诊断性输尿管镜检查对上尿路尿路上皮癌术后膀胱内复发的影响:双中心958例回顾性研究

袁易初; 陈继民; 杜传军; 张进; 陈勇辉; 薛蔚; 黄翼然; 黄吉炜; 张楠

doi:10.13201/j.issn.1001-1420.2021.01.004

诊断性输尿管镜检查对上尿路尿路上皮癌术后膀胱内复发的影响:双中心958例回顾性研究

- 1. 浙江大学医学院附属第二医院泌尿外科(杭州, 310009);
- 2. 上海交通大学医学院附属仁济医院泌尿外科

详细信息

通讯作者: 张楠,E-mail:nanzhang@zju.edu.cn

中图分类号: R737.14

收稿日期: 2020-07-16

Impact of diagnostic ureteroscopy on intravesical recurrence in patients with upper tract urothelial carcinoma: a retrospective study of 958 patients in double centers

- 1. Department of Urology, Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, 310009, China;
- 2. Department of Urology, Renji Hospital, School of Medicine, Shanghai Jiao Tong University

More Information

Corresponding author: ZHANG Nan, E-mail: nanzhang@zju.edu.cn

Received Date: 16 July 2020

摘要

摘要: 目的：探讨诊断性输尿管镜检查（URS）对上尿路尿路上皮癌（UTUC）患者根治手术后膀胱内复发（IVR）的影响。方法：回顾性分析1998年1月—2019年6月于浙江大学医学院附属第二医院（156例）和上海仁济医院（802例）就诊的958例UTUC患者的临床及随访资料。男630例，女328例，中位年龄67（30~89）岁。518例行诊断性URS （URS组），440例未行诊断性URS （非URS组）。伴有术前肾积水499例，糖尿病史138例，有吸烟史252例，非肌层浸润型膀胱癌（NMIBC）病史或合并NMIBC119例；肿瘤位于肾盂489例，位于输尿管394例，同时位于肾盂及输尿管75例。543例采取了腹腔镜手术，415例采取了开放手术。196例术后进行辅助化疗。病理检查结果显示，肿瘤直径≤3 cm 543例，>3 cm 415例；病理分级为低级别275例，高级别683例；病理分期为T_a~1期441例，T₂期180例，T₃期308例，T₄期29例；227例进行淋巴结清扫，其中62例病理检查证实淋巴结转移；516例肿瘤呈乳头状，442例呈平坦状；48例伴有鳞状或腺样分化；150例存在淋巴血管侵犯（LVI）；134例为多灶性生长。两组年龄（P=0.660）、性别（P=0.618）、糖尿病史（P=0.418）、吸烟史（P=0.173）、术前肾盂积水（P=0.777）、WHO分级（P=0.105）和肿瘤形态（P=0.051）比较差异均无统计学意义。而相较于非URS组，URS组有着更低的开放手术（P=0.032）、伴有NMIBC病史或合并NMIBC （P<0.001）、>3 cm肿瘤（P<0.001）、浸润性分期（P<0.001）、淋巴结转移（P<0.001）、鳞状或腺样分化（P=0.018）、LVI阳性（P=0.031）及多灶性生长（P=0.032）的比例。比较两组术后1年和5年膀胱内无复发生存率（IRFS）。Kaplan-Meier法绘制生存曲线，采用Cox比例风险模分析影响IRFS的因素。结果：本研究中位随访39（2~206）个月，192例（20.0%）发生IVR，其中URS组121例，非URS组71例。URS组1年和5年IRFS分别为87.1%和71.6%，低于非URS组的90.6%和80.9%（P=0.014）。Cox多因素回归分析结果显示URS （P<0.001）、伴有NMIBC病史或合并NMIBC （P<0.001）及肿瘤直径>3 cm （P=0.005）是IVR的独立危险因素。结论：20.0%的UTUC患者行根治手术后会出现IVR，URS是IVR的独立危险因素之一。
- 上尿路尿路上皮癌 /
- 输尿管镜 /
- 根治性肾输尿管切除术 /
- 复发
Abstract: Objective: To access the effect of diagnostic ureteroscopy(URS) on intravesical recurrence(IVR) in patients with upper tract urothelial carcinoma(UTUC) after radical nephroureterectomy(RNU).Methods: Clinical and follow-up data of 958 patients who underwent nephroureterectomy in Second Affiliated Hospital of Zhejiang University(156) and Renji Hospital(802) between January 1998 and June 2019 were retrospectively analyzed. There were 630 males and 328 females with median age 67 years old(30-89). Among them, 518 patients underwent URS, 499 patients were found preoperative hydronephrosis, diabetes in 138, 252 with history of smoking and 119 with history of non-muscle invasive bladder cancer(NMIBC) or with NMIBC. Four hundred and eighty-nine patients had tumor in renal pelvic, 394 had tumor in ureter and 75 had tumor in both sites. Laparoscopic surgery was performed in 543 patients while open surgery was performed in 415 patients. One hundred and ninety-six patients received adjuvant chemotherapy after RNU. Pathologic results showed that 543 patients had a tumor ≤ 3 cm and 415 had a tumor>3 cm. Low pathological grade and high grade was diagnosed in 275 and 683 patients, respectively. The distribution of pathological stage was pT_a-1in 441, pT₂in 180, pT₃in 308 and pT₄in 29. Lymphadenectomy was performed in 227 patients and 62 patients were pathologically confirmed lymph node metastasis. Five hundred and sixteen cases(53.9%) showed papillary architecture and 442 cases(46.1%) showed sessile architecture. Forty-eight patients were found squamous or glandular differentiation. Lymphovascular invasion(LVI) was observed in 150 patients. One hundred and thirty-four patients were multifocality. There was no statistically significant difference between two groups in age(P=0.660), sex(P=0.618), history of diabetes(P=0.418), history of smoking(P=0.173), preoperative hydronephrosis(P=0.777), WHO grade(P=0.105) or tumor architecture(P=0.051). Compared with URS(-), URS(+) had lower proportion of open surgery(P=0.032), history of NMIBC or with NMIBC(P<0.001), tumor>3 cm(P<0.001), advanced pathological stage(P<0.001), lymph node metastasis(P<0.001), squamous or glandular differentiation(P=0.018), LVI(P=0.031) and multifocality(P=0.032). Kaplan-Meier method with the log-rank test was used to assess survival analysis. Multivariate analyses were conducted using Cox proportional-hazards regression model.Results: During the median follow-up period of 39(range, 2-206) months, IVR occurred in 192 patients, including 121 patients with URS and 71 patients without URS. One-year and 5-year intravesical-free survival were 87.1% and 71.6%, respectively, in patients with URS, which were significantly lower than 90.6% and 80.9% in patients without URS(P=0.014). Cox multivariate regression analysis showed that URS(P<0.001), history of NMIBC or with NMIBC(P=0.003) and tumor>3 cm(P=0.009) were independent risk factors for IVR.Conclusion: IVR occurred in 20.0% UTUC patients after RNU. URS was one of independent risk factors for IVR.
- upper tract urothelial carcinoma /
- ureteroscopy /
- radical nephroureterectomy /
- recurrence

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参考文献(18)

[1]	Rouprêt M, Babjuk M, Compérat E, et al.European Association of Urology Guidelines on Upper Urinary Tract Urothelial Cell Carcinoma:2015 Update[J].Eur Urol, 2015, 68(5):868-879.
[2]	Siegel R, Naishadham D, Jemal A.Cancer statistics, 2012[J].CA Cancer J Clin, 2012, 62(1):10-29.
[3]	Cosentino M, Palou J, Gaya JM, et al.Upper urinary tract urothelial cell carcinoma:location as a predictive factor for concomitant bladder carcinoma[J].World J Urol, 2013, 31(1):141-145.
[4]	Seisen T, Granger B, Colin P, et al.A Systematic Review and Meta-analysis of Clinicopathologic Factors Linked to Intravesical Recurrence After Radical Nephroureterectomy to Treat Upper Tract Urothelial Carcinoma[J].Eur Urol, 2015, 67(6):1122-1133.
[5]	Xylinas E, Kluth L, Passoni N, et al.Prediction of intravesical recurrence after radical nephroureterectomy:development of a clinical decision-making tool[J].Eur Urol, 2014, 65(3):650-658.
[6]	Brierley JD, Mary K, Gospodarowicz MK, et al.TNM classification of malignant tumors.UICC International Union Against Cancer[M].8th ed.NYC:Wiley-Blackwell, 2017:196-198.
[7]	Moch H, Humphrey PA, Ulbright TM, et al.WHO Classification of Tumours of the Urinary System and Male Genital Organs[M].4th ed.Lyon:IARC Press, 2016:77-98.
[8]	Fritsche HM, Novara G, Burger M, et al.Macroscopic sessile tumor architecture is a pathologic feature of biologically aggressive upper tract urothelial carcinoma[J].Urol Oncol, 2012, 30(5):666-672.
[9]	Novara G, Matsumoto K, Kassouf W, et al.Prognostic role of lymphovascular invasion in patients with urothelial carcinoma of the upper urinary tract:an international validation study[J].Eur Urol, 2010, 57(6):1064-1071.
[10]	Green DA, Rink M, Xylinas E, et al.Urothelial carcinoma of the bladder and the upper tract:disparate twins[J].J Urol, 2013, 189(4):1214-1221.
[11]	Catto JW, Yates DR, Rehman I, et al.Behavior of urothelial carcinoma with respect to anatomical location[J].J Urol, 2007, 177(5):1715-1720.
[12]	Jinzaki M, Matsumoto K, Kikuchi E, et al.Comparison of CT urography and excretory urography in the detection and localization of urothelial carcinoma of the upper urinary tract[J].AJR Am J Roentgenol, 2011, 196(5):1102-1109.
[13]	周利群, 熊耕砚, 李学松.中国人群上尿路尿路上皮癌诊疗策略选择和东西方差异[J].临床泌尿外科杂志, 2019, 34(2):83-87.
[14]	Nison L, Rouprêt M, Bozzini G, et al.The oncologic impact of a delay between diagnosis and radical nephroureterectomy due to diagnostic ureteroscopy in upper urinary tract urothelial carcinomas:results from a large collaborative database[J].World J Urol, 2013, 31(1):69-76.
[15]	Ishikawa S, Abe T, Shinohara N, et al.Impact of diagnostic ureteroscopy on intravesical recurrence and survival in patients with urothelial carcinoma of the upper urinary tract[J].J Urol, 2010, 184(3):883-887.
[16]	Luo HL, Kang CH, Chen YT, et al.Diagnostic ureteroscopy independently correlates with intravesical recurrence after nephroureterectomy for upper urinary tract urothelial carcinoma[J].Ann Surg Oncol, 2013, 20(9):3121-3126.
[17]	Liu P, Su XH, Xiong GY, et al.Diagnostic Ureteroscopy for Upper Tract Urothelial Carcinoma is Independently Associated with Intravesical Recurrence after Radical Nephroureterectomy[J].Int Braz J Urol, 2016, 42(6):1129-1135.
[18]	中国医师协会泌尿外科医师分会肿瘤专业委员会, 中国医师协会泌尿外科医师分会上尿路尿路上皮癌(CUDA-UTUC)协作组.上尿路尿路上皮癌诊断与治疗中国专家共识[J].中华泌尿外科杂志, 2018, 39(7):485-488.