根治性膀胱全切术后不同尿流改道方式的并发症比较和肾功能下降影响因素分析

Comparison of complications and analysis of factors affecting renal function decline after laparoscopic radical cystectomy with different urinary diversion methods

目的探讨肌层浸润性尿路上皮癌行根治性膀胱全切术后不同尿流改道方式的并发症及肾功能下降的影响因素。方法回顾性分析本院2017年1月至2021年12月间术前病理证实肌层浸润性膀胱癌行腹腔镜下根治性膀胱全切的46例患者临床资料,其中回肠导管改道方式21例,输尿管皮肤造口改道方式25例。比较两组的围术期资料、术后病理、术后并发症及随访结果。结果两组在年龄[(67±6)岁和(73±8)岁,t=3.132,P=0.003]、年龄调整后Charlson合并症指数[(3.80±1.15)和(4.52±1.03),t=2.223,P=0.031]、预后营养指数[(48.81±5.74)和(43.64±4.74),t=3.347,P=0.002]、手术时间[(449±108)min和(326±130)min,t=3.454,P=0.001]、住院时间[(20.1±11.1)d和(13.3±5.2)d,t=2.762,P=0.008)]、术后3个月内Clavien 3级及以上并发症比例(4/21和0/25,χ^(2)=2.105,P<0.05)以及无管化比例(18/21和5/25,χ^(2)=6.373,P<0.01)比较差异均有统计学意义。Logistic多因素分析显示围术期输血和尿路感染是术后12个月肾功能下降的独立影响因素。两组术后尿路感染培养出的最常见细菌均为屎肠球菌。结论腹腔镜下根治性膀胱全切输尿管皮肤造口术对于年龄较大及身体较虚弱的患者具有住院时间短、围手术期并发症少的特点,但需要留置输尿管支架的比例更高。围术期输血和尿路感染是根治性膀胱全切术后肾功能下降的主要影响因素。

Objective To compare the complications associated with various urinary flow diversion methods and identify the factors that contribute to the decline in renal function after radical total cystectomy for myoinfiltrating urothelial carcinoma.MethodsThis study conducted a retrospective analysis on the clinical data of 46 patients with pathologically confirmed muscle-invasive bladder cancer.The patients underwent laparoscopic radical cystectomy with either ileal conduit diversion(n=21)or ureterocutaneous diversion(n=25)between January 2017 and December 2021.Perioperative data,postoperative pathology,postoperative complications,and follow-up results were compared between the two groups.ResultsThe study found significant differences between the two groups in terms of age[(67±6)years vs.(73±8)years,t=3.132,P=0.003],Charlson comorbidity index adjusted for age[(3.80±1.15)vs.(4.52±1.03),t=2.223,P=0.031],prognostic nutritional index[(48.81±5.74)vs.(43.64±4.74),t=3.347,P=0.002],operation time[(449±108)minutes vs.(326±130)minutes,P=0.001]],hospital stay[(20.1±11.1)days vs.(13.3±5.2)days,t=2.762,P=0.008],proportion of Clavien grade 3 or higher complications within 3 months after surgery(4/21 vs 0/25,χ^(2)=2.105,P<0.05),and proportion of stoma-free patients(18/21 vs.5/25,χ^(2)=6.373,P<0.01).According to Logistic multivariate analysis,perioperative blood transfusion and urinary tract infection were identified as independent risk factors for renal function decline 12 months after surgery.Escherichia coli was found to be the most common bacteria cultured from urinary tract infections in both groups after surgery.ConclusionsLaparoscopic radical cystectomy with ureterocutaneous diversion offers benefits such as shorter hospital stays and fewer perioperative complications for older and frail patients.However,a higher proportion of patients may require ureteral stenting.It is important to note that perioperative blood transfusion and urinary tract infection are major risk factors for renal function decline following radical cystectomy.