探讨妊娠合并膀胱低度恶性潜能乳头状尿路上皮肿瘤(PUNLMP)的临床特点及诊治策略。

选择2022年8月4日，于四川大学华西第二医院分娩的1例妊娠合并PUNLMP孕妇为研究对象。采用回顾性研究方法，收集本例孕妇的临床病例资料，并对其临床表现、诊断及治疗过程进行总结、分析。以"妊娠合并膀胱肿瘤""妊娠合并低度恶性潜能乳头状尿路上皮肿瘤""bladder tumor""papillary urothelial neoplasms of low malignant potential""pregnancy"为关键词，在中国知网数据库、万方数据知识服务平台及PubMed、Web of Science(WOS)数据库中检索妊娠合并PUNLMP相关研究文献，检索时间设定为2004年1月1日至2023年1月31日。本研究符合2013年修订的《世界医学协会赫尔辛基宣言》要求，患者对本治疗及本研究均知情同意。

①本例患者为30岁初产妇，因"孕龄为35孕周，反复肉眼血尿"，于2022年7月25日被收入本院治疗。本例孕妇体格检查：阴道内及肛周无血迹；胎儿超声检查未见异常；泌尿系统超声检查：膀胱后壁查见3.1 cm×2.5 cm×1.3 cm稍强回声；就诊1 d后，患者尿血自行停止，偶感尿频、尿急，四川大学华西医院泌尿外科就诊后，嘱其观察、随访。孕龄为35孕周时，其再次出现肉眼血尿。本例孕妇泌尿系统超声检查：膀胱后壁查见2.1 cm×1.7 cm×2.0 cm稍强回声，边界较清，未见确切血流信号，未见明显占位改变。再次就诊于华西医院泌尿外科，考虑膀胱占位实性包块不排除恶性可能，建议行膀胱镜检查。经充分医患沟通，患方选择等待分娩后处理膀胱占位。患者于孕龄为38⁺⁶孕周(2022年8月6日)自然分娩一活男婴，产时孕妇尿常规结果显示：潜血(2+)、尿蛋白(－)、尿细菌为19 048个/μL、未见脓细胞及病理管型。患者产褥期恢复良好，产后未再出现肉眼血尿，无尿路刺激症状，无腰痛等不适。产后88 d经尿道进行膀胱癌电切术(TURBT)，术后切除组织病理学检查结果示乳头状癌，支持PUNLMP诊断。②文献复习结果：根据本研究设定的文献检索策略，未检索到妊娠合并PUNLMP相关研究文献，检索到9篇妊娠合并膀胱肿瘤相关文献报道，共计纳入12例妊娠合并膀胱肿瘤患者，其中11例为孕期行TRUBT后被确诊，1例孕前行TRUBT并确诊；所有患者术后病理学诊断非PUNLMP；明确诊断后仅3例患者术后接受化疗，其中1例为孕期接受丝裂霉素化疗。

妊娠合并PUNLMP孕妇临床上较为少见，发生机制尚未明确，对其诊断方式选择，应避免可能导致胎儿丢失及畸形相关检查，需注意治疗时机及方案选择。

To explore the clinical characteristics and diagnosis and treatment strategies of papillary urothelial neoplasms of low malignant potential(PUNLMP).

One pregnant woman with PUNLMP delivered on 4 August 2022 was selected into this study. A retrospective study method was used to collect the clinical case data of this patient, and summarize the clinical manifestations, diagnosis and treatment process.With " pregnancy with bladder tumor" " pregnancy with papillary urothelial neoplasms with low malignant potential" " bladder tumor" " papillary urothelial neoplasms of low malignant potential" and " pregnancy", relevant documents were searched in CNKI, Wanfang service platform and PubMed database and Web of Science (WOS) databases, and the search time was set as the database establishment from January 2004 to January 2023.The procedure followed in this study met requirements of the Helsinki Declaration of the World Medical Association revised in 2013, and signed clinical study informed consent with all subjects.

①Clinical characteristics of this patient were as follows. This patient was a 30-year-old primipara woman who developed " gross hematuria" at 25 gestational weeks and came to the hospital. Physical examination: no blood in the vagina and perianus; obstetric ultrasound: no abnormality; urological ultrasound results: the posterior wall of the bladder found 3.1 cm×2.5 cm×1.3 cm slightly strong echo; after one day, the urine blood stopped. Occasional urinary frequency and urgency, urology observation and follow-up. Macroscopic hematuria appeared again at 35 gestational weeks. Urinary tract ultrasound: in the posterior wall of the bladder, a slightly strong echo of 2.1 cm×1.7 cm×2.0 cm appeared, with a clear boundary, no exact blood flow signal, and no obvious position change. She went to the Department of Urology of West China Hospital again. The doctor considering that the bladder was a solid mass, the possibility of malignancy was not ruled out, and cystoscopy was recommended. After full doctor-patient communication, the patient chose to wait for delivery before handling the bladder space. The patient delivered a live male baby after 38^{+ 6} weeks of gestation. Routine results of urinary catheterization during delivery: occult blood (2+ ), urinary protein (-), urinary bacteria were 19 048 cells/μL, no purulent cells and pathological tubes.The puerperum recovered well, and no gross hematuria appeared postpartum.Transurethral bladder tumor resection of TURBT (88 days postpartum), postoperative pathological results: papillary tumor, supported the diagnosis of papillary urothelial neoplasms with low malignant potential.The patient recovered well from the puerperium, no postpartum gross hematuria, no urinary tract irritation symptoms, no low back pain and other discomfort.②Results of literature review were as follows.According to the literature search strategy, no literature on pregnancy with PUNLMP was retrieved, and 9 articles were found on 12 cases of pregnancy with bladder tumor, 11 cases received TRUBT during pregnancy and 1 case without TRUBT during pregnancy; all patients were not PUNLMP; only 3 patients received postoperative chemotherapy after definite diagnosis, and 1 case received mitomycin chemotherapy during pregnancy.

Pregnancy combined with PUNLMP is relatively rare clinically, and the mechanism of its occurrence is not clear. The choice of diagnosis should avoid the examination that may cause fetal malformation, and attention should be paid to the choice of treatment timing and regimen.