保肾手术在老年人上尿路上皮肿瘤手术治疗中的疗效评价

Evaluation of curative effect of kidney-sparing surgery in elderly patients with upper urinary tract urothelial tumors

目的回顾性分析我院行保肾治疗的老年上尿路肿瘤患者临床资料,与同一时期行肾输尿管切除手术相比评价保肾手术在老年人上尿路疾病治疗中的价值。方法收集2004年4月至2017年7月在我院诊断为上尿路肿瘤行保肾治疗(输尿管镜或局段切除)并完成随访的30例老年患者,对照组为同一时期同一年龄段行肾输尿管切除术的149例老年患者,比较两组患者生存率及局部复发比例的差异。结果保肾组术后病理确诊肿瘤23例,炎性息肉3例,无病理结果4例。保肾治疗患者和根治治疗患者膀胱复发[4例(13.3%)比24例(16.1%),χ2=0.011、P=0.915]、盆腔原位复发[3例(10.0%)比6例(4.0%),χ2=0.825、P=0.364]、肿瘤特异性死亡率[2例(6.7%)比16例(10.7%),χ2=0.118、P=0.731]和总生存率[4例(13.3%)比22例(14.8%),χ2=0.410、P=0.550]比较,差异均无统计学意义。保肾组和根治组患者术后1年、5年和10年的总生存率分别为100.0%和95.1%、85.9%和84.1%、80.5%和60.8%,术后1年、5年和10年的肿瘤特异性生存率分别为100.0%和95.1%、85.7%和87.6%、85.7%和76.8%,术后1年、5年和10年的无进展生存率分别为100.0%和100.0%、90.9%和96.0%、90.9%和79.7%,生存率经Log-rank检验差异均无统计学意义(P=0.156、0.380、0.680)。结论老年患者机体状况较差,对根治术耐受不佳,术后肾功能影响较大,内镜下切除和局段性切除的保肾手术作为上尿路疾病的治疗方式,能最大限度地降低手术风险、优化患者的生活质量,应根据患者个体情况、术后并发症、肾功能恢复情况予以个体化评估,采取获益最大的术式。

Objective To evaluate the value of kidney-sparing surgery in the treatment of upper urinary tract urothelial tumors by retrospectively analyzing and comparing the clinical data of elderly patients with upper urinary tract urothelial tumors between patients undergoing kidney-sparing surgery and nephroureterectomy in our hospital during the same period. Methods Thirty elderly patients with upper urinary tract urothelial tumors were treated with kidney-sparing surgery(ureteroscopy, segmental ureteral resection)and followed up from April 2004 to July 2017.One hundred and forty-nine patients who underwent nephroureterectomy during the same period were selected as the control group.The survival rate and local recurrence rate were compared between the two groups. Results In the kidney-sparing group, 23 cases were pathologically diagnosed as tumors, 3 cases as inflammatory polyps and 4 cases without pathological findings.There were no statistically significant differences between kidney-sparing surgery and nephroureterectomy in bladder recurrence[4 cases(13.3%)vs.24 cases(16.1%),χ2= 0.011, P=0.915], pelvic orthotopic recurrence[3 cases(10.0%)vs.6 cases(4.0%),χ2=0.825, P=0.364], cancer-specific death rate[2 cases(6.7%)vs.16 cases(10.7%),χ2=0.118, P=0.731]and overall survival rate[4 cases(13.3%)vs.22 cases(14.8%),χ2=0.410, P=0.550]. There were no significant differences between kidney-sparing surgery versus nephroureterectomy among postoperative 1-year, 5-year and 10-year in the overall survival rates(100.0%vs.95.1%、85.9%vs.84.1%、80.5%vs.60.8%, P=0.156), tumor-specific survival rates(100.0%vs.95.1%, 85.7%vs.87.6%, 85.7%vs.76.8%, P=0.380)and progression-free survival rates(100.0%vs.100.0%, 90.9%vs.96.0%, 90.9%vs.79.7%, P=0.680). Conclusions Elderly patients have poor physical conditions and poor tolerance to radical surgery with a significant damage on postoperative renal function.Kidney-sparing surgery(ureteroscopy, segmental ureteral resection)as the treatment of upper urinary tract tumors can minimize the risk of surgery and optimize the quality of life.The individual assessment based on individual conditions, postoperative complications, and the recovery of renal function should be conducted and the operation with the greatest benefit should be adopted.