肾输尿管全长切除术两种不同术式的双中心疗效对比

doi:10.19723/j.issn.1671-167X.2019.04.009

摘要/Abstract

摘要：

目的:比较经腹完全腹腔镜肾输尿管全长切除术(complete transperitoneal laparoscopic nephroureterectomy, CTNU)和传统后腹腔镜肾输尿管全长切除术(traditional retroperitoneoscopic nephroureterectomy, TRNU)治疗上尿路尿路上皮癌(upper urinary tract urothelial carcinoma, UTUC)的手术安全性和疗效。方法:收集2011年1月至2018年12月期间在北京大学第一医院泌尿外科和福建省立医院泌尿外科接受CTNU和TRNU手术治疗的UTUC病例,比较两种手术方式患者在临床资料、围术期参数、术后随访结果等方面的差异。结果:最终共纳入病例266例,其中CTNU组94例,TRNU组172例。与CTNU组相比,TRNU组左侧病变比例更大(P<0.05)。两组患者年龄、性别分布、体重指数(body mass index,BMI)、美国麻醉医师学会评分(American society of anesthesiologists score, ASA score)、肿瘤所在侧别等方面均差异无统计学意义(P>0.05)。所有病例均完成手术,TRNU中有1例因左肾动脉损伤加行开放血管修补术。CTNU组手术时间为(202.9±76.7) min、术中出血量(68.4±73.3) mL、术后引流管留置天数(3.9±1.5) d、引流液总量(181.7±251.5) mL、术后住院天数(7.8±4.1) d;TRNU组手术时间为(203.5±68.7) min、术中出血量(130.2±252.1) mL、术后引流管留置天数(4.3±1.6) d、引流液总量(179.1±167.5) mL、术后住院天数(8.2±3.7) d。CTNU组术中出血量少于TRNU组,且差异有统计学意义(P=0.005)。中位随访时间39个月(1~88个月),TRNU组的5年总体生存率(overall survival, OS)、肿瘤特异性生存率(cancer specific survival, CSS)、无膀胱复发生存率(intra-vesical recurrence free survival, IvRFS)、无病生存率(disease free survival, DFS)分别为75.6%、86.9%、73.8%、57.5%;CTNU组的5年OS、CSS、IvRFS、DFS分别为66.3%、83.5%、75.9%、58.6%,两组间差异均无统计学意义。结论:CTNU手术是一种安全有效的手术治疗方式,但尚需更进一步的前瞻性随机对照研究加以证实。

关键词: 上尿路, 尿路上皮癌, 肾输尿管全长切除术

Abstract:

Objective: To compare the efficacy and safety of complete transperitoneal laparoscopic nephroureterectomy (CTNU) and traditional retroperitoneoscopic nehroureterectomy (TRNU) for the management of upper urinary tract urothelial carcinoma(UTUC).Methods: We retrospectively collected the clinical data of UTUC patients who underwent CTNU or TRNU surgery from January 2011 to December 2018 in Peking University First Hospital and Fujian Provincial Hospital, and compared the clinical characteristics, perioperative parameters, and follow-up results between the CTNU and TRNU surgeries.Results: Finally, a total of 266 cases were included, with 94 cases in the CTNU group and 172 cases in the TRNU group. The proportion of left side lesions was bigger in TRNU group when compared with CTNU group (P<0.05). No significant differences were observed in clinical characteristics, such as age, gender, body mass index(BMI), American society of anesthesiologists score(ASA score) and tumor laterality. All surgery procedures were completed. The vascular resparing was performed by reason that left arteria renalis was injured accidently during surgical operation in one case of TRNU group. No serious complications were observed in both CTNU and TRNU groups. In CTNU group, operating time was (202.9±76.7) min, estimated blood loss was (68.4±73.3) mL, drainage duration was (3.9±1.5) d, drainage volume was (181.7±251.5) mL, and postoperative hospital stay was (7.8±4.1) d. In TRNU group, operating time was (203.5±68.7) min, estimated blood loss was (130.2±252.1) mL, drainage duration was (4.3±1.6) d, drainage volume was (179.1±167.5) mL, and postoperative hospital stay was (8.2±3.7) d. The estimated blood loss in CTNU group was significantly less than that in TRNU group (P =0.005).The median follow-up time was 39 months (range: 1-88 months). The 5-year overall survival rate (OS), cancer specific survival rate (CSS), intra-vesical recurrence free survival rate (IvRFS), disease free survival rate (DFS) of CTNU group was 75.6%, 86.9%, 73.8%, 57.5%, respectively. The OS, CSS, IvRFS and DFS of TRNU group was 66.3%, 83.5%, 75.9%, 58.6%, respectively.No significant differences were observed in the OS, CSS, IvRFS and DFS between the CTNU and TRNU groups.Conclusion: CTNU technique is a safe and effective surgical option, and further prospective randomized controlled trial is needed for further evaluation.

Key words: Upper urinary tract, Urothelial carcinoma, Nephroureterectomy

中图分类号:

R737.11

吴进锋,林榕城,林友成,蔡旺海,朱庆国,方冬,熊耕砚,张雷,周利群,叶烈夫,李学松. 肾输尿管全长切除术两种不同术式的双中心疗效对比[J]. 北京大学学报（医学版）, 2019, 51(4): 646-652.

Jin-feng WU,Rong-cheng LIN,You-cheng LIN,Wang-hai CAI,Qing-guo ZHU,Dong FANG,Geng-yan XIONG,Lei ZHANG,Li-qun ZHOU,Lie-fu YE,Xue-song LI. Comparison of efficacy and safety between two different methods of nephroureterectomy in two centers[J]. Journal of Peking University(Health Sciences), 2019, 51(4): 646-652.

图/表 5

图1

图2

表1

所有病例的临床及病理资料"

Items	TRNU group(n=172)	CTNU group(n=94)	P value
Age/years, $x ? ± s$	67.1±11.5	66.0±9.2	0.437
Gender, n(%)			0.650
Male	92 (53.5)	53 (56.4)
Female	80 (46.5)	41 (43.6)
BMI(256 patients available)/(kg/m²), $x ? ± s$	24.4±2.9	23.9±3.4	0.342
Side, n(%)			0.001
Left	107 (62.2)	39 (41.5)
Right	65 (37.8)	55 (58.5)
Ureteroscopy, n(%)			0.517
Yes	29 (16.9)	13 (13.8)
No	143 (83.1)	81 (86.2)
ASA score (225 patients available), n(%)			0.085
1	6 (4.1)	9 (11.4)
2	112 (76.7)	59 (74.7)
3	28 (19.2)	11 (13.9)
Concomitant bladder cancer (206 patients available), n(%)			0.987
Yes	16 (11.2)	7 (11.1)
No	127 (88.8)	56 (88.9)
T stage, n(%)			0.523
Ta	4 (2.3)	2 (2.1)
T1	67 (39.0)	30 (31.9)
T2	50 (29.1)	30 (31.9)
T3	44 (25.6)	31 (33.0)
T4	5 (2.9)	1 (1.1)
Grade, n(%)			0.103
G1	51 (29.7)	37 (39.4)
G2	83 (48.3)	45 (47.9)
G3	38 (22.1)	12 (12.8)
Lymph node invasion, n(%)			0.403
N+	7 (4.1)	6 (6.4)
N0 or Nx	165 (95.9)	88 (93.6)

表1

表2

所有病例的术中和术后情况"

Items	TRNU group (n=172)	CTNU group (n=94)	P value
Operating time/min, $x ? ± s$	203.5±68.7	202.9±76.7	0.865
Estimated blood loss/mL, $x ? ± s$	130.2±252.1	68.4±73.3	0.005
Drainage duration/d, $x ? ± s$	4.3±1.6	3.9±1.5	0.090
Drainage volume/mL, $x ? ± s$	179.1±167.5	181.7±251.5	0.150
Postoperative hospital stay/d, $x ? ± s$	8.2±3.7	7.8±4.1	0.075
Perioperative complications,n/Clavien-Dindo grading			0.972
Intra-vesical hemorrhage	2/Ⅱ	1/Ⅱ
Reanal fossa hemorrhage	1/Ⅱ
Lymphatic fluid leakage	1/Ⅰ	1/Ⅰ
Ileus		1/Ⅱ

表2

图3

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