改良型保留盆腔自主神经的子宫颈癌根治性手术对患者膀胱功能及预后的影响

Evaluation of postoperative bladder function and prognosis after modified nerve sparing radical hysterectomy

目的 探讨改良型保留盆腔自主神经的子宫颈癌根治性手术——保留神经平面的子宫广泛性切除术（NPSRH）对患者膀胱功能及预后的影响.方法 收集2008年1月-2013年3月在中国医学科学院北京协和医学院肿瘤医院接受开腹NPSRH治疗的102例Ⅰ b1～Ⅱa2期子宫颈癌患者（NPSRH组）,采用Excel 2010软件中随机选取公式随机选取同期接受常规开腹子宫广泛性切除术（CRH）的204例Ⅰ b1～Ⅱa2期子宫颈癌患者作为对照（CRH组）,两组患者的年龄、体质指数、临床分期、病理类型以及是否接受新辅助化疗、术后辅助治疗等相关指标比较,差异均无统计学意义（P＞0.05）.对两组患者的手术相关指标、术后膀胱功能的恢复情况（以术后导尿时间评价术后近期膀胱功能,采用生命质量调查法评价术后远期膀胱功能）及复发、生存状况进行比较,并对影响子宫颈癌患者预后的因素进行单因素和多因素分析.结果 （1）手术相关指标：NPSRH组、CRH组患者的中位手术时间分别为268.8、242.4 min,中位住院时间分别为14.6、17.2d,分别比较,差异均有统计学意义（P＜0.01）;两组患者的中位术中出血量（分别为394、450 ml）、术中输血比例[分别为46.1％（47/102）、41.7％ （85/204）]和术后并发症发生率[分别为14.7％ （15/102）、11.8％（24/204）]较,差异均无统计学意义（P＞0.05）.（2）术后膀胱功能：NPSRH组、CRH组患者的中位术后导尿时间分别为9.1、15.2d,两组比较,差异有统计学意义（P＜0.01）;生命质量调查法显示,NPSRH组、CRH组（末次随访时无复发生存且配合随访的患者分别为85、167例）患者术后远期尿频[14.1％ （12/85）、33.5％ （56/167）]、尿潴留[23.5％（20/85）、38.9％（65/167）]、尿失禁[36.5％ （31/85）、54.5％（91/167）]及用力排尿[10.6％（9/85）、40.7％ （68/167）]的发生率比较,差异均有统计学意义（P＜0.05）.（3）复发和生存情况：NPSRH组、CRH组患者的复发率分别为10.8％（11/102）、12.2％（25/204）,两组比较,差异无统计学意义（P =0.707）;3年无复发生存率（RFS）分别为88.5％及91.1％,3年总生存率（OS）分别为93.7％及96.3％,两组分别比较,差异均无统计学意义（P＞0.05）.（4）预后影响因素分析：单因素分析显示,病理类型、淋巴结转移和淋巴脉管间隙受侵是影响患者3年RFS和3年OS的危险因素（P＜0.05）,而保留神经平面与否对患者3年RFS和3年OS无明显影响（P＞0.05）;多因素分析显示,病理类型、淋巴结转移是影响患者3年RFS的独立危险因素（P＜0.05）,淋巴结转移也是影响患者3年OS的独立危险因素（P=0.001）.结论 NPSRH治疗能明显改善了患者术后的膀胱功能,且不影响患者的预后.

Objective To compare the nerve plane sparing radical hysterectomy （NPSRH） with conventional radical hysterectomy （CRH） in terms of postoperative bladder function and prognosis.Methods One hundred and two patients with International Federation of Gynecology and Obstetrics （FIGO） stage Ⅰ b1-Ⅱa2 cervical cancer were treated by open NPSRH （study group） from January 2008 to March 2013.During the same time periods,two hundred and four patients who underwent open CRH were randomly selected as the control group.Age,pathological type and FIGO stage were matched.Results The median operation time in NPSRH group and CRH group were 268.8 and 242.4 minutes,respectively （P 〈 0.01）.The median hospital stay were 14.6 and 17.2 days （P 〈 0.01）.The median volume of blood loss in the two groups were respectively 394 and 450 ml （P 〉 0.05）.The blood transfusion rate was respectively 46.1% （47/102） and 41.7% （85/204; P 〉 0.05）.The rate of postoperative complications were not significantly difference [14.7% （15/102） vs 11.8% （24/204）,P 〉 0.05].The median duration of catheterization was 9.1 and 15.2 days between two groups （P 〈0.01）.Eighty-five patients in NPSRH group and one hundred and sixty-seven patients in CRH group completed the telephone interview about the long-term bladder function.The incidence of long-term urinary frequency [14.1% （12/85） vs 33.5% （56/167）],urinary incontinence[36.5% （31/85） vs 54.5% （91/167）],urinary retention [23.5% （20/85） vs 38.9% （65/ 167）] and straining to void [10.6% （9/85） vs 40.7% （68/167）],there were significantly lower in NPSRH group than those in CRH group（all P 〈0.05）.The rate of recurrence was 10.8% （11/102） in NPSRH group and 12.2% （25/204） in CRH group（P =0.707）.Three-year recurrence-free survival（RFS） estimate was 88.5% in NPSRH group and 91.1% in CRH group （P =0.746）.Three-year overall survival （OS） estimate was 93.7% in NPSRH group and 96.3% in CRH group （P =0.701）.The univariate analysis shown that pathological type,lymph node metastases,and lymph-vascular space invasion （LVSI） presented the trend for a worst 3-year RFS and OS （P 〈 0.05）.The multivariate analyses shown that both pathological type and lymph node metastases were associated with a worst 3-year RFS （P 〈 0.05）.Lymph node metastases was a significant independent predictor of 3-year OS （P =0.001）.NPSRH was not a significant independent predictor by Cox regression model analyses.Conclusion NPSRH contributes to bladder function recovery without compromising survival.