肌层浸润性膀胱癌青年患者行机器人膀胱根治性切除术的疗效分析

Clinical outcomes for young patients with muscular invasive bladder cancer who received robot-assisted radical cystectomy

目的探索肌层浸润性膀胱癌青年患者行机器人膀胱根治性切除术的疗效。方法回顾性分析2014年10月1日至2018年10月31日郑州大学第一附属医院收治的行机器人膀胱癌根治术的肌层浸润性膀胱癌青年(≤44岁)患者的临床资料,包括年龄、性别、体质指数、肿瘤发现方式、肿瘤位置、肿瘤大小、合并疾病、手术时间、术中失血量、尿流改道方式、术后并发症、术后住院时间、术后病理结果以及术后恢复情况。结果共纳入24例患者,其中男18例(75%)、女6例(25%),年龄(40.4±3.5)岁,体质指数(24.7±2.5)kg/m2。初次就诊时临床表现为肉眼血尿19例(79%),下尿路刺激症状者4例(17%),剩余1例(4%)由体检发现。肿瘤单发者15例(62%),多发者9例(38%);14例(58%)膀胱肿瘤直径≥3 cm;术前合并肾积水者3例(13%)。24例患者均成功实施机器人膀胱癌根治术,手术时间(325.8±57.2)min,失血量200(162,300)ml,术后住院时间11(9,22)d。17例(80%)患者尿流改道采用回肠原位新膀胱术,剩余7例(20%)采用Bricker回肠膀胱术。对于保留性神经的男性患者,有6例(6/9)在术后1年恢复性功能。术后病理分期及分级:T2期16例(67%),T3期7例(29%),T4期1例(4%);6例(25%)发生淋巴结转移;低级别尿路上皮癌8例(33%),高级别尿路上皮癌14例(58%),腺癌1例(4%),小细胞神经内分泌癌1例(4%)。术后早期并发症多轻微,2例(8%)患者发生ClavienⅢ级并发症,远期并发症少。患者随访时间(26±12)个月,1例(4%)患者因化疗死于肝肾功能衰竭,1例(4%)患者发生复发,4例(17%)患者发生远处转移。淋巴结转移(P=0.018)和≥T3分期(P=0.038)与术后肿瘤发生远处转移和复发有关联。结论血尿是青年肌层浸润性膀胱癌的首要临床表现,且肿瘤级别高和分期晚;机器人膀胱癌根治术治疗青年肌层浸润性膀胱癌安全有效,术后并发症少,保留性神经有助于性功能恢复;高肿瘤分期(≥T3)和淋巴转移与肿瘤发生远处转移和复发有关联。

Objective To evaluate the clinical features,surgical effects and factors that may affect prognosis of muscular invasive bladder cancer in young people.Methods The clinical data of young(aged 44 and below)patients with muscle invasive bladder cancer who underwent robot-assisted radical cystectomy at the First Affiliated Hospital of Zhengzhou University from October 1st,2014 to October 31st,2018 were retrospectively analyzed,which included age,gender,body mass index(BMI),tumor discovery method,tumor location,tumor size,comorbid diseases,operation time,intraoperative blood loss,urinary diversion method,postoperative complications,postoperative hospital stay,postoperative pathology and follow-up results.Results A total of 24 patients were enrolled in this study,and 18(75%)were male and 6(25%)were female.The age was(40.4±3.5)years and the BMI was(24.7±2.5)kg/m2.At initial visit,there were 19(79%)patients who presented with hematuria,4(17%)with lower urinary tract symptoms,and 1(4%)was discovered by routine examination.Fifteen(62%)patients had single tumor,and 9(38%)had multiple tumors.The tumor diameter of 14(58%)patients were≥3 cm and 3(13%)patients were combined with hydronephrosis.All patients received robot-assisted radical cystectomy successfully.The operative time was(325.8±57.2)min,and the blood loss during operation was 200(162,300)ml.The duration of postoperative hospital stay was 11(9,22)days.And according to different urinary diversion methods,17(80%)patients had ileal orthotopic neobladder and 7(20%)had ileal conduit.For patients whose sexual nerves were preserved,6(6/9)recovered their sexual function after one year of the surgery.The final pathological results showed that 16(67%)patients were in T2 stage,7(29%)patients were in T3 stage and that 1(4%)patient in T4 stage.There were 6(25%)patients with lymphatic metastasis,8(33%)with low-grade papillary urothelial carcinoma,14(58%)with high-grade papillary urothelial carcinoma,1(4%)with adenocarcinoma and 1(4%)with small cell neuroendocrine carcinoma.Early complications of the patients were mostly slight,and only 2(8%)patients had ClavienⅢdegree complications,while few patients had late complications.The follow-up time was(26±12)months.During the follow-up time,there was 1(4%)patient who died because of liver and kidney failure.Distant metastasis occurred in 4(17%)cases and 1(4%)patient had urothelial carcinoma on one side of the ureter.Lymphatic metastasis(P=0.018)and≥T3(P=0.038)stage were associated with the prognosis.Conclusions For young patients with muscular invasive bladder cancer,the major initial presentation is hematuria,and most of them have advanced tumor stage and high malignant degree.Robot-assisted radical cystectomy is a safe and effective operation method with less postoperative complications,and protecting sexual nerve contributes to the recovery of sexual function.Advanced tumor stage(≥T3)and lymphatic metastasis are associated with distant metastasis and recurrence.