基于MRI前列腺腺体相关参数构建腹腔镜前列腺癌术后尿失禁的预测模型

doi:10.19723/j.issn.1671-167X.2023.05.007

摘要/Abstract

摘要：

目的: 评估基于MRI前列腺腺体相关参数构建的列线图预测腹腔镜前列腺癌术后尿失禁的临床价值。方法: 纳入经前列腺穿刺活检诊断为前列腺腺癌并于北京大学第三医院行腹腔镜根治性前列腺切除术(laparo-scopic radical prostatectomy，LRP)的202例患者，所有患者的术前MRI检查于前列腺穿刺活检术前1周内完成，腺体相关参数包含前列腺上下径、左右径、前后径、前列腺体积、前列腺尖部突入深度(intravesical prostatic protrusion length，IPPL)、前列腺尖部形态分型等。自术后第1个月起，每个月对患者的控尿功能恢复情况进行随访，以全天不需要使用尿垫作为控尿功能恢复标准。应用Logistic多因素回归分析影响术后早期控尿功能恢复的危险因素，绘制各模型预测术后控尿功能恢复的受试者操作特征(receiver operator characteristic，ROC)曲线，以DeLong检验比较曲线下面积的差异，以决策曲线分析评价模型的临床净获益。结果: 202例患者的平均年龄为69.0(64.0, 75.5)岁，穿刺前平均前列腺特异性抗原(prostate specific antigen，PSA)为12.12 (7.36, 20.06) μg/L，穿刺Gleason评分 < 7分和≥7分者分别为73例(36.2%)和129例(63.9%)，临床分期为T1/T2期者100例(49.5%)，T3期者102例(50.5%)。经术前MRI测量，前列腺体积为35.4 (26.2, 51.1) mL，前列腺上下径与左右径的比值为0.91 (0.77, 1.07)，膜性尿道长度为15 (11, 16) mm，IPPL为2 (0, 6) mm，前列腺尖部形态分型A~D型分别为67例(33.2%)、80例(39.6%)、24例(11.9%)和31例(15.3%)，训练集和验证集分别为141例和61例。所有患者手术均顺利完成，随访3个月患者的控尿率为59.4%(120/202例)。训练集多因素分析结果显示，膜性尿道长度(P < 0.001)、IPPL(P=0.017)和临床分期(P=0.022)是术后早期(3个月)尿失禁发生的独立危险因素。根据多因素分析结果制作列线图和临床决策曲线，计算训练集ROC曲线下面积为0.885 (0.826, 0.944)，计算验证集ROC曲线下面积为0.854 (0.757, 0.950)。在验证集里对模型进行Hosmer-Lemeshow拟合优度检验，卡方值为5.426 (P=0.711)。结论: 术前膜性尿道长度、IPPL、临床分期是LRP术后早期尿失禁发生的独立危险因素，基于MRI前列腺腺体相关参数构建的列线图可有效预测LRP术后早期控尿功能恢复，但此结果还需更大规模的临床研究证实。

关键词: 前列腺肿瘤, 控尿功能, 腹腔镜手术, 前列腺切除术, 列线图

Abstract:

Objective: Constructing a predictive model for urinary incontinence after laparoscopic radical prostatectomy (LRP) based on prostatic gland related MRI parameters. Methods: In this study, 202 cases were included. All the patients were diagnosed with prostate cancer by prostate biopsy and underwent LRP surgery in Peking University Third Hospital. The preoperative MRI examination of all the patients was completed within 1 week before the prostate biopsy. Prostatic gland related parameters included prostate length, width, height, prostatic volume, intravesical prostatic protrusion length (IPPL), prostate apex shape, etc. From the first month after the operation, the recovery of urinary continence was followed up every month, and the recovery of urinary continence was based on the need not to use the urine pad all day long. Logistic multivariate regression analysis was used to analyze the influence of early postoperative recovery of urinary continence. Risk factors were used to draw the receiver operator characteristic (ROC) curves of each model to predict the recovery of postoperative urinary continence, and the difference of the area under the curve (AUC) was compared by DeLong test, and the clinical net benefit of the model was evaluated by decision curve analysis (DCA). Results: The average age of 202 patients was 69.0 (64.0, 75.5) years, the average prostate specific antigen (PSA) before puncture was 12.12 (7.36, 20.06) μg/L, and the Gleason score < 7 points and ≥ 7 points were 73 cases (36.2%) and 129 cases (63.9%) respectively, with 100 cases (49.5%) at T1/T2 clinical stage, and 102 cases (50.5%) at T3 stage. The prostatic volume measured by preoperative MRI was 35.4 (26.2, 51.1) mL, the ratio of the height to the width was 0.91 (0.77, 1.07), the membranous urethral length (MUL) was 15 (11, 16) mm, and the IPPL was 2 (0, 6) mm. The prostatic apex A-D subtypes were 67 cases (33.2%), 80 cases (39.6%), 24 cases (11.9%) and 31 cases (15.3%), respectively. The training set and validation set were 141 cases and 61 cases, respectively. The operations of all the patients were successfully completed, and the urinary continence rate was 59.4% (120/202) in the 3 months follow-up. The results of multivariate analysis of the training set showed that the MUL (P < 0.001), IPPL (P=0.017) and clinical stage (P=0.022) were independent risk factors for urinary incontinence in the early postoperative period (3 months). The nomogram and clinical decision curve were made according to the results of multivariate analysis. The AUC value of the training set was 0.885 (0.826, 0.944), and the AUC value of the validation set was 0.854 (0.757, 0.950). In the verification set, the Hosmer-Lemeshow goodness-of-fit test was performed on the model, and the Chi-square value was 5.426 (P=0.711). Conclusion: Preoperative MUL, IPPL, and clinical stage are indepen-dent risk factors for incontinence after LRP. The nomogram developed based on the relevant parameters of MRI glands can effectively predict the recovery of early urinary continence after LRP. The results of this study require further large-scale clinical research to confirm.

Key words: Prostate neoplasm, Urinary continence, Laparoscopic surgery, Prostatectomy, Nomogram

中图分类号:

R737.25

毛海,张帆,张展奕,颜野,郝一昌,黄毅,马潞林,褚红玲,张树栋. 基于MRI前列腺腺体相关参数构建腹腔镜前列腺癌术后尿失禁的预测模型[J]. 北京大学学报（医学版）, 2023, 55(5): 818-824.

Hai MAO,Fan ZHANG,Zhan-yi ZHANG,Ye YAN,Yi-chang HAO,Yi HUANG,Lu-lin MA,Hong-ling CHU,Shu-dong ZHANG. Predictive model of early urinary continence recovery based on prostate gland MRI parameters after laparoscopic radical prostatectomy[J]. Journal of Peking University (Health Sciences), 2023, 55(5): 818-824.

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参考文献 18

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Items	All patients (n=202)	Training dataset (n=141)	Validation dataset (n=61)
Age/years, n (%)
≥70	109 (54.0)	77 (54.6)	32 (52.5)
< 70	93 (46.0)	64 (45.4)	29 (47.5)
Pre-biopsy PSA/(μg/L), M (P₂₅, P₇₅)	12.12 (7.36, 20.06)	10.98 (7.43, 19.31)	12.90 (7.10, 21.80)
Biopsy Gleason score, n (%)
＜7	73 (36.1)	56 (39.7)	17 (27.9)
≥7	129 (63.9)	85 (60.3)	44 (72.1)
cT, n (%)
T1/T2	100 (49.5)	66 (46.8)	34 (55.7)
T3	102 (50.5)	75 (53.2)	27 (44.3)
PV/mL, M (P₂₅, P₇₅)	35.4 (26.2, 51.1)	35.8 (27.1, 50.5)	33.9 (23.4, 53.7)
MUL/mm, M (P₂₅, P₇₅)	15 (11, 16)	15 (11, 16)	15 (11, 17)
IPPL/mm, M (P₂₅, P₇₅)	2 (0, 6)	2 (0, 6)	2 (0, 8)
Length/width, M (P₂₅, P₇₅)	0.91 (0.77, 1.07)	0.91 (0.82, 1.07)	0.89 (0.74, 1.06)
Prostate apex shape, n (%)
A-C	171 (84.7)	122 (86.5)	49 (80.3)
D	31 (15.3)	19 (13.5)	12 (19.7)

Items	Continence (n=58)	Incontinence (n=83)	t/χ²/z value	P value
Age/years, n (%)			1.595	0.207
≥70	28 (48.3)	49 (59.0)
< 70	30 (51.7)	34 (41.0)
Pre-biopsy PSA/(μg/L), M (P₂₅, P₇₅)	13.59 (7.62, 22.31)	10.27 (7.16, 17.15)	0.953	0.340
Biopsy Gleason score, n (%)			0.114	0.736
＜7	24 (41.4)	32 (38.6)
≥7	34 (58.6)	51 (61.4)
cT, n (%)			6.012	0.014
T1/T2	20 (34.5)	46 (55.4)
T3	38 (65.5)	37 (44.6)
PV/mL, M (P₂₅, P₇₅)	41.51 (31.49, 56.42)	34.53 (23.7, 44.33)	2.786	0.005
MUL/mm, M (P₂₅, P₇₅)	11 (9, 14)	15 (14, 17)	-6.059	< 0.001
IPPL/mm, M (P₂₅, P₇₅)	6 (0, 10)	0 (0, 3)	4.788	< 0.001
Prostate apex shape, n (%)			3.657	0.056
A-C	54 (93.1)	68 (81.9)
D	4 (6.9)	15 (18.1)
Length/width, M (P₂₅, P₇₅)	0.99 (0.85, 1.13)	0.88 (0.77, 1.01)	2.506	0.012

Items	B	S.E.	z	P	OR (95%CI)
IPPL	-0.140	0.059	-2.384	0.017	0.87 (0.78, 0.98)
MUL	0.367	0.073	5.021	< 0.001	1.44 (1.25, 1.67)
cT	-1.086	0.475	-2.286	0.022	0.34 (0.13, 0.86)
Length/width	-2.476	1.269	-1.950	0.051	0.08 (0.01, 1.01)
Constant	-0.143	1.597	-0.089	0.929