输尿管镜活体组织检查对上尿路尿路上皮癌根治性手术的影响
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摘要
目的:探讨术前输尿管镜活体组织检查(ureteroscopy and biopsy,UB)对上尿路尿路上皮癌(upper tract urothelial carcinoma,UTUC)肾输尿管全长膀胱袖状切除术(radical nephroureterectomy,RNU)及肿瘤学预后的影响。方法:回顾性分析北京大学第三医院2007年1月至2016年12月行RNU手术的UTUC患者资料,中位随访时间40个月,比较行UB和未行UB两组患者RNU手术时长及手术出血量的差异,按UB术至RNU术的间隔时间和输尿管末端手术方式进行亚组分析,采用线性回归模型对常见手术难度的影响因素进行校正。结果:纳入UTUC患者163例,输尿管下段行开放切除者91例(55.9%),行后腹腔镜切除者72例(44.1%),110例(67.5%)术前行UB。与未行UB组相比,行UB组的平均手术时间显著延长[(221.3±79.8) min vs.(252.5±79.8) min,P=0.019],而中位出血量(50 mL vs.50 mL,P=0.143)差异无统计学意义。亚组分析显示,UB术1周后行RNU手术的患者平均手术时间显著延长(P=0.023),等待2周以上的患者中位失血量(100 mL)显著多于未行BU的患者(50 mL,P=0.012)。多因素分析中,术前行UB(P=0.049)、≥p T3(P=0.039)、p N+(P=0.018)及输尿管下段切除术式(P=0.005)与手术时间的延长显著相关。本组患者3年肿瘤特异性生存率(cancer specific survival,CSS)为87.2%,UB对其无显著影响(P=0.435)。结论:术前UB是RNU手术时间延长的独立危险因素,但对肿瘤特异性生存无显著影响。
Objective:To investigate the impact of preoperative diagnostic ureteroscopy and biopsy(UB) on radical nephroureterectomy(RNU) and the prognosis of upper tract urothelial carcinoma(UTUC).Methods:The clinical data of UTUC patients receiving RNU between Jan.2007 and Dec.2016 were retrospectively collected.The median follow up time was 40 months.The operation time and blood loss of RNU were compared between UB group and non-UB group.Subgroup analyses were conducted according to the time interval between UB and RNU,and surgery methods of lower ureter.The linear regression model was used to adjust for other common factors that impacted operation time.Results:A total of 163 UTUC patients were included in the final analysis.For the lower ureter,open ureterectomies were performed in 91 patients(55.9%),while retroperitoneal laparoscopic ureterectomies were performed in 72 patients(44.1%).A total of 110(67.5%) patients received preoperative UB.Compared with non-UB group,the average operation time of UB group was significantly longer [(252.5 ± 79.8)min vs.(221.3 ± 79.8) min,P=0.019],but no difference of blood loss was found(median,50 mL vs.50 mL,P=0.143).In subgroup analysis,the average operation time of RNU was significantly prolonged when RNU was performed after 1 week of UB(P=0.023).Meanwhile,the median blood loss of RNU increased significantly when it was done after 2 weeks of UB compared with non-UB group(100 mL vs.50 mL,P=0.012).UB was also significantly prolonged the operation time of RNU in retroperitoneal laparoscopic ureterectomy group(P=0.012).In multivariable analysis,UB(P=0.049),≥ pT3(P=0.039),pN +(P=0.018) and ureterectomy method(P=0.005) were independent risk factors of prolonged operation time.The 3-year cancer specific survival(CSS) rate was 87.2% in our cohort.UB had no significant impact on cancer specific survival(P=0.435).Conclusion:UB was an independent risk factor of prolonged RNU time,but did not significantly influence cancer specific survival of upper tract urothelial carcinoma patients.
Objective:To investigate the impact of preoperative diagnostic ureteroscopy and biopsy(UB) on radical nephroureterectomy(RNU) and the prognosis of upper tract urothelial carcinoma(UTUC).Methods:The clinical data of UTUC patients receiving RNU between Jan.2007 and Dec.2016 were retrospectively collected.The median follow up time was 40 months.The operation time and blood loss of RNU were compared between UB group and non-UB group.Subgroup analyses were conducted according to the time interval between UB and RNU,and surgery methods of lower ureter.The linear regression model was used to adjust for other common factors that impacted operation time.Results:A total of 163 UTUC patients were included in the final analysis.For the lower ureter,open ureterectomies were performed in 91 patients(55.9%),while retroperitoneal laparoscopic ureterectomies were performed in 72 patients(44.1%).A total of 110(67.5%) patients received preoperative UB.Compared with non-UB group,the average operation time of UB group was significantly longer [(252.5 ± 79.8)min vs.(221.3 ± 79.8) min,P=0.019],but no difference of blood loss was found(median,50 mL vs.50 mL,P=0.143).In subgroup analysis,the average operation time of RNU was significantly prolonged when RNU was performed after 1 week of UB(P=0.023).Meanwhile,the median blood loss of RNU increased significantly when it was done after 2 weeks of UB compared with non-UB group(100 mL vs.50 mL,P=0.012).UB was also significantly prolonged the operation time of RNU in retroperitoneal laparoscopic ureterectomy group(P=0.012).In multivariable analysis,UB(P=0.049),≥ pT3(P=0.039),pN +(P=0.018) and ureterectomy method(P=0.005) were independent risk factors of prolonged operation time.The 3-year cancer specific survival(CSS) rate was 87.2% in our cohort.UB had no significant impact on cancer specific survival(P=0.435).Conclusion:UB was an independent risk factor of prolonged RNU time,but did not significantly influence cancer specific survival of upper tract urothelial carcinoma patients.
引文
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[10]Liu Z,Zheng S,Li X,et al.Oncologic outcomes of patients undergoing diagnostic ureteroscopy before radical nephroureterectomy for upper urinary tract urothelial carcinomas:a systematic review and meta-analysis[J].J Laparoendosc Adv Surg Tech A,2018,28(11):1316-1325.
[11]Lee HY,Yeh HC,Wu WJ,et al.The diagnostic ureteroscopy before radical nephroureterectomy in upper urinary tract urothelial carcinoma is not associated with higher intravesical recurrence[J].World J Surg Oncol,2018,16(1):135.
[12]Xylinas E,Kluth L,Passoni N,et al.Prediction of intravesical recurrence after radical nephroureterectomy:development of a clinical decision-making tool[J].Eur Urol,2014,65(3):650-658.
[13]Luo HL,Kang CH,Chen YT,et al.Diagnostic ureteroscopy independently correlates with intravesical recurrence after nephroureterectomy for upper urinary tracturothelial carcinoma[J].Ann Surg Oncol,2013,20(9):3121-3126.
[14]Lee JK,Kim KB,Park YH,et al.Correlation between the timing of diagnostic ureteroscopy and intravesical recurrence in upper tract urothelial cancer[J].Clin Genitourin Cancer,2016,14(1):e37-e41.
[15]Horuz R,Goktas C,Cetinel CA,et al.Simple preoperative parameters to assess technical difficulty during a radicalperineal prostatectomy[J].Int Urol Nephrol,2013,45(1):129-133.
[16]Liu P,Su XH,Xiong GY,et al.Diagnosticureteroscopy for upper tract urothelial carcinoma is independently associated with intravesical recurrence after radical nephroureterectomy[J].Int Braz JUrol,2016,42(6):1129-1135.
[17]Sankin A,Tin AL,Mano R,et al.Impact ofureteroscopy before nephroureterectomy for upper tract urothelial carcinoma on oncologic outcomes[J].Urology,2016,94:148-153.
[18]Lee JN,Kwon SY,Choi GS,et al.Impact of surgical wait time on oncologic outcomes in upper urinary tracturothelial carcinoma[J].J Surg Oncol,2014,110(4):468-475.
[19]Waldert M,Karakiewicz PI,Raman JD,et al.A delay in radical nephroureterectomy can lead to upstaging[J].BJU Int,2010,105(6):812-817.
[20]Boorjian S,Ng C,Munver R,et al.Impact of delay to nephroureterectomy for patients undergoing ureteroscopic biopsy and laser tumor ablation of upper tract transitional cell carcinoma[J].Urology,2005,66(2):283-287.
[21]Nison L,Roupret M,Bozzini G,et al.The oncologic impact of a delay between diagnosis and radicalnephroureterectomy due to diagnostic ureteroscopy in upper urinary tract urothelial carcinomas:results from a large collaborative database[J].World JUrol,2013,31(1):69-76.
[22]Shibing Y,Liangren L,Qiang W,et al.Impact of tumour size on prognosis of upper urinary tract urothelial carcinoma after radical nephroureterectomy:a multi-institutional analysis of 795 cases[J].BJU Int,2016,118(6):902-910.
[23]Simone G,Papalia R,Loreto A,et al.Independent prognostic value of tumour diameter and tumour necrosis in upper urinary tracturothelial carcinoma[J].BJU Int,2009,103(8):1052-1057.
[24]Espiritu PN,Sverrisson EF,Sexton WJ,et al.Effect of tumor size on recurrence-free survival of upper tract urothelial carcinoma following surgical resection[J].Urol Oncol,2014,32(5):619-624.
[25]Pieras E,Frontera G,Ruiz X,et al.Concomitant carcinoma in situ and tumour size are prognostic factors for bladder recurrence after nephroureterectomy for upper tract transitional cell carcinoma[J].BJU Int,2010,106(9):1319-1323.
[26]Milenkovic-Petronic D,Milojevic B,Djokic M,et al.The impact of tumor size on outcomes in patients with upper urinary tracturothelial carcinoma[J].Int Urol Nephrol,2014,46(3):563-569.
[27]Su X,Fang D,Li X,et al.Theinfluence of tumor size on oncologic outcomes for patients with upper tract urothelial carcinoma after radical nephroureterectomy[J].Biomed Res Int,2016,2016:4368943.
[2]Soria F,Shariat SF,Lerner SP,et al.Epidemiology,diagnosis,preoperative evaluation and prognostic assessment of upper-tract urothelial carcinoma(UTUC)[J].World J Urol,2017,35(3):379-387.
[3]Marchioni M,Primiceri G,Cindolo L,et al.Impact of diagnostic ureteroscopy on intravesical recurrence in patients undergoing radical nephroureterectomy for upper tract urothelial cancer:a systematic review and meta-analysis[J].BJU Int,2017,120(3):313-319.
[4]Guo RQ,Hong P,Xiong GY,et al.Impact of ureteroscopy before radical nephroureterectomy for upper tract urothelial carcinomas ononcological outcomes:a meta-analysis[J].BJU Int,2018,121(2):184-193.
[5]Ma YC,Zuo L,Chen JH,et al.Modified glomerular filtration rate estimating equation for Chinese patients with chronic kidney disease[J].J Am Soc Nephrol,2006,17(10):2937-2944.
[6]Brierley JD.TNM classification of malignant tumors[M].8th ed.Wiley-Blackwell:UICC International Union Against Cancer,2017.
[7]Eble J,Sauter G,Epstein J,et al.Pathology and genetics of tumours of the urinary system and male genital organs[J].Histopathology,2010,46(5):586.
[8]Moch H,Humphrey PA,Ulbright TM,et al.WHO classification of tumours of the urinary system and male genital organs[M].4th ed.France:Lyon,2016.
[9]Tan P,Xie N,Yang L,et al.Diagnosticureteroscopy prior to radical nephroureterectomy for upper tract urothelial carcinoma increased the risk of intravesical recurrence[J].Urol Int,2018,100(1):92-99.
[10]Liu Z,Zheng S,Li X,et al.Oncologic outcomes of patients undergoing diagnostic ureteroscopy before radical nephroureterectomy for upper urinary tract urothelial carcinomas:a systematic review and meta-analysis[J].J Laparoendosc Adv Surg Tech A,2018,28(11):1316-1325.
[11]Lee HY,Yeh HC,Wu WJ,et al.The diagnostic ureteroscopy before radical nephroureterectomy in upper urinary tract urothelial carcinoma is not associated with higher intravesical recurrence[J].World J Surg Oncol,2018,16(1):135.
[12]Xylinas E,Kluth L,Passoni N,et al.Prediction of intravesical recurrence after radical nephroureterectomy:development of a clinical decision-making tool[J].Eur Urol,2014,65(3):650-658.
[13]Luo HL,Kang CH,Chen YT,et al.Diagnostic ureteroscopy independently correlates with intravesical recurrence after nephroureterectomy for upper urinary tracturothelial carcinoma[J].Ann Surg Oncol,2013,20(9):3121-3126.
[14]Lee JK,Kim KB,Park YH,et al.Correlation between the timing of diagnostic ureteroscopy and intravesical recurrence in upper tract urothelial cancer[J].Clin Genitourin Cancer,2016,14(1):e37-e41.
[15]Horuz R,Goktas C,Cetinel CA,et al.Simple preoperative parameters to assess technical difficulty during a radicalperineal prostatectomy[J].Int Urol Nephrol,2013,45(1):129-133.
[16]Liu P,Su XH,Xiong GY,et al.Diagnosticureteroscopy for upper tract urothelial carcinoma is independently associated with intravesical recurrence after radical nephroureterectomy[J].Int Braz JUrol,2016,42(6):1129-1135.
[17]Sankin A,Tin AL,Mano R,et al.Impact ofureteroscopy before nephroureterectomy for upper tract urothelial carcinoma on oncologic outcomes[J].Urology,2016,94:148-153.
[18]Lee JN,Kwon SY,Choi GS,et al.Impact of surgical wait time on oncologic outcomes in upper urinary tracturothelial carcinoma[J].J Surg Oncol,2014,110(4):468-475.
[19]Waldert M,Karakiewicz PI,Raman JD,et al.A delay in radical nephroureterectomy can lead to upstaging[J].BJU Int,2010,105(6):812-817.
[20]Boorjian S,Ng C,Munver R,et al.Impact of delay to nephroureterectomy for patients undergoing ureteroscopic biopsy and laser tumor ablation of upper tract transitional cell carcinoma[J].Urology,2005,66(2):283-287.
[21]Nison L,Roupret M,Bozzini G,et al.The oncologic impact of a delay between diagnosis and radicalnephroureterectomy due to diagnostic ureteroscopy in upper urinary tract urothelial carcinomas:results from a large collaborative database[J].World JUrol,2013,31(1):69-76.
[22]Shibing Y,Liangren L,Qiang W,et al.Impact of tumour size on prognosis of upper urinary tract urothelial carcinoma after radical nephroureterectomy:a multi-institutional analysis of 795 cases[J].BJU Int,2016,118(6):902-910.
[23]Simone G,Papalia R,Loreto A,et al.Independent prognostic value of tumour diameter and tumour necrosis in upper urinary tracturothelial carcinoma[J].BJU Int,2009,103(8):1052-1057.
[24]Espiritu PN,Sverrisson EF,Sexton WJ,et al.Effect of tumor size on recurrence-free survival of upper tract urothelial carcinoma following surgical resection[J].Urol Oncol,2014,32(5):619-624.
[25]Pieras E,Frontera G,Ruiz X,et al.Concomitant carcinoma in situ and tumour size are prognostic factors for bladder recurrence after nephroureterectomy for upper tract transitional cell carcinoma[J].BJU Int,2010,106(9):1319-1323.
[26]Milenkovic-Petronic D,Milojevic B,Djokic M,et al.The impact of tumor size on outcomes in patients with upper urinary tracturothelial carcinoma[J].Int Urol Nephrol,2014,46(3):563-569.
[27]Su X,Fang D,Li X,et al.Theinfluence of tumor size on oncologic outcomes for patients with upper tract urothelial carcinoma after radical nephroureterectomy[J].Biomed Res Int,2016,2016:4368943.