膀胱镜下电凝止血治疗儿童异基因造血干细胞移植后迟发性出血性膀胱炎

摘要

Objective To explore the efficacy of cystoscopy for late onset hemorrhagic cystitis (LOHC) after hematopoietic stem cell transplantation (HSCT).Methods Retrospective analysis was conducted for 11 hospitalized children with severe LOHC after HSCT receiving cystoscopy after ineffective conservative treatment from January 2014 to May 2017.Twenty-four-Foley (24F) resectoscope,18F nephroscope or 8/9.8F ureteroscope was employed according to urinary tract development.Blood clot in bladder was removed by electronic loop,Elick irrigator,3.3 mm ultrasonic lithotripsy probe and basket.Then bipolar or monopolar electrocoagulation was utilized for hemostasis.Results There were 7 boys and 4 girls with a median age of 9 (5-15) years.The median occurring time of LOHC after HSCT was 35 days (21-85 days) and the median time of initial cystoscopy after LOHC 57 (11-182) days.The grades of LOHC were Ⅲ LOHC (n=7,63.7％) and Ⅳ (n=4,36.3％).A total of 14 endoscopic operations were performed with a median operative duration of 76 (43-179) min.LOHC was cured in 8 children (72.7％) and improved in another (9.1％).The overall response rate was 81.8％.Two children (18.2 ％) responded to neither cystoscopy nor subsequent selective bladder artery embolization plus internal iliac artery embolization.And both ultimately died of non-operativerelated pulmonary infection at 1 week and 1 month post-operation respectively.In 8 children with complete remission,gross hematuria disappeared at 4 (3-10) days post-operation and microscopic hematuria disappeared at 30 (25-38) days post-operation.There was no onset of severe postoperative complications.Both operative duration and effective ratio had statistical differences between children with grades Ⅲ and Ⅳ LOHC (P=0.038,0.044).Conclusions For children with severe LOHC after HSCT,cystoscopy is both safe and effective.If conservative therapy fails,surgery should be performed as soon as possible.%目的 观察膀胱镜下电凝止血治疗异基因造血干细胞移植(hematopoietic stem cell transplantation,HSCT)后迟发性出血性膀胱炎(late onset hemorrhagic cystitis,LOHC)的疗效.方法 回顾性分析2014年1月至2017年5月在北京大学人民医院接受HSCT后出现重度LOHC的患儿,均为经保守治疗无效后接受膀胱镜手术治疗.根据不同年龄儿童尿路发育情况,使用24F电切镜、18F肾镜或8/9.8F输尿管镜进行操作,使用电切环、Ellick冲洗器、3.3mm超声碎石探针及套石网篮清除膀胱内沉积血块,再以双极电凝或单极电凝对膀胱黏膜出血进行电凝止血.结果 共纳入11例患儿,男7例,女4例,中位年龄9岁(5～15岁).HSCT后发生LOHC的中位时间为35 d(21～85 d),发生LOHC到首次膀胱镜治疗的中位时间为57d(11～182d).Ⅲ度LOHC为7例,Ⅳ度为4例.11例患儿共接受14例次手术,中位手术时间为76min(43～179min).8例患儿达到完全缓解,1例患儿达到部分缓解.2例患儿未缓解,随后行选择性膀胱动脉或髂内动脉栓塞术仍未缓解,分别于1周及1个月后死于非手术相关的肺部感染.8例完全缓解患儿术后肉眼血尿消失的中位时间为4 d(3～10 d),镜下血尿消失的中位时间为30 d(25～38 d).所有患儿均未出现术后严重并发症.Ⅲ度与Ⅳ度LOHC患儿的手术时间与手术有效率差异有统计学意义(P=0.038,0.044).结论 膀胱镜下电凝止血治疗儿童HSCT后重度LOHC安全有效,保守治疗无效患儿应尽早选择外科治疗.