前列腺穿刺后不同时间间隔行根治性前列腺切除术患者的生存预后分析

Comparing survival outcomes of patients with different time intervals between puncture and radical resection forprostatecancer

目的比较前列腺癌患者前列腺穿刺后不同时间间隔行根治性前列腺切除术(RP)的短期并发症和长期生存预后的差异。方法回顾性分析2014年5月至2019年5月武汉协和医院收治的185例前列腺癌患者的病例资料, 所有患者均接受RP。根据患者前列腺穿刺确诊至根治手术的时间间隔分为≤2周组和≥4周组。≤2周组103例, 年龄67(63, 73)岁;体质量指数(BMI)23.66(22.17, 25.44)kg/m^(2);伴高血压病40例(38.8%), 糖尿病13例(12.7%);总前列腺特异性抗原(tPSA)20.63(11.88, 48.50)ng/ml, 53例(51.0%)≥20 ng/ml, f/tPSA 0.10(0.07, 0.15);30例(29.1%)穿刺病理Gleason评分≥8分;73例(70.9%)行机器人辅助根治性前列腺切除术(RARP);39例(37.8%)根治术后病理Gleason评分≥8分;69例(67.0%)病理分期Ⅲ~Ⅳ期。≥4周组82例, 年龄67(62, 69)岁;BMI 23.56(21.73, 24.91)kg/m^(2);伴高血压病35例(42.7%), 糖尿病11例(13.4%);tPSA 20.84(14.38, 46.25)ng/ml, 43例(52.0%)≥20 ng/ml, f/tPSA 0.12(0.10, 0.15);31例(37.8%)穿刺病理Gleason评分≥8分;66例(80.5%)行RARP;41例(50.0%)根治术后病理Gleason评分≥8分;58例(70.7%)病理分期Ⅲ~Ⅳ期。为减少数据偏差和混杂因素干扰, 基于患者年龄、BMI、高血压病、糖尿病、tPSA、穿刺Gleason评分、手术方式等进行倾向得分匹配, 获得71对可比病例, 两组的基线资料比较差异无统计学意义(P>0.05)。分析配对后两组的术中出血量、手术时间、术后住院时间、切缘阳性率、尿控功能等指标差异。采用Kaplan-Meier法绘制生存曲线。采用Cox回归比较两组的总生存率(OS)、无进展生存率(PFS)和疾病特异性生存率(DSS)差异, 分析影响患者生存的危险因素。比较PSA≥20 ng/ml、根治术后病理Gleason评分≥8分、病理分期Ⅲ~Ⅳ期亚组患者中不同时间间隔分组的生存差异。结果匹配的71对患者中130例有完整生存信息, 中位随访时间52(39, 71)个月。≤2周组的手术时间为244(186, 252)min, 术中出血量137(87, 300)ml;≥4周组的手术时间为246(186, 288)min, 术中出血量108(68, 228)ml, 两组比较差异无统计学意义(P>0.05)。≤2周组和≥4周组的切缘阳性率均为40.8%(29例)(P=1.000);尿失禁例数分别为14例(19.7%)和18例(25.0%)(P=0.541)。生存分析结果显示, ≤2周组和≥4周组的5年DSS分别为83.1%和98.4%(P=0.023)。单因素Cox回归分析结果显示, 穿刺病理Gleason评分≥8分(HR=18.439, 95%CI 2.262~150.337, P=0.01)、切缘阳性(HR=12.041, 95%CI 1.477~98.174, P=0.02)是不良DSS的危险因素。亚组分析结果显示, 在根治术后病理Gleason评分≥8分患者中, ≤2周组和≥4周组的5年OS分别为54.6%和95.8%(P=0.021), DSS分别为54.6%和95.8%(P=0.021);在PSA≥20 ng/ml患者中, ≤2周组和≥4周组的5年OS分别为70.1%和97.3%(P=0.028), DSS分别为72.5%和100.0%(P=0.008);在病理分期Ⅲ~Ⅳ期患者中, ≤2周组和≥4周组的5年OS分别为53.9%和92.3%(P=0.045), DSS分别为53.9%和96.1%(P=0.014)。结论与时间间隔≤2周相比, 前列腺穿刺后间隔≥4周行RP, 在术中出血量、切缘阳性率和尿失禁发生率等方面无明显差异, 但间隔≥4周可显著提高患者的DSS, 尤其对于高危前列腺癌患者, 可以同时提高OS和DSS。

Objective To investigate the differences in short-term postoperative complications and long-term survival prognosis in patients with different time interval between prostate needle biopsy and radical prostatectomy(RP).Methods The clinical data of 185 patients who underwent RP at the department of urology,Wuhan Union hospital between May 2014 and May 2019 were analyzed retrospectively.According to the time interval between biopsy and RP,they were divided into≤2 weeks and≥4 weeks group.Among them,103 cases underwent RP within 2 weeks with age of 67(63,73)years old,with BMI of 23.66(22.17,25.44)kg/m^(2),hypertension in 40 cases(38.8%),diabetes in 13 cases(12.7%),and diagnosed PSA of 20.63(11.88,48.50)ng/ml,including 53 cases(51.0%)above 20 ng/ml.The f/t PSA value was 0.1(0.07,0.15),with 30(29.1%)cases of biopsy Cleason score≥8,and 73(70.9%)cases undergoing RARP.In 39 cases(37.8%),the radical Gleason score was≥8,and 69(67.0%)cases were pathologically staged II-IV.There were 82 cases undergoing RP after 4 weeks,with age of 67(62,69)years old,BMI of 23.56(21.73,24.91)kg/m^(2),hypertension in 35 cases(42.7%),diabetes in 11 cases(13.4%)and diagnosed PSA of 20.84(14.38,46.25)ng/ml,including 43 cases(52.0%)above 20 ng/ml.The f/t PSA value was 0.12(0.10,0.15),with 27(32.9%)cases of biopsy Gleason score≥8,and 66(80.5%)cases undergoing RARP.In 41 cases(50.0%),the radical Gleason score was≥8,and 58(70.7%)cases were pathologically staged II-IV.To reduce data bias and confounding factors,71 pairs of comparable cases were obtained after propensity score matching(PSM)based on patient age,BMI,hypertension,diabetes,total prostate-specific antigen(TPSA)value,Gleason score,and surgical modality,with no statistically significant differences between the two groups at baseline.The differences in blood loss,duration of surgery,postoperative hospital stay,positive margins,and urinary incontinence between the two groups were determined using SPSS 26 software.The variation in overall survival rate(OS),progression-free survival rate(PFS)and disease-specific survival rate(DSS)among the two groups and independent risk factors were also assessed by Kaplan-Meier curves and Cox regression,and finally high risk subgroup survival differences between the two groups were evaluated according to PSA≥20,radical Gleason score≥8 and pathological stage Ⅲ~Ⅳ,respectively.Results There were 185 patients being obtained after screening,with 71 pairs remaining after matching,of which 130 had complete survival information.The median followup time was 52(39,71)months.Patients in the≤2 weeks group had an operative time of 244(186,252)min and blood loss of 137(87,300)ml,with no statistically significant differences compared with 246(186,288)min and 108(68,228)ml in the≥4-weeks group.The rate of positive margins were 40.8%in both groups(P=1.000).Urinary incontinence rates were[14(19.7%)and 18(25.0%),P=0.541],respectively.The results of survival analysis showed that the 5-year DSS rates of patients in the≤2-week group and≥4-week group were 83.1%and 98.4%,respectively(P=0.023).Univariate Cox regression analysis showed that Gleason score≥8(HR=18.439,95%CI 2.262-150.337,P=0.01)and positive margin(HR=12.041,95%CI=1.477-98.174,P=0.02)were independent risk factors for DSS.The results of subgroup analysis among radical score≥8 showed that the 5-year OS of the≤2-week group and the≥4-week group were 54.6%and 95.8%(P=0.021),and the DSS was 54.6%and 95.8%,respectively(P=0.021).Among patients with PSA≥20 ng/ml,the 0S were 54.6%and 95.8%(P=0.028),and the DSS rates were 72.5%and 100.0%(P=0.008).Among patients with pathologically staged II-IV,the 0S were 53.9%and 92.3%(P=0.045),and the DSS rates were 53.9%and 96.1%(P=0.014).Conclusions Compared with an interval of≤2 weeks,there was no significant difference in the incidence of complications such as blood loss,positive margins and urinary incontinence when RP was performed at an interval of≥4 weeks.However,a better DSS was observed in time interval≥4 weeks patients.Especially,for the high-risk prostate cancer,both OS and DSS were improved in≥4 weeks group.