會危及病情，及日後可能引起陽萎，尿失禁及尿道狹窄 之併發症因此目前除非有合併腹腔內臟器受傷，需剖腹探查修補時順便施 行外，大多數人均不採取此法。
(B) 前尿道受傷(Anterior urethral trauma).
原因：Straddle injury, iatrogenic 或 self instrumentation 造成。
臨床表徵:
a. 跌倒，或跨騎受傷之病史。
b. 尿道接受 instrumentation 的病史。
c. 尿道口出血，會陰部或陰莖血腫，疼痛時切勿逕行置放導尿管，應 作 Urethrogram，必要時以 suprapubic cystostomy 作尿液分流。
治療：
a. urethral contusion -- 病人通常可自解小便，且無繼續出血之情形，無 需進一步治療，但如繼續出血時，需置放導尿管。
b. urethral laceration -- 此時不可作內視鏡檢查，先作 suprapubic cystostomy 引流。
c. urethral laceration with extensive urinary extravasation.
因常會有發炎或化膿之情形，需以抗生素預防或冶療之，以及 suprapubic cystostomy 引流，俟 3 月後再作進一步處置。
§陰莖受傷(penile trauma)
性交時可能會造成 tunica Albuginea 斷裂，形成陰莖血腫，需手術治療修補之。
此外，陰莖根部如有 obstructing ring 時可能造成陰莖壞死及尿道受傷。
機械性傷害有時會造成陰莖皮膚之撕裂及缺損，需立即手術治療或補皮手術。
有一點需注意就是大部份之陰莖受傷常會合併尿道受傷，所以記得要作 urethrography 檢查。
§陰囊受傷(scrotal trauma)
superficial laceration -- 修補縫合即可。
鈍挫傷引起之瘀血或血腫，需注意有無合併睪九破裂，如果機械性傷害引起陰 囊皮膚之缺失時應馬上手術治療，可先將裸露之睪九及精索移位到大腿內側之 皮下，容日後再以皮瓣作重建手術。
§睪丸受傷(testis trauma)
睪丸鈍挫傷時會引起很利害之疼痛及噁心，嘔吐和下腹痛，有時會形成血腫，
此時可藉助超音波掃描，幫忙診斷睪丸外或內之血腫，有無睪丸破裂，如有的 話，應立即手術治療之。
肆、 攝護腺肥大(Benign Nodular Hyperplasia of Prostate) 診斷:
初步評估(Initial Evaluation)
一、 病史詢問: focusing on the urinary tract, previous surgical procedure, and general health issues include a history of hematuria, UTI, DM, nervous system disease(e.g., Parkinson’s disease or stroke), urethral stricture disease, urinary retension, and aggravation of symptoms by cold or sinus medication.
二、 理學檢查: digital rectal examination and a focused neurologic examination must be done to detect prostate or rectal malignancy, to evaluate anal sphincter tone, and to rule out any neurologic problems.
三、 尿液分析: to rule out urinary tract infection and hematuria.
四、 腎功能評估: serum creatinine should be performed in all patients with symptoms of prostatism to exclude renal insufficiency due to the presence of obstructive uropathy. Elevated serum creatinine is an indication for imaging studies(ultrasound) to evaluate the upper urinary tract.
五、 攝護腺抗原檢查: PSA and DRE to detect prostate cancer 症狀評估(Symptom Assessment)
IPSS(AUA Symptom Index): for the baseline assessment of symptom severity in each patient presenting with prostatism, assess the response to therapy, and detect symptom progression in those men managed by watchful waiting.
Mild 0-7, moderate 8-19, severe 20-35.(參考附表) 其他輔助檢查(Additional Diagnostic Tests)
一、 Uroflowmetry, postvoid residual urine, pressure-flow studies
二、 膀胱鏡檢查: Urethrocystoscopy is recommended for men with prostatism who have a history of microscopic or gross hematuria, urethral stricture disease, bladder cancer, or prior lower urinary tract surgery(e.g., TURP).
三、 影 像 學 檢 查 (IVU or Sono): hematuria, urinary tract infection, renal insufficiency(ultrasound recommended), a history of urolithiasis, or a history of urinary tract surgery.
藥物治療
一、 Alpha-Blockers: based on the hypothesis that clinical BPH is, in part, dut to prostate smooth muscle-mediated bladder outlet obstruction.
Nonselective—phenoxybenzamine 10mg bid Alpha 1—prazosin 2mg bid
Long-Acting Alpha 1—terazosin 5 or 10mg qd doxazosin 4 or 8mg qd Subtype(Alpha 1a) Selective—tamsulosin 0.4 or 0.8mg qd
副作用: dizziness, fatigue, headache, somnolence, hypotension, nausea, flulike syndrome, asthenia and syncope.
二、 Androgen Suppression: based on the observation that the embryonic development of the prostate is dependent on the androgen dihydrotestosterone
藥物 Finasteride(Proscar) 5mg qd—a selective competitive inhibitor of isozyme type II of 5α-reductase. 注意用藥 3 至 6 個月後 serum PSA 值約降 40%至 50%.
手術之適應症補充(AHCPR Guideline):
1. Refractory urinary retension(failing at least one attempt of catheter removal) 2. Recurrent urinary tract infection
3. Recurrent gross hematuria 4. Bladder stones
5. Renal insufficiency 6. Large bladder diverticula
伍、 泌尿道結石之診治
尿路結石是一種古老的疾病，遠在古埃及的木乃伊身上就曾發現膀胱結石。
西元前 1500 年，在北美的印地安人身上也發現過磷酸鈣膀胱結石：先哲 Hippocrate 時代治療尿路結石的任務掉在 Lithotomist 所謂治療膀胱結石的專門醫師身上，但 由於他們對人體解剖學並不熟悉，所以治療效果非常差。歷經 Celsus，Franco，
Dupuytren 等外科先輩之努力，一些新穎，安全的傳統手術都陸續地解決了尿路結 石的問題。尤其是近十年來，由 Frenstorm，Marberger 等人發展內視鏡泌尿道學 (endourology), Chaussy 在體外震波碎石術(Extracorporeal shockwave lithotripsy, ESWL)之詴驗成功，更是大放異彩，使尿路結石的手術治療，由傳統的大刀口手 術法進步到小刀口的手術法，甚至無傷口的 ESWL。
遺憾的是雖然外科手術進步非凡，但是尿石發生的確實原因，仍然不明，所 以術後的保養和預防，很難進行，無怪乎尿石病人之復發率特別高。在門診，我 們常可發現患者左右腰部各一刀疤，還很痛苦的告訢我們說他(她)又有了。這真叫 泌尿科醫師汗顏。幸虧近年來 Finlayson, Coe 和 Pak 在尿路形成的物理、化學理論 上有重大突破，而引導出相當有效的尿路結石藥物治療。在他們長期的追蹤觀察，
經過他們的分類，再給予特定，單一的藥物，這些病人之尿石復發率降到非常低，
再手術率也幾乎等於零。
以下，我們將摘要地把尿路結石之成因，症狀，手術適應症，手術方法，尿 石成份分析，新陳代謝評估及藥物療法，作一簡單介紹，希望對新進住院醫師，
實習醫師及其他醫護人員和患者有所幫忙，讓我們共同合作來克服這個難纏的痼 疾。
一、Pathogenesis of urinary calculi:
尿路結石的致石機轉，理論很多，但以下面兩種說法最為大家所接受：
1. Urinary supersaturation:
尿中的結石成份過飽和。例如鈣離子、草酸離子或尿酸離子之濃度過高，
即容易沉澱造成結石。當然尿中之 PH 值影響很大，例如尿酸在 PH 值低時 (PH<5.5)很容易凝集，而感染性結石(struvite)則在 PH 值高時(PH>7.0)，其 溶解度非常低。
2. Stone formation inhibitor:
這些抑制物包括有機物與無機物，例如 glycopeptide, chondroitin sulfate, glycosaminoglycans (GAGS), citrate, pyrophosphate, magnesium 等。
這些 inhibitors 可以使尿石的凝集和生長減緩，所以當 inhibitors 減少時，
尿石非常容易形成。
簡單的以方程式表示如下:
Saturation factor
Urine at equilibrium --- Cystal formation
Absence of inhibitors 二、Symptoms/signs and Diagnosis
絕大部份的尿路結石所造成的尿路阻塞都是不完全的。所以泌尿科醫師 要確定病人的阻塞是急性或慢性，持續性或間歇性，完全或不完全。同時要 判定其阻塞的位置，有無腎功能缺損和有無尿路惑染。
尿路結石之臨床症狀大致如下:
l. 腎絞痛(renal colic) 2. 血尿(Hematuria) 3. 發燒(Fever)
4. 尿毒(uremia) -- 兩側性尿石併阻塞，單一腎臟併結石或感染性結石(struvite) 若不治療，最後都會造成腎功能不全或尿毒。
診斷方法:
l. 尿液常規檢查(urinalysis)
可以發現血尿，大都只是 microscopic hematuria，少數是 gross hematuria；
膿尿和一些尿石的結晶。
2. 尿路攝影(Intravenous pyelogram, IVP.)
這是診斷尿路結石最有價值的檢查，可以知道尿石位置、大小、形狀、
阻塞的程度。
3. 超音波 – 非侵犯性，可診斷腎水腫的程度，檢視腎皮質，發現 Radiolucent stone，更可用於不適合 IVP 之病患(Cr > 2.0)。
4. 其它診斷方法:
諸如逆行性腎盂造影術(retrograde pyelogram)，甚至電腻斷層，都能提供 更多的資料供泌尿科醫師參考。
三、尿路結石的手術適應症:
發現有尿路結石，醫師和病人需馬上考慮如何治療。過去，由於手術的技術 較不進步，而且尿石之復發率很高，所以手術之適應症訂得比較嚴謹，例如:
1. 尿路阻塞(obstruction) 2. 尿路感染(infection) 3. 大量血尿(hematuria)
4. 不可控制的腎絞痛(intractable colic pain)
但目前，因各方面較進步，如果能用 non-invasive 或 less invasive procedure 治療，取出尿石，作尿石分析，再給病人藥物治療，並不失為一種早期診斷，
早期治療的好方法。至於如何來取捨，還是需由泌尿科醫師來診斷、決定。
四、手術方法:
目前之尿石手術治療，是以 endourology 和 ESWL 為主，傳統性手術為輔。
大致上的原則如下圖：
PCNL ESWL Ureterorenoscopy Laparoscope
Pelvic brim
Ureterorenoscopy ESWL
1. 在 pelvic brim 以上的輸尿管結石或腎結石，首先考慮 ESWL。如果沒有 ESWL 的設備，或結石>2cm 可用 PCNL(percutaneous nephrolithotomy)或 ureterorenoscopy來取石。
2. 中上段輸尿管結石如果結石太大，ESWL 或 URS 失敗，可以考慮腹腔鏡。
3. 在 pelvic brim 以下的輸尿管結石，用 ureterorenoscopy 來取石，輔以各種 碎石器械(Sono, Laser, lithoclast, EHL)及 forcep, basket 等將碎石取出。用 ESWL 定位較難，病人頇將 prone position。
4. 膀胱和尿道結石。使用膀胱尿道鏡，用碎石鉗或電震波碎石器將尿石擊碎 後，再將之沖出。結石太大、太硬或合併 large prostate，可考慮 open (suprapubic)。
以上述 endourology 和 ESWL 的方法，大約可解決 90~95%的各種尿石。
但仍有 5~10%的患者仍需借助傳統性的手術方法。尤其是(a)鹿角型腎結石，
(b)輸尿管狹窄併結石，(c)輸尿管鏡手術不能成功的病例(輸尿管粘連或先天異 常等)，(d)堅硬，難擊碎的尿石(e)操作 PCNL, ureteroscopy 和 ESWL 時發生併 發症時(大量出血或集尿系統破損)。
特別是鹿角型腎結石，幾乎所有的進步方法都無法很完美的取出所有結 石，最好的治療還是無萎縮性腎截石術(Anatrophic nephrolithotomy)，這種方 法是分離後腎動脈，確定腎臟無血管區，然後在局部低溫(使用冰花)的情況 下，自腎臟無血管區切開腎實質，迅速取出尿石，最後將大、小腎盞有狹窄 部位重建後，縫回腎實質。所有的步驟需在 30~60 分鐘內完成。這種方法是 最徹底，腎實質傷害最小的手術，但其併發症亦多，所以宜由資深泌尿科醫 師來執行。
五、尿石成份分析:
成功的外科手術，只是完美的尿石治療的第一步。因為尿石的復發率極高，
不加上飲食及藥物治療，常在幾年內又有大結石，又需第二次的手術。所以 所有經由手術或自行排出的尿石都應作尿石成份分析。
由尿石成份分析檢查，可將所有尿石分類成:
l. 鈣尿石(Calcium stone)，約 75%。
2. 感染性尿石(Struvite stone)，磷酸胺鎂結石，約 15%。
3. 尿酸鹽尿石(Uric acid stone)，約 10%。
4. Cystine 尿石，小於 l%。
對於尿酸鹽和 Cystine 尿石，其生理致石機轉已為大家所了解，可以給予藥物 治療;而感染性尿石患者，也可接受抗生素治療。但對於佔大多數的鈣尿石患 者，其生理致石原因仍有待進一步新陳代謝評估才能確定。
六、新陳代謝評估(Metabolic evaluation)(repeat, active stone former)
尿石患者抽血驗 SMA-12, PTH, T3, T4，並在普通飲食及低鈣、低鈉限制飲食 之情況下收集二次 24 小時尿液檢驗尿中之 PH 值，Ca, P, uric acid, oxalate, citrate Na, K 及其總尿量。由這些結石，可做新陳代謝評估，依 Dr. Pak 的分 類而確定其尿石之原因，包括:
l. 吸收性高尿鈣症(Absorptive hypercalciuria, type I, type II) 2. 腎性高尿鈣症(Renal hypercalciuria)
3. 原發性副甲狀腺亢進症(Primary hyperparathyroidism) 4. 高尿酸鈣尿石症(Hyperuricosuric calcium urolithiasis) 5. 腸性高草酸症(Enteric hyperoxaluria)
6. 尿酸尿石(Uric acid lithiasis) 7. 感染性尿石症(Infection lithiasis) 8. 腎小管酸血症(Renal tubular acidosis) 9. 非代謝性異常類(No metabolic abnormality) 10.未分類高尿鈣症(Unclassified hypercalciuria) 其中各種成因的比率大致如表一。
表一、尿路結石症之成因分類
成因 病例數 百分比(%)
吸收性高尿鈣症
Type I 59 24.5
Type II 72 29.8
腎性高尿鈣症 20 8.3
原發性副甲狀腺亢進症 14 5.8
高尿酸鈣尿石症 21 8.7
腸性高草酸症 5 2.1
尿酸尿石症 5 2.1
感染性尿石症 5 2.1
腎小管酸血症 1 0.4
非代謝異常類 26 10.8
未分類高尿鈣症 13 5.4
合計 241 100.0
七、尿石的藥物治療
依據新陳代謝評估的結果，可以給予病人單一、高度選擇性的藥物治療，當 然鼓勵病人多喝開水(每天尿量至少 2 公升)和避免食用含豐富鈣質、草酸及 尿酸的食物是最基本的原則，絕對不可忽視。
以下摘要出各種尿石之藥物治療:
l. 吸收性高尿鈣症
Type I: thiazide 或 sodium cellulose phosphate.
Type II: 飲食治療。
2. 腎性高尿鈣症 Thiazide。
3. 原發性副甲狀腺亢進症: 副甲狀腺切除手術。
4. 高尿酸鈣尿石症: Allopurinol, potassium citrate.
5. 腸性高草酸症: B6, Mg-gluconate 和飲食治療。
6. 尿酸尿石症: Allopurinol 和 Potassium citrate.
7. 感染性尿石症: 抗生素和 Acetahydromatic acid (AHA).
8. 腎小管酸血症: Potassium citrate.
9. 非代謝異常類: 矯正腹瀉，喝水少之可能原因。
由於國內外學者及研究人員之努力，尿路結石之治療已漸趨完美，其結果也 非常良好。當然在實行方面一定還有很多困難，期待醫療人員及尿石患者，
大家能戮力以赴，使這個與人類歷史同樣久遠的疾病不再困擾我們。
陸、 性功能失調之診治
男性性功能是一套十分精密的有機體，藉著內分泌、神經、動靜脈及心理等 因素的協調，來達成它的基本任務 -- 陰莖勃起、流精、射精及性高潮。
ED: consistent inability to achieve an erection, or to maintain an erection long enough to successfully complete sexual intercourse.
一、病史詢問:
l. 確定有無陽萎。
2. 鑑別精神性或器質性陽萎。
3. 有無可致陽萎之疾病: 心肌梗塞、腻血管意外、糖尿病、高血壓、週邊 血管疾病或商脂血症、抽煙、喝酒。
4. 有無可致陽萎之手術或外傷。
5. 有無可致陽萎之藥物、如降血壓或抗憂鬱藥物。
二、理學檢查:
l. 總體外觀: 神智、營養狀態。
2. 內分泌系統: 第二性徵發育狀況，有無男性女乳化。
3. 血管系統: 血壓檢查有無足背動脈、膕動脈之脈動，並檢查頸動脈、腹主 動脈或股動脈有無異常。
4. 神經系統: 有系統地檢查全身感覺、運動與小腻功能特別注意會陰部及肛 門周圍之感覺，球海綿體反射及肛門反射。對糖尿病的病人檢查有無週邊 神經病變。
5. 外生殖器官，以及前列腺指診。
三、實驗數據檢查:
l. 一般 CBC, SMA, BS 血液檢查 2. 尿液檢查 3. FSH 4. LH 5. Prolactin 6. T3 7. T4 8. Testosterone 9. PSA 10. Fasting lipid profile
四、特別檢查:
l. 夜間陰莖膨脹檢查(NPT): 可用以區分器官性及心理性陽萎。用這種方法 可量度陰莖周徑之變化，勃起之次數及勃起時間之長短，特別是陰莖周徑
變化至最大及其維持時間之長短，更為重要。通常作三次。
2. 視覺性刺激檢查(VSS): 與 NPT 同樣器械，輔以影片與圖片性刺激。
3. 陰莖動脈壓: 陰莖動脈壓除以手臂壓即 penilebrachial index (PBI)。正常男 性的陰莖動脈接近手臂壓力，因而 PBI 大約是 l.0。若 PBI 是 0.6 或是低於 此值，就得考慮有血管性陽萎症的可能，而大於 0.75 則考慮是正常的。
4. 陰莖的杜卜勒複合超音波檢查 : 自藥物(PGE1)注射前後測動脈(arterial insufficiency)血流(RI)(間接測量有無 venous leak)，檢查者頇有熟悉技術。
5. 罌粟鹼或前列腺素注射陰莖海綿體詴驗。
6. 動脈攝影檢查: 陽萎病人經非侵襲性檢查，診斷為血管病變，在接受血管 手術前，血管攝影可提供一個解剖的診斷，以敬為手術之方針。
7. 陰莖海綿體攝影，亦可配合罌粟鹼或前列腺素陰莖海綿體注射，以得到勃 起時的解剖變化。可檢查 venous leak 之部位(Dorsal vein, crural vein, cavernosal vein)。
五、治療:
1. 性治療: 診斷為精神性陽萎時，性治療可幫助其重建信心; 當有精神性及 器官性陽萎併存時，性治療可改善其症狀。
2. 藥物治療:
A. 口服 – viagra, Levitra, Cilalis (PDE5 inhibitor)。
B. 海棉體內注射 – PGE1。
C. 尿道內置放 – PGE1。
B. 男性荷爾蒙 – 維持第二性徵及性慾，對勃起功能幫助不大，且會刺 激 prostate growth，引起 prostate ca.故頇小心。
3. 陰莖血管重建術或靜脈結紮。
4. 人工陰莖植入: 器官性陽萎且無法治療者可考慮人工陰莖植入。可分為半 硬體式及充水式。
A. 半硬體式人工陰莖的優點:
a. 病人可立即開始性交，陰莖部份不必事先有任何操作。
b. 手術簡單。
c. 便宜。
d. 很少發生故障。
e. 手術併發症少。
B. 半硬體式人工陰莖的缺點:
a. 陰莖經常在勃起狀，日常生活中不易隱藏。
b. 如因需要必頇倣膀胱鏡檢查時較為困難。
C. 充水式人工陰莖的優點:
a. 不充水時，病人的陰莖是軟的，不影響日常生活。
b. 充水後陰莖勃起的硬度甚強，甚至於比他以前正常還好。
c. 如因需要，仍可做膀胱鏡檢查。
D. 充水式人工陰莖的缺點:
a. 性交前必頇充水使陰莖勃起。
b. 手術較為複雜。
c. 費用較高。
d. 故障率較高。
5. 真空吸引器(Vacuum constriction device)：利用吸引器之負壓造成海棉充 血、膨脹，再用 constricting ring 放在 penile base 維持勃起。
優點 – 較不具侵襲性、可重複使用、可逆性(不同於人工陰莖)。
缺點 – 頇器械、操作麻煩、局部疼痛。
柒、 泌尿道腫瘤的診治工作
Prostate Cancer -- guidlines
The incidence of prostate cancer is dramatically increased in recent 10 years and become a most common urologic cancer. However the major problems still exist in this country as: 1. the mortality rate is also increasing. 2. majority of new cases are detected in late stage and 3. no curable treatment modality for advanced or metastatic disease. In most cases, death from prostate cancer results from distant metastatic disease. Increase of the clinical stage of local diseases will increase the incidence of metastasis. Therefore, early control of local disease before metastatic event happen is essential for possibility of cure.
Prostate cancer may cause symptoms of urinary obstruction, hematuria and bone pain that all are the manifestations of late stage disease. The early prostate cancer is usually asymptomatics. This early stage disease can be diagnosed incidentally by TURP due to prostatism and suspected by abnormal digital rectal examination or elevation of serum PSA. In addition of recent PSA tests the use of transrectal ultrasound (TRUS) guide systemic biopsy of prostate has much improved diagnostic sensitivity of prostate cancer.
Diagnostic problems: the dilemma between screening and case finding 1. Screening or nonscreening?
balance between benefit and cost
2. Awareness of Family practitioners and people.
for early detection program
3. Methodology to achieve early detection.
a. Annual serum PSA and DRE for men over the age of 50.
b. Do TRUS and systemic biopsy of prostate, if he has abnormal serum PSA c. level (3.5 to 5.5 ng/ml, according to age) or abnormal DRE.
Digital rectal examination (DRE) --
DRE for diagnosis and staging(From Whitmore's OSCC Committee): preperation of a two dimensional diagram indicating the estimated: actual size in centimetes and shape of the prostate, the size, shape, location, and degree of induration:
///// \\\\\
/////
\\\\\
/////
/////
first degree or equivocal one crosshatch second degree or moderate, two crosshatch third degree or stony hard 3 crosshatch
The diagram should include a transverse sectional view (s), at specified level (s) of the prostate, to characterize any symmetry of the rectal surface of gland.
eg:
4.5x4 cm, firm on Rt lobe with hard area 2.0x1.6cm, SV±
A definitive statement regarding the examiners opinion of stage should be made. Be specific ie. stage B2 (T2b) , or stage C (T3).
In addition, the anal sphincter function and any lesions of rectal wall should be also described.
The PSA test --
PSA is an organ specific serine protease produced by prostate epithelial cells of prostate acini and ducts. It is expressed in both benign and malignant cells of the prostate gland. Under normal physiologic conditions, PSA is secreted into the lumen of prostate duct system, and only a small proportion is absorted into the blood stream.
Although PSA is less expressed in prostate cancer cells than in benign acinar epithelium.
However the cancer cells leaks much more amount of PSA molecules into bloodstream that cause higher serum level of PSA in patients with prostate cancer. PSA has been introduced in this country for clinical use since 1990. It has been used as a marker to monitor the response of therapy, to measure the tumor relapse after therapy and also to be a marker for early detection (case finding or screening).
Indications for PSA test:
1. Men over the age of 50 years ( 40 years for high risk family) 2. Men who request PSA testing.
3. Prostate cancer patients on treatment or watch waiting.
4. Before prescribing drugs for BPH.
5. Following TURP or open prostatectomy on annual basis.
PSA test is not appropriate under the following conditions:
1. During the episodes of urinary infection.
2. During the episodes of urine retention.
3. Shortly after prostate biopsy or prostate surgery.
4. During the episodes of prostatitis.
5. Immediately after prostate massage.
6. Within 72 hr after ejaculation.
Transrectal Ultrasound for Diagnosis of Prostate Cancer --
Ttransrectal ultrasound (TRUS) of prostate has become the important diagnostic tool for prostate disease after recently developed 7.5 MH probe and coupled with biplane devices. The abilities of TRUS are:
1. To see the 3-dimentional texture of prostate
2. To visualize hypoechoic and other abnormal zones of prostate 3. To measure the size or abnormal lesion of prostate
4. To perform an accurate systemic biopsy of prostate 5. To evaluate pelvic recurrence following prostatectomy
The general accepted indications for TRUS of the prostate in patients with known or suspected prostate cancer are:
1. Evaluation of the patient with abnormal digital rectal examination (DRE) 2. Evaluation of the patient with abnormal PSA test
3. Guidance for directed sonographic biopsy 4. Monitoring response following treatment for prostate cancer 5. Staging of known prostate cancer (controversy)
Preperation of TRUS examination:
1. Antibiotics -- Bactrium or quinolone on the morning or 2hr before examination, and three days after.
2. Empty rectum -- fleet enema on the morning of examination if necessary.
3. Half full bladder.
Methods of TRUS examination:
1. The probe is covered with a condom and filled with ultrasound gel (without gas).
2. Left lateral decubitus position with flexible knee and hips.
3. With transverse plane, both seminal vesicles and prostate from base to apex are visualized, and record abnormal echo area.
4. Measure the size of prostate and abnormal lesion when it is presented.
The findings of TRUS in patients with abnormal DRE could be: hypoechoie lesion due to cancer, BPH, cyst or inflammatory lesion prostate calcification or stone normal TRUS. TRUS guide biopsy in indicated, if prostate cancer is still suspected.
Before performing TRUS and biopsy, obtaining informed consents is important.
Although the proceduce is generally well tolerated, possible complications of hematuria, blood in the stool, hemospermia and fever should be discussed with the patients.
Methods of TRUS guide biopsy:
1. Biopsies should be performed on any suspicious lesion on TRUS, as well as any palpable abnormality on DRE.
2. Systemic biopsies include cores with tissue from the peripheral zone and the transitional zone, as well as from the base, middle and apex of the prostate bilaterally.
Limtation of TRUS in prostate cancer detection
1. Most hypoechoic lesions found on TRUS are not cancer.
2. Around 50% of nonpalpable cancer more than one cm are not visnalized.
3. 25 to 30% of cancers would be missed if only hypoechoic area is biopsied.
Rebiopsy policy:
1. Suspicious pathological findings: (Atypical hyperplasia or high grade PIN) 2. Persistent high level of PSA or any PSA ≧10 ng/ml
3. Increased PSA velocity (> 0.75 ng/ml/yr) even PSA lever < 4 ng/ml 4. Considered 3rd
set biopsy if PSA level still ≧10 ng/ml, or free PSA percentage
< 25 or 30%
Staging Work up:
No further staging work up for clinical asymptomatic stage T1 or T2 with PSA level less than 10 and low Gleason score and CT scan
Bone scan:
1. For clinical stage T1 or T2 with PSA level over 10 or high Gleason score or symptomatics
2. Clinical stage T3a, T3b or T4
目前最為大家接受之 Staging system 為 1992 AJCC 與 UICC 版本及 1997 AJCC 版本 TNM system。
Staging 目標：(1) 評估預後、(2)引導治療方向
T1 Clinically inapparent tumor not palpable or visible by imaging
T1a Tumor incidental histologic finding in 5% or less of tissue resected
T1b Tumor incidental histologic finding in more than 5% of tissue resected T1c Tumor identified by needle biopsy
(because of elevated PSA)
T2 Tumor confined within the prostate Tumor confined within the prostate T2a Tumor involves half of a lobe or less Tumor involves one lobe
T2b Tumor involves more than half of a lobe, but not both lobes
Tumor involves both lobes T2c Tumor involves both lobes
T3 Tumor extends through the prostate capsule
Tumor extends through the prostate capsule T3a Unilateral extracapsular extension Extracapsular extension (unilateral or
bilateral)
T3b Bilateral extracapsular extension Tumor invades seminal vesicle(s) T3c Tumor invades seminal vesicle(s)
T4 Tumor is fixed or invades adjacent
structures other than the seminal vesicles
Tumor is fixed or invades adjacent structures other than the seminal vesicles: bladder neck, external sphincter, rectum, levator muscles, and/or pelvic wall
T4a Tumor invades bladder neck, external sphincter, rectum
T4b Tumor invades levator muscle or pelvic wall
Regional lymph node(N)
N0 No regional lymph node metastasis
N1 Metastasis in a single regional lymph node≦2cm in greatest diameter
取消 N1, N2, N3 之分 N2 Metastasis in a single regional lymph node 2～5cm
or multiple regional lymph node≦5cm N3 Metastasis in a regional lymph node ≧ 5cm Distant metastases (M)
M0 no distant metastasis
M1a involvement of nonregional lymph node M1b involvement of bone(s)
M1c involvement of other distant site
Histologic grading (註) 相當於 Gleason grade
G1 well differentiated 2-4
G2 moderately differentiated 5-7
G3-4 poorly differentiated 8-10
1992 AJCC 與 UICC 版本 1997 AJCC 修正版本
Stage 0 T1a N0 M0 G1 Stage I T1a N0 M0 G1 Stage I T1a N0 M0 G2,3-4 Stsge II T1a N0 M0 G2,3-4
T1b N0 M0 any G T1b N0 M0 any G
T1c N0 M0 any G T1c N0 M0 any G
Stsge II T2 N0 M0 any G T2 N0 M0 any G
Stage III T3 N0 M0 any G Stage III T3 N0 M0 any G Stage IV T4 N0 M0 any G Stage IV T4 N0 M0 any G
Prediction of risk of recurrence according to clinical stage, Gleason score and PSA level
Stage Gleason score PSA level Risk of recurrence
T1a, T1b 2-6 <10 Low
T1c, T2a 10-20 Intermediate
>20 High
7 ≦20 Intermediate
>20 High
8-10 Any High
T2b 2-7 ≦20 Intermediate
>20 High
8-10 Any High
T3a Any Any High
T3b, T4 Any Any High
Treatment options – guidelines
Stage Recurrence Life expectancy Initial therapy Adjuvant therapy Risk (years)
Any T (1-4) Low less than 10 Observation
N0 or Nx 10-20 Observation
M0 or Mx Radical prostatectomy 1.Observation
Radiation 2.onsider adiation more than 20 Radical prostatectomy formen who had
Radiation RRP with cancer Intermediate less than 10 Observation remaining
Radiation or
Radical prostatectomy consider ormon 10 or more Radiation therapy for men
Radical prostatectomy who had RRP High less than 5 Observation with spread of
Hormonal therapy cancer to lymph 5 or more Hormonal therapy + radiation nodes
Radiation
Radical prostatectomy
Very high Hormonal therapy
Hormonal therapy + radiation
Stage Treatment
Any TN1 Observation or Follow up
Hormonal therapy or Hormonal + Radiation
Any T Any N. M1 Hormonal therapy
The application of free PSA --
Age ≧ 50 years
or Age ≧ 40 years of positive family history
↓
Annual DRE + PSA
↓
↓ ↓ ↓
DRE negative DRE negative DRE positive or
PSA < 4.0 ng/ml PSA 4.0-10.0 ng/ml PSA > 10.0 ng/ml
∣ ↓ ∣
∣ % free PSA ∣
∣ determination ∣
∣ ∣ ∣
∣ ∣
∣ ↓ ↓ ∣
∣ % free PSA % free PSA ∣
∣ within normal range ≦ 0.25 ∣
∣ ／ ＼ ∣
∣ ／ ＼ ∣
↓ ↙ ↘ ↓
Annual evaluation TRUS-guide biopsy
and PSA velocity
膀胱癌 (Carcinoma of bladder)
一、 History:
1. Family history of cancer.
2. Local symptoms; Hematuria, dysuria, frequency.
3. Other symptoms: Flank pain, bone pain, sciatica, peripheral edema, weight loss.
4. Carefully record nature and date and pathology finding relative to all previous treatments.
二、 Past and social history:
1. Occupation related Carcinogen exposure, time, durations.
2. Smoking habit: Amount and duration.
3. Faimily factors: Parents occuption, or special prefer food intake.
4. Analgesico or herb drugs medication (Dose and duration) 三、 Physical examination:
Palpation of neck, abdomen, groins, urethra and pelvic examination (rectal in males;
rectal and pelvic examination in females.) 四、 Special laboratory studies:
Urine cytology, initially and immediately post treatment and at appropriate intervals during follow up.
五、 Tumor spreading:
1. Regional Lymph Nodes. The regional lymph nodes are the nodes of the true pelvis, which essentially are the pelvic nodes below the bifurcation of the common iliac arteries.
The significance of regional lymph node metastasis in stasins bladder cancer lies in the number and size and not in whether metastasis is unilateral or contralateral.
Regional nodes include:
Hypogastric Obturator
Iliac (internal, external, NOS) Perivesical
Pelvic, NOS
Sacral (lateral, sacral promontory [Gerota's]) Presacral
The common iliac nodes are considered sites of distant metastasis and should be coded as Ml.
2. Metastatic Sites. Distant spread to lymph nodes, lung, bone, and liver is most common.
六、 Clinical Staging:
Primary tumor assessment includes bimanual examination under anesthesia before and after endoscopic surgery (biopsy or transurethral resection) and histologic verification of the presence or absence of tumor when indicated. Bimanual examination following endoscopic surgery is an indicator of clinical stage. The
finding of bladder wall thickening, a mobile mass, or a fixed mass suggests the presence ofT3a, T3b, and T4b disease, respectively. Add "m" for multiple tumors.
Add "is" to anv T to indicate associated carcinoma in situ.
Appropriate imaging techniques for lymph node evaluation should be used. When indicated, evaluation for distant metastases includes imaging of the chest, biochemical studies, and isotopic studies to detect common metastatic sites.
Computed tomography or other modalities may subsequently be used to supply information concerning minimal requirements for staging. The primary tumor may be superficial or invasive and can be partially or totally resected with sufficient tissue from the tumor base for evaluation of full depth of tumor invasion. Visually adjacent cystoscopically normal mucosa should be considered for biopsy; urinary cytology and pyelography are important.
七、 Pathologic Staging:
Microscopic examination and confirmation of extent is required. Total cystectomy and lymph node dissection generally are required for this staging. Laterality does not affect the N classification.
DEFINITION OF TNM 1. Primary Tumor (T)
TX Primary tumor cannot be assessed T0 No evidence of primary tumor Tis Carcinoma in situ: "flat tumor"
Tl Tumor invades subepithelial connective tissue T2 Tumor invades muscle
T2a Tumor invades superficial muscle (inner half) T2b Tumor invades deep muscle (outer half) T3 Tumor invades perivesical tissue
T3a microscopically
T3b macroscopically (extravesical mass)
T4 Tumor invades any of the following: prostate, uterus, vagina, pelvic wall, abdominal wall
T4a Tumor invades prostate, uterus, vagina T4b Tumor invades pelvic wall, abdominal wall 2. Regional Lymph Nodes (N)
Regional lymph nodes are those within the true pelvis; all others are distant lymph nodes. NX Regional lymph nodes cannot be assessed
N0 No regional lymph node metastasis
N1 Metastasis in a single lymph node, 2 cm or less in greatest dimension N2 Metastasis in a single lymph node, more than 2 cm but not more than 5 cm
in greatest dimension; or multiple lymph nodes, none more than 5 cm in greatest dimension
N3 Metastasis in a lymph node more than 5 cm in greatest dimension Distant Metastasis (M)
MX Distant metastasis cannot be assessed M0 No distant metastasis
3. STAGE GROUPING
Stage 0a Ta N0 M0 Stage 0is Tis N0 M0 Stage I Tl N0 M0 Stage II T2a N0 M0
T2b N0 M0 Stage III T3a N0 M0
T3b N0 M0 T4a N0 M0 Stage IV T4b N0 M0
AnyT N1 M0 Any T N2 M0 Any T N3 M0 Any T Any N M1 八、 HISTOPATHOLOGIC TYPE
The histologic types are:
Transitional cell carcinoma (urothelial) In situ
Papillary Flat
With squamous metaplasia With glandular metaplasia
With squamous and glandular metaplasia Squamous cell carcinoma
Adenocarcinoma Undifferentiated carcinoma
The predominant cancer is transitional cell carcinoma.
九、 HISTOPATHOLOGIC GRADE (G) GX Grade cannot be assessed G1 Well differentiated G2 Moderately differentiated
G3-4 Poorly differentiated or undifferentiated 十、 X-ray and scans:
1. I.V.P.
2. Staging procedures.
CT Scan of abdomen &
pelvis Liver & bone scan.
十一、 Every patients subjected to bimanual examination
Endoscopic procedure under general anesthesia. TURBt for resectable lesion with deep cut (to musule) biopsies. Complete bladder diagram include representation of the size and extent of the tumors, and operator's impression of clinical stage.
十二、 Treatment.
1. Benign papilloma/low stage, low grade carcinoma:
TUR. and/or fulguration. Follow up cystoscopy 6 months intervals for two years, thereafter one year intervals.
In-travesical therapy for multiple, or recurrent low stage &; low grade tumor
following TUR.
2. In situ carcinoma:
Focal: TUR
Diffuse: Intravesicle BCG or chemotherapy (MMC or Doxorubicin). Follow up cystoscopy and cytology at 2-3 months interval. Cystourethrectomy for patients failing conservative treatment.
3. Low stage, high grade carcinoma.
TUR. with Intravesical BCG therapy and close follow up.
Consider repeat TUR staging following BCG immunotherapy in selected case.
Radical cystectomy preceded or recurrent or advanced cases.
4. High stage carcinoma:
a. Segmental resection or radical cystectomy with ilial conduit or continent ilial bladder.
b. Adjuvant MEC chemotherapy for high risk patients.
十三、 Follow up:
1. For patients with superfical TCC of bladder who have had T.U.R.B.
Cystoscopy and cytology every 3 months for first 2 years thereafter every 6 months.
2. In patients who have had cystectomy:
Arranged IVP before dischange or within one month after surgery.
Follow up visits are scheduled every 3 months for 3 years and at 6 months interval thereafter. Urine cytology at each vist.
Examination include neek, abdomen, pelvis, perineum and stoma (periodic check of residual urine)
Careful palpation of urethra with cytologic studies ofurthral washing every 6 months.
I.V.P. every year for 3 years and every 2 years thereafter
I.V.P. every year for 3 years and every 2 years thereafter
BUN, creatinine, electrolyte and chest x-ray every 6 months.
Abdominal CT scan.
十四、 Pre-operative preparation for radical cystectomy:
1. Chest physiotherapy instruction.
2. Preoperative electrolyte & fluid supplements.
3. Mark the Suitable site for stoma.
4. Urine culture & sensitivity test.
5. Complete date (CBC, coagulation profile/chest, EKG.) 6. Bowel Preparation:
Low residual diet for 2 days.
Citrate of magnesia 240ml (or caster oil 30ml) 2 days preop.
Clear fluids for 48hr preop.
Enema until clear night before surgery.
Neormycin 1.0 gm p.o. at 12N, 2:00 pm, 6:00 pm 10:00 pm on day prior to surgery.
十五、 Post-operative care:
1. Antibiotics pre-op. and immediately post-op.
No antibiotics without specific indication.
3. Early ambulation.
4. Periodic electrolyte CBC, BUN.
5. Heal conduit are intubated with 26 F catheter at least until small bowel peristalsis return.
6. In patients with ureteral stent placed is generally removed at day 10 and the remaining stent one day later.
7. In patients having cutaneous ureterostomies, the ureteral catheter should be kept securely in place until such time as either primary skin to mucosa healing, or slough with secondly organization of tract has occurred.
腎盂及輸尿管癌 (Carcinoma of the renal pelvis and/or ureter)
一、History:
1. Family history of cancer.
2. Local symptoms: Gross hematuria, flank pain, mass.
3. Systemic symptoms: weight loss, weakness, fever back pain.
4. G-I symptoms: Anorexia nausea, vomiting.
二、 Past history:
1. Past history of bladder tumor.
2. Renal calculus, disease, prior hematuria or prior surgery.
3. If the patient has already been treated elsewhere then include the details of prior surgery, radiation or chemotherapy.
三、 Social history:
History of exposure to known carcinogens; smoking habits, analgesics and herb drug.
四、 Laboratory Studies:
Urine cytology. Renal function test, ERPF 五、 Diagnostic X-ray:
1. I.V.P.
2. Retrograde pyelograms.
3. CT Scan of abdomen when indicated for staging work up.
六、 Possible spreading:
1. Regional Lymph Nodes. The regional lymph nodes are:
For Renal Pelvis:
Renal hilar Paracaval Aortic
Retroperitoneal For Ureter:
Renal hilar
Iliac (common, internal [hypogastric], external) Paracaval
Peri-ureteral Pelvic, .KgS
Any amount of regional lymph node metastasis is a poor prognostic finding and outcome is minimally influenced by the number, size, or location of the regional nodes which are involved.
2. Metastatic Sites. Distant spread to lung, bone, or liver is most common.
七、 Staging:
Clinical Stagins. Primary turmor assessment includes radiographic imaging, usually by intravenous and/or retrograde pyelography. Computerized tomography
is desirable and tissue biopsy through the ureterocope may be performed if feasible.
Urine cytology may help determine tumor grade if tissue is not available. Staging of tumors of the renal pelvis and ureter is not influenced by the presence of any concomitant bladder tumors which may be identified.
八、 Pathologic Staging.
Pathologic staging depends upon histologic determination of the extent of invasion by the primary tumor. Treatment frequently requires resection of the entire kidney, ureter, and a cuff of bladder surrounding the ureteral orifice.
Appropriate regional nodes may be sampled. A more conservative surgical resection may be performed, especially with distal ureteral tumors or in the presence of compromised renal function.
Endoscopic resection through a ureteroscope or a percutaneous approach may be used in some circumstances. Submitted tissue may be insufficient for accurate histologic examination and pathologic staging. Laser or electrocautery coagulation or vaporization of the tumor may be performed, especially if the visible appearance is consistent with a low grade and low stage tumor. Under these circumstances, there may be no material available for histologic review.
DEFINITION OF TNM
1. Primary Tumor (T)
TX Primary tumor cannot be assessed T0 N0 evidence of primary tumor Ta Papillary noninvasive carcinoma Tis Carcinoma in situ
Tl Tumor invades subepithelial connective tissue T2 Tumor invades the muscularis
T3 (For renal pelvis only) Tumor invades beyond muscular is into peripelvic fat or the renal parenchyma
T4 Tumor invades adjacent organs, or through the kidney into the perinephric fat 2. Regional Lymph Nodes (N)*
NX Regional lymph nodes cannot be assessed N0 No regional lymph node metastasis
N1 Metastasis in a single lymph node, 2 cm or less in greatest dimension
N2 Metastasis in a single lymph node, more than 2 cm but not more than 5 cm in greatest dimension; or multiple lymph nodes, none more than 5 cm in greatest dimension
N3 Metastasis in a lymph node more than 5 cm in greatest dimension
* Note: Laterality does not affect the N classification.
3. Distant Metastasis (M)
MX Distant metastasis cannot be assessed M0 N0 distant metastasis
Ml Distant metastasis STAGE GROUPING
Stage 0a Ta N0 M0 Stage 0is Tis N0 M0 Stage I Tl N0 M0
Stage II T2 N0 M0 Stage III T3 N0 M0 Stage IV T4 N0 M0
Any T N1 M0 Any T N2 M0 Any T N3 M0 Any T Any N Ml 九、 HISTOPATHOLOG1C TYPE
The histologic types are:
Transitional cell carcinoma Squamous cell carcinoma Epidermoid carcinoma Adenocarcinoma Urothelial carcinoma 十、 HISTOPATHOLOGIC
GX Grade cannot be assessed Gl Well differentiated G2 Moderately differentiated
G3-4 Poorly differentiated or undifferentiated 十一、 Preoperative evaluation:
1. Cystoscopy-evaluation of bladder.
2. Retrograde catheterization of the ureter for retrograde pyelograply or obtaine cytology with the help of a brush ureteral catheter.
3. C. Ureteroscopy with poto record and biopsy for grading when indicate.
十二、 Treatment:
A. Radical nephroureterectomy with resection of bladder cuff.
Regional lymph node dissection is done depending on circumstance.
B. Selected patients may be considered for local resection, or endoscopic fulguration.
十三、 Treatment of far advanced disease (≧T3 or N+)
Systemic chemotherapy with MEC Protocol. For a. definete therapy of metastastic disease, b. Adjuvant therapy after complete surgical excision.
十四、 Following up:
1. Urine cytology and cystoscopy every 3 months for the first two years and every 6 months thereafter.
2. I.V.P. every one year for first 2 years and very 2 years.
3. Abdominal CT scan every 3-6 months for 2 years, for advanced or high risk disease.
Guidelines on Renal Cell Carcinoma
1. Introduction (Reference 1-5):
A. Renal cell carcinoma (RCC)佔所有癌症約 2%，每年增加約 1.5-5.9%。診斷平 均年齡約 70 歲，男性是女性的 1.5-3.1 倍。
B. 由於診斷技術的進步，近年來許多腎細胞癌是由超音波或電腻斷層診斷意外 發現，本院每年新診斷的病例約 20 例。Incidental RCC 佔所有 RCC 的比率 為 4.8% (1982-1989)，25.5% (1990-1995)，40.3% (1996-2001)，近年有明顯 增加，但還是約有 25%~30%的 RCC 在診斷時已經轉移，近年存活率稍有增 加，本院的結果：10 年存活率分別為 87% (第一期)，65% (第二期)，40% (第 三期)；第四期 5 年存活率為 8%，10 年存活率為零。
2. Classification and stage (Reference 6-9):
A. Classification Clear cell: 60-85%
Chromophilic: 7-14%
Chromophobic: 4-10%
Oncocytic: 2-5%
Collecting duct: 1-2%
B. Stage
Table 1. Staging system of Renal Cell carcinoma
The staging system used is that of Robson and is adequate for practical purposes.
Stage I- tumor confined to kidney
Stage II- tumor beyond renal capsule but confined to Gerota's space Stage III- local spread
a. Renal vein or inferior vena cava b. Local lymph nodes
c. Venous and lymphatic involvement Stage IV- advanced disease
a. Adjacent organs other than adrenal b. Distant metastases
Table 2. UICC TNM Classification of Renal Cell Carcinoma (1997) Kidney ICD-0 C64
Rules for Classification
The classification applies only to renal cell carcinoma. There should be histological confirmation of the disease.
The following are the procedures for assessing T, N, and M categories:
T categories Physical examination and imaging N categories Physical examination and imaging M categories Physical examination and imaging
Regional Lymph Nodes
The regional lymph nodes are the hilar, abdominal para-aortic, and paracaval nodes. Laterality does not affect the N categories.
TNM Clinical Classification T—Primary Tumour
TX Primary tumor cannot be assessed T0 No evidence of primary tumor
Tl Tumor 7.0 cm or less in greatest dimension, limited to the kidney (Tla ≦ 4cm, 7cm ≧ T1b > 4cm)
T2 Tumor more than 7.0 cm in greatest dimension, limited to the kidney T3 Tumor extends into major veins or invades adrenal gland or
perinephric tissues but not beyond Gerota fascia
T3a Tumor invades adrenal gland or perinephric tissues but not beyond Gerota fascia
T3b Tumor grossly extends into renal vein(s) or vena cava below diaphragm
T3c Tumor grossly extends into vena cava above diaphragm T4 Tumor invades beyond Gerota fascia
N-Regional Lymph Nodes
NX Regional lymph nodes-cannot be assessed N0 No regional lymph node metastasis
N1 Metastasis in a single regional lymph node N2 Metastasis in more than one regional lymph node M-Distant Metastasis
MX Distant metastasis cannot be assessed M0 No distant metastasis
M1 Distant metastasis
pTNM Pathological Classification
The pT, pN, and pM categories correspond to the T, N, and M categories.
G Histopathological Grading GX Grade of differentiation cannot be assessed G1 Well differentiated
G2 Moderately differentiated
G3-4 Poorly differentiated/undifferentiated Stage Grouping
Stage I T1 N0 M0
Stage II T2 N0 M0
Stage III Tl N1 M0
T2 N1 M0
T3 N0, N1 M0 Stage IV T4 N0, N1 M0
Any T N2 M0 Any T AnyN M1 Summary
T1 ≦7.0 cm; limited to the kidney T2 >7.0 cm; limited to the kidney
T3 Into major veins; adrenal or perinephric invasion T4 Invades beyond Gerota fascia
