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北京大学学报（医学版） ›› 2026, Vol. 58 ›› Issue (4): 808-817. doi: 10.19723/j.issn.1671-167X.2026.04.018

• 论著 • 上一篇    下一篇

术前营养相关指标对上尿路尿路上皮癌根治术后生存结局的预测价值

郭泽菁1,*, 孙长海1,2,*, 赖世聪1, 高汉林1, 杜依青1,*(), 徐涛1   

  1. 1. 北京大学人民医院泌尿外科, 北京 100044
    2. 北京大学人民医院青岛医院泌尿外科, 青岛大学附属妇女儿童医院, 山东青岛 266034
  • 收稿日期:2026-02-27 出版日期:2026-08-18 发布日期:2026-05-27
  • 通讯作者: 杜依青
  • 作者简介:

    * These authors contributed equally to this work

  • 基金资助:
    科技创新2030-“癌症、心脑血管、呼吸和代谢性疾病防治研究”国家科技重大专项(2024ZD0525700); 国家自然科学基金(82471866); 国家自然科学基金(82472912); 北京市自然科学基金(L252190)

Comparison of preoperative nutritional scoring systems for predicting survival in upper tract urothelial carcinoma

Zejing GUO1, Changhai SUN1,2, Shicong LAI1, Hanlin GAO1, Yiqing DU1,*(), Tao XU1   

  1. 1. Department of Urology, Peking University People's Hospital, Beijing 100044, China
    2. Department of Urology, Peking University People's Hospital Qingdao Hospital, Qingdao University Affiliated Women and Children's Hospital, Qingdao 266034, Shandong, China
  • Received:2026-02-27 Online:2026-08-18 Published:2026-05-27
  • Contact: Yiqing DU
  • Supported by:
    the Noncommunicable Chronic Diseases-National Science and Technology Major Project(2024ZD0525700); the National Natural Science Foundation of China(82471866); the National Natural Science Foundation of China(82472912); the Beijing Natural Science Foundation(L252190)

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摘要：

目的: 探讨术前营养相关指标与上尿路尿路上皮癌(upper tract urothelial carcinoma，UTUC)患者根治性肾输尿管切除术(radical nephroureterectomy，RNU)后生存结局的相关性，并比较不同营养评分体系的预测效能。方法: 选择2007年1月至2021年4月在北京大学人民医院接受RNU治疗UTUC患者的病例资料进行回顾性分析，收集术前临床病理资料及实验室指标，计算老年营养风险指数(geriatric nutritional risk index，GNRI)、预后营养指数(prognostic nutritional index，PNI)、控制营养状态评分(controlling nutritional status，CONUT)，以及甘油三酯-总胆固醇-体重指数(triglycerides-total cholesterol-body weight index，TCBI)。采用Cox比例风险模型进行单因素和多因素分析，单因素分析中P < 0.10的变量通过向后逐步回归法(基于Akaike信息准则)筛选纳入多因素模型并构建列线图，以总生存期(overall survival，OS)和癌症特异性生存期(cancer-specific survival，CSS)为主要终点指标，采用Kaplan-Meier法绘制生存曲线并进行Log-rank检验，应用时间依赖性受试者工作特征曲线(time-dependent receiver operating characteristic curve，time-dependent ROC)评估各营养指标预测效能。结果: 研究共纳入481例UTUC患者。多因素分析显示，OS的独立影响因素包括病理分期T3/T4期、N1/N2期、WHO/ISUP(World Health Organization/International Society of Urological Pathology)高级别、估算的肾小球滤过率(estimated glomerular filtration rate, eGFR)、输血、输尿管末端处理、GNRI及PNI(P < 0.05)；CSS的独立影响因素包括病理分期T2~T4期、N1/N2期、术式(腹腔镜)、输血、GNRI及PNI(P < 0.05)。基于独立影响因素构建的列线图具有良好的校准度，GNRI < 98组、PNI < 52组患者OS和CSS明显缩短(Log-rank P < 0.05)。60个月时，GNRI和PNI预测OS的曲线下面积(area under the curve，AUC)分别为0.623和0.632，预测CSS的AUC分别为0.632和0.645。时间依赖性ROC分析显示，GNRI和PNI两指标对CSS的预测效能较为稳定，对OS的预测能力随随访时间延长呈轻度增强趋势。结论: 术前GNRI和PNI与UTUC患者RNU术后OS和CSS独立相关，在不同随访阶段均具有稳定的预测能力。

关键词: 上尿路尿路上皮癌, 术前营养, 总生存期, 癌症特异性生存期

Abstract:

Objective: To investigate the association between preoperative nutritional indicators and survival outcomes in patients with upper tract urothelial carcinoma (UTUC) undergoing radical nephroureterectomy (RNU), and to compare the predictive performance of different nutritional scoring systems. Methods: A retrospective analysis was conducted on UTUC patients who underwent RNU. Nutritional scores [geriatric nutritional risk index (GNRI), prognostic nutritional index (PNI), controlling nutritional status (CONUT), triglycerides-total cholesterol-body weight index (TCBI)] were calculated. Variables with P < 0.10 in univariable Cox regression were entered into multivariable analysis using backward stepwise selection based on the Akaike Information Criterion (AIC) to identify independent predictors and construct a nomogram. Kaplan-Meier curves with log-rank tests and time-dependent ROC curves were applied for survival analysis. A two-sided P < 0.05 was considered statistically significant. Results: A total of 481 UTUC patients were included. Multivariable analysis identified pathological T3/T4 stage, N1/N2 stage, high World Health Organization/International Society of Urological Pathology (WHO/ISUP) grade, estimated glomerular filtration rate (eGFR), blood transfusion, ureteral management, GNRI, and PNI as independent predictors of overall survival (OS) (P < 0.05). Independent predictors of cancer-specific survival (CSS) included pathological T2-T4 stage, N1/N2 stage, laparoscopic surgical approach, blood transfusion, GNRI, and PNI (P < 0.05). The nomogram constructed based on these independent predictors demonstrated good calibration. Patients with GNRI < 98 or PNI < 52 had significantly shorter OS and CSS (Log-rank P < 0.05). At the end of 60 months, the area under the curve (AUC) values of GNRI and PNI for predicting OS were 0.623 and 0.632, respectively, and for predicting CSS were 0.632 and 0.645, respectively. Time-dependent ROC analysis showed that both indicators had stable predictive performance for CSS, while their predictive ability for OS showed a mild increasing trend over the follow-up time. Conclusion: Preoperative GNRI and PNI are independently associated with OS and CSS in patients with UTUC after RNU, demonstrating stable predictive performance across different follow-up periods.

Key words: Upper tract urothelial carcinoma, Preoperative nutrition, Overall survival, Cancer-specific survival

中图分类号: 

  • R737.1

表1

UTUC患者的临床资料"

Indicator Total (n=481)
Age/years 66.55±9.78
Gender
  Male 248 (51.6)
  Female 233 (48.4)
Smoking 73 (15.2)
Previous bladder cancer 30 (6.2)
Concomitant bladder cancer 41 (8.5)
T
  Ta/T1 119 (24.7)
  T2 121 (25.2)
  T3/T4 241 (50.1)
N
  Nx/N0 464 (96.5)
  N1/N2 17 (3.5)
Location
  Ureter 192 (39.9)
  Renal pelvis 227 (47.2)
  Ureter + Renal pelvis 62 (12.9)
Multifocality 112 (23.3)
WHO/ISUP grade
  Low grade 86 (17.9)
  High grade 395 (82.1)
eGFR/[mL/(min·1.73 m2)] 64.44±25.42
Surgical approach
  Open 39 (8.1)
  Laparoscopic 442 (91.9)
Surgical access
  Transabdominal 80 (16.6)
  Retroperitoneal 401 (83.4)
Distal ureter management
  Total laparoscopic 129 (26.8)
  Bladder opening 321 (66.7)
  Endoscopic-assisted 31 (6.4)
Lymph node dissection 88 (18.3)
Intravesical instillation 31 (6.4)
Blood transfusion 96 (20.0)

表2

影响UTUC术后OS的单因素和多因素Cox回归分析"

Variable Univariate analysis Multivariate analysis
HR 95%CI P HR 95%CI P
Age/years 1.027 1.010-1.044 0.002 1.008 0.990-1.026 0.401
Gendera
  Male Reference
  Female 0.863 0.636-1.172 0.346
Smoking index (cigarettes·years) 1.000 0.999-1.000 0.334
Previous bladder cancera 1.779 1.045-3.026 0.034 1.396 0.806-2.420 0.234
Concomitant bladder cancera 1.552 0.951-2.533 0.079 1.180 0.712-1.958 0.520
Ta
  Ta/T1 Reference
  T2 2.250 1.235-4.102 0.008 1.681 0.908-3.112 0.098
  T3/T4 4.906 2.907-8.278 < 0.001 3.716 2.166-6.374 < 0.001
Na
  Nx/N0 Reference
  N1/N2 3.298 1.783-6.098 < 0.001 2.003 1.071-3.748 0.030
Locationa
  Renal pelvis Reference
  Ureter 1.022 0.734-1.422 0.899
  Ureter + renal pelvis 0.999 0.615-1.622 0.997
Multiple vs. singlea 0.967 0.669-1.396 0.857
WHO/ISUP gradea
  Low grade Reference
  High grade 2.399 1.467-3.923 < 0.001 1.827 1.095-3.046 0.021
eGFR/[mL/(min·1.73 m2)] 0.985 0.978-0.991 < 0.001 0.993 0.986-1.000 0.038
Surgical approacha
  Open Reference
  Laparoscopic 0.571 0.363-0.898 0.015 0.687 0.431-1.096 0.115
Surgical accessa
  Transabdominal Reference
  Retroperitoneal 0.932 0.608-1.429 0.748
Distal ureter managementa
  Total laparoscopic Reference
  Bladder opening 0.479 0.348-0.660 < 0.001 0.574 0.412-0.798 < 0.001
  Endoscopic-assisted 0.431 0.214-0.867 0.018 0.465 0.228-0.950 0.036
Lymph node dissectiona 0.983 0.640-1.509 0.937
Intravesical instillationa 0.992 0.538-1.831 0.980
Blood transfusiona 2.117 1.521-2.948 < 0.001 1.807 1.275-2.562 < 0.001
GNRI 0.969 0.953-0.985 < 0.001 0.979 0.963-0.996 0.017
PNI 0.946 0.921-0.972 < 0.001 0.969 0.941-0.997 0.032
CONUT 1.145 1.028-1.274 0.014 1.045 0.932-1.171 0.453
TCBI 1.000 0.999-1.001 0.899

表3

影响UTUC术后CSS的单因素和多因素Cox回归分析"

Variable Univariate analysis Multivariate analysis
HR 95%CI P HR 95%CI P
Age/years 1.009 0.989-1.030 0.376
Gendera
  Male Reference
  Female 0.806 0.541-1.200 0.288
Smoking index (cigarettes×years) 0.999 0.998-1.000 0.081 0.999 0.998-1.000 0.104
Previous bladder cancera 1.132 0.495-2.585 0.769
Concomitant bladder cancera 1.730 0.945-3.166 0.075 1.294 0.690-2.426 0.422
Ta
  Ta/T1 Reference
  T2 6.232 1.826-21.266 0.003 4.159 1.194-14.484 0.025
  T3/T4 16.667 5.259-52.828 < 0.001 11.988 3.708-38.759 < 0.001
Na
  Nx/N0 Reference
  N1/N2 4.867 2.523-9.386 < 0.001 2.986 1.530-5.826 0.001
Locationa
  Renal pelvis Reference
  Ureter 1.184 0.770-1.822 0.441
  Ureter+renal pelvis 1.142 0.613-2.128 0.676
Multiple vs. singlea 1.137 0.722-1.791 0.580
WHO/ISUP gradea
  Low grade Reference
  High grade 3.554 1.644-7.682 0.001 1.838 0.831-4.063 0.133
eGFR/[mL/(min·1.73 m2)] 0.988 0.980-0.996 0.005 0.999 0.989-1.009 0.837
Surgical approacha
  Open Reference
  Laparoscopic 0.475 0.269-0.839 0.010 0.515 0.287-0.925 0.026
Surgical accessa
  Transabdominal Reference
  Retroperitoneal 0.637 0.392-1.034 0.068 0.901 0.529-1.534 0.700
Distal ureter managementa
  Total laparoscopic Reference
  Bladder opening 0.509 0.334-0.777 0.002 0.646 0.416-1.005 0.053
  Endoscopic-assisted 0.672 0.299-1.510 0.335 0.789 0.341-1.824 0.579
Lymph node dissectiona 1.323 0.807-2.168 0.267
Intravesical instillationa 0.913 0.400-2.087 0.829
Blood transfusiona 2.024 1.309-3.131 0.002 1.835 1.169-2.880 0.008
GNRI 0.966 0.946-0.987 0.002 0.971 0.950-0.991 0.005
PNI 0.946 0.913-0.980 0.002 0.959 0.924-0.995 0.025
CONUT 1.165 1.017-1.335 0.027 1.122 0.974-1.292 0.110
TCBI 1.000 0.998-1.001 0.511

图1

GNRI和PNI预测60月OS(A)和CSS(B)生存情况的ROC"

图2

GNRI(A和B)和PNI(C和D)二分类的生存曲线，风险集人数小于10截断"

图3

GNRI(A和B)和PNI(C和D)预测生存AUC随时间变化曲线，AUC阶段峰值标注"

图4

GNRI预测OS(A)、PNI预测OS(B)、GNRI预测CSS(C)和PNI预测CSS(D)的列线图"

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ISSN 1671-167X
CN 11-4691/R
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