诊断性输尿管镜检查对上尿路尿路上皮癌术后膀胱内复发的影响:双中心958例回顾性研究  

Impact of diagnostic ureteroscopy on intravesical recurrence in patients with upper tract urothelial carcinoma:a retrospective study of 958 patients in double centers

作　　者：袁易初 陈继民[1] 杜传军[1] 张进[2] 陈勇辉[2] 薛蔚[2] 黄翼然[2] 黄吉炜[2] 张楠[1] YUAN Yichu;CHEN Jimin;DU Chuanjun;ZHANG Jin;CHEN Yonghui;XUE Wei;HUANG Yiran;HUANG Jiwei;ZHANG Nan(Department of Urology,Second Affiliated Hospital,School of Medicine,Zhejiang University,Hangzhou,310009,China;Department of Urology,Renji Hospital,School of Medicine,Shanghai Jiao Tong University)

机构地区：[1]浙江大学医学院附属第二医院泌尿外科,杭州310009 [2]上海交通大学医学院附属仁济医院泌尿外科

出　　处：《临床泌尿外科杂志》2021年第1期18-23,共6页Journal of Clinical Urology

摘　　要：目的:探讨诊断性输尿管镜检查(URS)对上尿路尿路上皮癌(UTUC)患者根治手术后膀胱内复发(IVR)的影响。方法:回顾性分析1998年1月—2019年6月于浙江大学医学院附属第二医院(156例)和上海仁济医院(802例)就诊的958例UTUC患者的临床及随访资料。男630例,女328例,中位年龄67(30~89)岁。518例行诊断性URS(URS组),440例未行诊断性URS(非URS组)。伴有术前肾积水499例,糖尿病史138例,有吸烟史252例,非肌层浸润型膀胱癌(NMIBC)病史或合并NMIBC119例;肿瘤位于肾盂489例,位于输尿管394例,同时位于肾盂及输尿管75例。543例采取了腹腔镜手术,415例采取了开放手术。196例术后进行辅助化疗。病理检查结果显示,肿瘤直径≤3 cm 543例,>3 cm 415例;病理分级为低级别275例,高级别683例;病理分期为Ta~1期441例,T2期180例,T3期308例,T4期29例;227例进行淋巴结清扫,其中62例病理检查证实淋巴结转移;516例肿瘤呈乳头状,442例呈平坦状;48例伴有鳞状或腺样分化;150例存在淋巴血管侵犯(LVI);134例为多灶性生长。两组年龄(P=0.660)、性别(P=0.618)、糖尿病史(P=0.418)、吸烟史(P=0.173)、术前肾盂积水(P=0.777)、WHO分级(P=0.105)和肿瘤形态(P=0.051)比较差异均无统计学意义。而相较于非URS组,URS组有着更低的开放手术(P=0.032)、伴有NMIBC病史或合并NMIBC(P<0.001)、>3 cm肿瘤(P<0.001)、浸润性分期(P<0.001)、淋巴结转移(P<0.001)、鳞状或腺样分化(P=0.018)、LVI阳性(P=0.031)及多灶性生长(P=0.032)的比例。比较两组术后1年和5年膀胱内无复发生存率(IRFS)。Kaplan-Meier法绘制生存曲线,采用Cox比例风险模分析影响IRFS的因素。结果:本研究中位随访39(2~206)个月,192例(20.0%)发生IVR,其中URS组121例,非URS组71例。URS组1年和5年IRFS分别为87.1%和71.6%,低于非URS组的90.6%和80.9%(P=0.014)。Cox多因素回归分析结果显示URS(P<0.001)、伴有NMIBC病史或合并NMIBC(P<0.001)及肿瘤直径>3 cm(P=0.Objective:To access the effect of diagnostic ureteroscopy(URS)on intravesical recurrence(IVR)in patients with upper tract urothelial carcinoma(UTUC)after radical nephroureterectomy(RNU).Methods:Clinical and follow-up data of 958 patients who underwent nephroureterectomy in Second Affiliated Hospital of Zhejiang University(156)and Renji Hospital(802)between January 1998 and June 2019 were retrospectively analyzed.There were 630 males and 328 females with median age 67 years old(30-89).Among them,518 patients underwent URS,499 patients were found preoperative hydronephrosis,diabetes in 138,252 with history of smoking and 119 with history of non-muscle invasive bladder cancer(NMIBC)or with NMIBC.Four hundred and eighty-nine patients had tumor in renal pelvic,394 had tumor in ureter and 75 had tumor in both sites.Laparoscopic surgery was performed in 543 patients while open surgery was performed in 415 patients.One hundred and ninety-six patients received adjuvant chemotherapy after RNU.Pathologic results showed that 543 patients had a tumor≤3 cm and 415 had a tumor>3 cm.Low pathological grade and high grade was diagnosed in 275 and 683 patients,respectively.The distribution of pathological stage was pTa-1in 441,pT2in 180,pT3in 308 and pT4in 29.Lymphadenectomy was performed in 227 patients and 62 patients were pathologically confirmed lymph node metastasis.Five hundred and sixteen cases(53.9%)showed papillary architecture and 442 cases(46.1%)showed sessile architecture.Forty-eight patients were found squamous or glandular differentiation.Lymphovascular invasion(LVI)was observed in 150 patients.One hundred and thirty-four patients were multifocality.There was no statistically significant difference between two groups in age(P=0.660),sex(P=0.618),history of diabetes(P=0.418),history of smoking(P=0.173),preoperative hydronephrosis(P=0.777),WHO grade(P=0.105)or tumor architecture(P=0.051).Compared with URS(-),URS(+)had lower proportion of open surgery(P=0.032),history of NMIBC or with NMIBC(P<0.001),tumor>3 cm(P<0.001)

关 键 词：上尿路尿路上皮癌 输尿管镜 根治性肾输尿管切除术 复发 

分 类 号：R737.14[医药卫生—肿瘤]