根治性膀胱切除术前行最大限度TURBT对膀胱多发肿瘤预后的影响

Effect of maximum TURBT before radical cystectomy on the prognosis of multiple bladder tumors

目的探讨根治性膀胱切除术(RC)前行最大限度经尿道膀胱肿瘤切除术(TURBT)对膀胱多发肿瘤患者预后的影响。方法回顾性分析新疆医科大学第一附属医院2010年8月至2018年8月收治的90例行RC的膀胱多发肿瘤患者的临床资料及随访记录。男72例,女18例。平均年龄(64.6±11.7)(20~84)岁,<60岁50例,≥60岁40例;男性中位年龄68岁,女性中位年龄69岁。肿瘤直径≥3 cm 52例,<3 cm 38例。肿瘤病灶为2处53例,>2处37例。根据TURBT切除范围将患者分为最大限度组和诊断性电切组。最大限度组55例(61.1%),男42例,女13例;平均年龄(56.2±12.0)岁;肿瘤直径≥3 cm 29例,<3 cm 26例。诊断性电切组35例(38.9%),男30例,女5例;平均年龄(59.8±13.4)岁;肿瘤直径≥3 cm 23例,<3 cm 12例。两组术前资料比较差异均无统计学意义(P>0.05)。最大限度组于电切镜下完整切除所有肉眼可见的肿瘤,并从基底部和周围黏膜取组织单独送病理检查。诊断性电切组:术中发现膀胱内多发肿物,表面粗糙,并且两侧输尿管口未见,在肿瘤较多处、输尿管口及周围黏膜组织取标本送活检,膀胱内肿瘤未全切除。两组患者术后均行RC。分析两种术式与各临床病理因素的关系。采用Kaplan-Meier法分析膀胱多发肿瘤患者无复发生存率(RFS)和总生存率(OS),并采用log-rank法分析生存曲线的差异。采用单因素log-rank与多因素Cox回归分析RFS和OS的影响因素。结果本研究90例RC均顺利完成,术后中位随访时间30(15~46)个月,失访1例。RC术后尿道复发6例(6.7%),盆腔复发9例(10.0%)。死亡15例(16.7%),其中8例因术后盆腔复发死亡,3例因心肌梗死死亡,2例因骨转移死亡,2例因肺转移死亡。Kaplan-Meier法结果显示,最大限度组RC术后1、3、5年OS分别为96.67%、86.05%、80.86%,1、3、5年RFS分别为89.97%、76.93%、71.41%。单因素分析结果显示,病理分期(P=0.018)、尿道复发(P<0.01)、盆腔复发(P<0.01)、最大限度TURBT(P<0.01)为OS和RFS的影响因素。盆腔复发患者死亡风险高于无盆腔复发患者(HR=41.850,95%CI 12.597~139.036,P<0.01);尿道复发患者死亡风险高于无尿道复发患者(HR=8.128,95%CI 1.551~42.606,P<0.01);最大限度组RC术后死亡风险低于诊断性电切组(HR=0.164,95%CI 0.036~0.746,P<0.01)。最大限度组RC术后仅2例(3.9%)盆腔复发,无尿道复发;诊断性电切组RC术后盆腔复发7例(6.1%),尿道复发6例(6.7%),两组比较差异有统计学意义(P<0.05)。多因素分析结果显示,尿道复发(HR=8.128,95%CI 1.551~42.606,P=0.013)、盆腔复发(HR=41.850,95%CI 12.597~139.036,P<0.01)是OS的独立危险因素;尿道复发(HR=18.637,95%CI 5.443~63.817,P<0.01)和盆腔复发(HR=22.94,95%CI 8.635~60.973,P<0.01)是RFS的独立危险因素。最大限度TURBT是OS(HR=0.164,95%CI 0.036~0.746,P=0.019)和RFS(HR=0.153,95%CI 0.048~0.493,P<0.01)的独立保护因素。结论对于膀胱多发肿瘤患者,RC术前行最大限度TURBT可减少RC术后尿道和盆腔复发,能改善患者的预后。最大限度TURBT是OS和RFS的独立保护因素。尿道复发、盆腔复发是OS和RFS的独立危险因素。

Objective to investigate the effect of maximum transurethral cystectomy((TURBT))before radical cystectomy on the prognosis of patients with multiple bladder tumors.Methods the clinical data and follow-up records of 90 patients with multiple bladder tumors treated in our hospital from August 2010 to August 2018 were analyzed retrospectively.There were 72 males and 18 females.The age ranged from 20 to 84 years old,with an average of(64.6±11.7)years.There were 50 cases of age<60 years old and 40 cases of≥60 years old.The median age of male was 68 years old and that of female was 69 years old.The diameter of Tumor was≥3 cm in 52 cases and<3 cm in 38 cases.There were 53 cases with 2 lesions and 37 cases with more than 2 lesions.According to the extent of TURBT resection,55 patients(61.1%)were divided into maximum TURBT group,42 males and 13 females,with an average age of(56.2±12.0)years.Tumor diameter≥3 cm(n=29)and<3 cm(n=26).There were 35 cases(38.9%)in the non-maximal TURBT group,including 30 males and 5 females,with an average age of(59.8±13.4)years.In the non-maximum TURBT group.The diameter of tumor was≥3 cm in 23 cases and<3 cm in 12 cases.There was no significant difference in preoperative data between the two groups(P>0.05).In the maximum TURBT group,all the tumors visible to the naked eye were completely removed,and the tissues were taken from the base and surrounding mucosa for pathological examination.Diagnostic TURBT group:multiple tumors in the bladder were found during the operation,the surface was rough,and there were no ureteral orifices on both sides.Samples of ureteral orifice and surrounding mucosal tissues were taken for biopsy,and the bladder tumor was not completely removed.Radical cystectomy was performed in both groups.The relationship between two different surgical methods and clinicopathological factors was analyzed.After that,the recurrence-free survival time(RFS)and overall survival time(OS)of patients were analyzed by Kaplan-Meier method,and the statistical difference of survival curve was analyzed by Log-rank method.Univariate Log-rank and multivariate Cox regression analysis were used to analyze the influencing factors of RFS and OS.Results In this study,90 cases of radical cystectomy were completed successfully.The postoperative follow-up time was 7-60 months,1 case lost follow-up,and the median follow-up time was 30(15-46)months.There was no significant difference in all data between maximum TURBT group and diagostic TURBT group(P>0.05).Urethral recurrence occurred in 6(6.7%)cases and pelvic recurrence in 9(10%)cases after RC.15(16.7%)cases died,of which 8 cases died of postoperative pelvic recurrence,3 cases died of myocardial infarction,2 cases died of bone metastasis and 2 cases died of pulmonary metastasis.The results of Kaplan-Meier method showed that the 1-,3-and 5-year overall survival rates of patients with RC after maximum TURBT were 96.67%,86.05%and 80.86%,respectively,and the 1-,3-and 5-year relapse-free survival rates were 89.97%,76.93%and 71.41%,respectively.Univariate Log-rank results showed that pathological stage(P=0.018),urethral recurrence(P<0.01),pelvic recurrence(P<0.01)and maximum TURBT(P<0.01)were the risk factors of OS and RFS.The risk of death in patients with pelvic recurrence was higher than that in patients without pelvic recurrence(HR=41.850,95%CI 12.597-139.036,P<0.01).The risk of death in patients with urethral recurrence was higher than that in patients without urethral recurrence(HR=8.128,95%CI 1.551-42.606,P<0.01).The risk of death in patients with RC after maximum TURBT was lower than that in patients with diagnostic TURBT(HR=0.164,95%CI 0.036-0.746,P<0.01).Among them,there were only 2(3.9%)pelvic recurrence in patients with maximum TURBT combined with RC,7(6.1%)pelvic recurrence and 6(6.7%)urethral recurrence in patients without maximum TURBT combined with RC,and there was significant difference between patients without maximum TURBT and patients without maximum urethral recurrence.Multivariate Cox analysis showed that urethral recurrence(HR=8.128,95%CI 1.551-42.606,P=0.013,P<0.01)and pelvic recurrence(HR=41.850,95%CI:12.597-139.036,P<0.01)were independent risk factors for OS,and urethral recurrence(HR=18.637,95%CI 5.443-63.817,P<0.01)and pelvic recurrence(HR=22.94,95%CI 8.635-60.973,P<0.01)were independent risk factors for RFS.The maximum TURBT was the independent protective factor of OS(HR=0.164,95%CI 0.036-0.746 P<0.01)and RFS(HR=0.153,95%CI 0.048-0.493,P<0.01).Conclusions For patients with multiple bladder tumors,radical cystectomy with maximum TURBT before radical cystectomy might reduce urethral and pelvic recurrence after radical cystectomy,and might improve the prognosis of patients with multiple bladder cancer.Maximum TURBT is an independent protective factor for OS and RFS.Urethral recurrence and pelvic recurrence are independent risk factors for OS and RFS.