腹腔镜下根治性膀胱切除术中扩大淋巴结清扫与标准淋巴结清扫的疗效比较

Comparison of efficacy between extended pelvic lymph node dissection and standard pelvic lymph node dissection in laparoscopic radical cystectomy

目的探讨膀胱癌患者行腹腔镜下根治性膀胱切除术中，扩大淋巴结清扫（extended pelvic lymph node dissection，ePLND）和标准淋巴结清扫（standard pelvic lymph node dissection，sPLND）的疗效差异。方法回顾性分析我院2011年1月至2016年10月行腹腔镜下根治性膀胱切除术＋盆腔淋巴结清扫术、病例完整且符合纳入标准的62例膀胱癌患者的临床资料。男52例，女10例。年龄42～83岁，平均（62.5±9.6）岁。其中ePLND组27例，sPLND组35例，比较两组患者的手术时间、术中出血量、术中及术后并发症发生率、术后进食时间、术后下地活动时间、术后住院天数、淋巴结阳性率、淋巴结密度，以及患者的无病生存率差异。结果62例手术均顺利完成。ePLND组和sPLND组在手术时间[（326.2±77.5）min与（345.5±66.8）min，P＝0.297]、出血量[（198.2±77.5）ml与（213.7±160.0）ml，P＝ 0.590]、术中并发症发生例数（0例与5例，F＝0.063）、术后并发症发生例数（8例与9例，P＝0.732）、术后进食时间[（4.8±2.2）d与（4.6±1.9）d，P＝0.817]、术后下地活动时间[（1.9±0.8）d与（1.9±0.9）d，P＝0.838]、术后住院天数[（15.6±7.5）d与（16.0±5.9）d，P＝0.483]等方面比较差异均无统计学意义（均P〉0.05）。两组共清扫淋巴结994枚，阳性淋巴结100枚。ePLND组和sPLND组每例患者清扫淋巴结数量比较差异有统计学意义[（23.2±6.6）枚与（10.5±3.6）枚，P〈0.01]。ePLND组淋巴结阳性患者比率为40.74%（11/27），淋巴结密度为11.66%（73/626）；sPLND组分别为28.57%（10/35）和7.34%（27/368），差异有统计学意义（P〈0.05）。ePLND组和sPLND组随访3、6、12、24个月的无病生存率分别为96%、91%、80%、71%和97%、94%、84%、80%，差异无统计学意义（P＝0.546）。结论腹腔镜下根治性膀胱切除术中，ePLND和sPLND具有相似的手术安全性和预后，应根据患者情况选择合适术式。

Objective To investigate the difference of surgical efficacy between extended lymph node dissection and standard lymph node dissection in laparoscopic radical cystectomy. Methods We retrospectively analyzed 62 bladder cancer cases, icluding 52 males and 10 females patients in our hospital from January 2011 to October 2016, who underwent laparoscopic radical cystectomy and pelvic lymph node dissection. Their mean age was （62.5 _＋ 9.6 ） years, ranged from 42 to 83 years. 27 cases were underwent extended lymph node dissection and 35 cases were underwent standard lymph node dissection respectively. The basic characters, operative time, intraoperative blood loss, intraoperative and postoperative complications, postoperative eating time, postoperative activity time, postoperative hospital stay, lymph nodes positive rate, lymph node density, and cancer-free survival were evaluated. Results All patients were underwent successful operation. There was no significant difference in operation time[ （326. 2 ± 77. 5 ） min vs. （345.5 ± 66. 8） min, P = 0. 297 ], blood loss [ （ 198.2 ± 77.5 ） ml vs. （213.7 ± 160. 0） ml, P = 0. 590] , intraoperative complications （0/27 vs. 5/35, F = 0. 063 ）, postoperative complications （ 8/27 and 9/35, P = 0. 732 ）, postoperative eating time [ （4. 8 ± 2. 2 ） d vs. （4. 6 ± 1.9 ） d, P = 0. 8171, postoperative activity time[ （ 1.9 ± 0. 8）d vs. （1.9 ±0. 9）d, P = 0. 838 ] and postoperative hospital stay[（15.6 ±7.5 ）d vs. （16. 0±5.9） d, P = 0. 483 ]. In this study, 994 lymph nodes and 100 positive lymph nodes were dissected. There were significant differences in the number of lymph nodes dissected in the two groups （23.2 ± 6. 6 vs. 10. 5 ± 3.6, P 〈 0. 01 ）. 40. 74% （11/27） of cases in ePLND were lymph node positive and the lymph node density was 11.7% （73/626）, which was higher than that of the sPLND group （28. 57% vs. 7. 34% , respectively）. In regard to prognosis, the cancer-flee survival rate （ DFS） of ePLND group was 96% , 91% , 80% and 71% at 3, 6, 12 and 24 months follow-up respectively. The other group was 97% 94% , 84% , 80% correspondingly. And no significant difference was detected （ P = 0. 546 ）. Although there was no significant difference （ P 〉 0. 05 ） , DFS of ePLND group tended to be higher than that of sPLND group in lymph node positive subgroups. Conclusions Extended lymph node dissection and standard lymph node dissection have similar surgical safety and prognosis, and appropriate surgical procedures should be selected according to the patient＇s condition.