机器人辅助腹腔镜根治性膀胱切除术的预后风险因素

Prognostic risk factors in robot-assisted laparoscopic radical cystectomy

目的探讨机器人辅助腹腔镜根治性膀胱切除术(RARC)后的预后风险因素。方法回顾性分析南京鼓楼医院2014年12月至2018年12月收治的224例行RARC患者的临床和随访资料,男193例,女31例。平均年龄68(36~92)岁。7例(3.1%)接受新辅助化疗。125例(55.8%)美国麻醉医师协会(ASA)评分>2分。平均体质指数23.4(15.4~35.5)kg/m2。所有患者均行RARC。使用Kaplan-Meier法绘制无复发生存率(RFS)、癌症特异性生存率(CSS)和总生存率(OS)曲线。使用Cox比例风险回归模型评估RARC患者生存结局与围手术期和病理因素的相关性。结果本组224例手术,中位手术时间380(160~670)min。中位术中估计失血量为350(100~1900)ml,72例(32.1%)术中输血。术后T分期分别为≤T1期82例,T2期64例,T3期57例,T4期21例。淋巴结转移49例(21.9%),手术切缘阳性12例(5.4%),伴淋巴脉管侵犯(LVI)82例(36.6%)。术后辅助化疗41例(18.3%)。中位随访时间24(11~60)个月。5年累积OS、RFS和CSS分别为57.15%、48.84%和59.60%。单因素Cox回归分析结果显示T分期(HR=5.764,95%CI 1.926~17.249,P=0.002;HR=4.086,95%CI 1.611~10.364,P=0.003;HR=9.391,95%CI 2.118~41.637,P=0.003)、N分期(HR=6.446,95%CI 3.438~12.087,P<0.001;HR=5.661,95%CI 3.086~10.385,P<0.001;HR=5.980,95%CI 2.982~11.992,P<0.001)、LVI(HR=3.319,95%CI 2.008~5.486,P<0.001;HR=2.894,95%CI 1.782~4.701,P<0.001;HR=3.471,95%CI 2.017~5.974,P<0.001)、ASA评分(HR=2.888,95%CI 1.619~5.150,P<0.001;HR=1.765,95%CI 1.060~2.940,P=0.029;HR=2.612,95%CI 1.424~4.792,P=0.002)、体质指数(HR=0.886,95%CI 0.819~0.957,P=0.002;HR=0.885,95%CI 0.819~0.955,P=0.002;HR=0.862,95%CI 0.792~0.938,P=0.001)、年龄(HR=1.580,95%CI 1.250~1.997,P<0.001;HR=1.362,95%CI 1.088~1.705,P=0.007;HR=1.530,95%CI 1.190~1.968,P=0.001)和术中输血(HR=1.899,95%CI 1.160~3.108,P=0.011;HR=2.218,95%CI 1.371~3.587,P=0.001;HR=2.227,95%CI 1.312~3.782,P=0.003)是OS、RFS和CSS的显著预测因素。多因素Cox回归分析结果显示,T分期(HR=4.506,95%CI 1.433~14.175,P=0.01;HR=3.159,95%CI 1.180~8.454,P=0.022;HR=7.810,95%CI 1.674~36.444,P=0.009),N分期(HR=6.096,95%CI 2.981~12.467,P<0.001;HR=5.368,95%CI 2.683~10.740,P<0.001;HR=5.539,95%CI 2.497~12.288,P<0.001)和ASA评分(HR=6.180,95%CI 2.371~16.110,P<0.001;HR=2.702,95%CI 1.175~6.215,P=0.019;HR=6.471,95%CI 2.290~18.286,P<0.001)分别是OS、RFS和CSS的独立预测因素,辅助化疗(HR=0.434,95%CI 0.202~0.930,P=0.032)是OS的独立预测因素。结论T分期、N分期和ASA评分是RARC术后患者OS、RFS和CSS的独立预测因素,辅助化疗是OS的独立预测因素。

Objective To analyze the prognostic factors of robot-assisted radical cystectomy(RARC).Methods The clinical data of 224 patients underwent RARC from December 2014 to December 2018 in Nanjing Drum Hospital were reviewed.There were 193 males and 31 females,aged 36-92 years,with mean of 68 years.There were 7 patients(3.1%)undergoing neoadjuvant chemotherapy,the ASA scores of 125 patients(55.8%)were more than 2,and the mean body mass index was 23.4(15.4-35.5)kg/m2.All patients were treated with RARC,with 72(32.1%)patients undergoing intraoperative blood transfusion.Kaplan-Meier method was used to analyze recurrence-free survival rate(RFS),cancer-specific survival rate(CSS)and overall survival rate(OS).Cox multivariate risk ratio model was used to evaluate the correlation between survival outcome and perioperative and pathological factors in patients treated with RARC.Results For pathological status,there were 82 of≤T1,64 of T2,57 of T3 and 21 of T4.Of all the patients,49(21.9%)had lymph node metastasis,12(5.4%)had positive surgical margin,82(36.6%)had lymphovascular invasion(LVI),and 41(18.3%)underwent adjuvant chemotherapy.Follow-up time was between 11-60 months,and the median follow-up time was 24 months.The 5-year cumulative OS,RFS and CSS were 57.15%,48.84%and 59.60%,respectively.Univariate Cox regression analysis showed that T stage(HR=5.764,95%CI 1.926-17.249,P=0.002;HR=4.086,95%CI 1.611-10.364,P=0.003;HR=9.391,95%CI 2.118-41.637,P=0.003),N stage(HR=6.446,95%CI 3.438-12.087,P<0.001;HR=5.661,95%CI 3.086-10.385,P<0.001;HR=5.980,95%CI 2.982-11.992,P<0.001),LVI(HR=3.319,95%CI 2.008-5.486,P<0.001;HR=2.894,95%CI 1.782-4.701,P<0.001;HR=3.471,95%CI 2.017-5.974,P<0.001),American Society of Anesthesia(ASA)score(HR=2.888,95%CI 1.619-5.150,P<0.001;HR=1.765,95%CI 1.060-2.940,P=0.029;HR=2.612,95%CI 1.424-4.792,P=0.002),body mass index(HR=0.886,95%CI 0.819-0.957,P=0.002;HR=0.885,95%CI 0.819-0.955,P=0.002;HR=0.862,95%CI 0.792-0.938,P=0.001),age(HR=1.580,95%CI 1.250-1.997,P<0.001;HR=1.362,95%CI 1.088-1.705,P=0.007;HR=1.530,95%CI 1.190-1.968,P=0.001)and intraoperative blood transfusion(HR=1.899,95%CI 1.160-3.108,P=0.011;HR=2.218,95%CI 1.371-3.587,P=0.001;HR=2.227,95%CI 1.312-3.782,P=0.003)were significantly related to survival outcome.Multivariate Cox regression analysis showed that T stage(HR=4.506,95%CI 1.433-14.175,P=0.01;HR=3.159,95%CI 1.180-8.454,P=0.022;HR=7.810,95%CI 1.674-36.444,P=0.009),N stage(HR=6.096,95%CI 2.981-12.467,P<0.001;HR=5.368,95%CI 2.683-10.740,P<0.001;HR=5.539,95%CI 2.497-12.288,P<0.001)and ASA score(HR=6.180,95%CI 2.371-16.110,P<0.001;HR=2.702,95%CI 1.175-6.215,P=0.019;HR=6.471,95%CI 2.290-18.286,P<0.001)were independent predictors of RFS,CSS and OS,and adjuvant chemotherapy(R=0.434,95%CI 0.202-0.930,P=0.032)could only predict OS.Conclusion T stage,N stage and ASA were main independent predictors of postoperative survival outcomes,and adjuvant chemotherapy was independent predictor of OS.