Study on influence of CT pelvimetry and clinicopathological parameters on the difficulty of laparoscopic radical cystectomy for bladder cancer
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摘要: 目的 利用术前CT测量骨盆各径线和临床病理参数评估腹腔镜下膀胱癌根治术难度的影响因素。方法 收集2018年1月—2021年8月连续腹腔镜下膀胱癌根治手术的70例患者，通过薄层增强CT建立三维图像，测量骨盆各径线大小，根据骨盆各径线参数和基础资料，判断对因变量手术时间和术中出血量的影响，对这些参数进行单变量和多变量分析，筛选出可能影响手术时间和出血量的因素。再将筛选出来的危险因素进行logistic多因素分析，根据logistic回归分析特点对危险因素赋值，建立评分系统，最后利用受试者工作曲线(ROC)评价该评分系统效能，并用校准曲线判断其预测准确性。结果 中骨盆前后径、上耻骨到尾骨的距离以及中骨盆棘突直径对手术操作难度的影响较大。根据以上因素建立函数Y，ROC曲线结果表明，Y值为0.83可作为判断腹腔镜下膀胱癌根治术难易程度的预测值，其灵敏度和特异度分别为97.1%和66.6%。结论 术前CT骨盆测量可以为腹腔镜下膀胱癌根治术难度的评估提供有用的指标。Abstract: Objective To evaluate the influencing factors of difficulty of laparoscopic radical cystectomy by measuring the diameter of pelvis and clinicopathologic parameters with preoperative CT.Methods From January 2018 to August 2021, 70 consecutive patients who underwent radical cystectomy were examined by three-dimensional images established by thin-section contrast-enhanced CT to measure the size of each diameter line of the pelvis. According to the parameters of each diameter line of the pelvis and basic data, the effects on the dependent operation time and intraoperative blood loss were judged. Univariate and multivariate analyses were performed for these parameters to screen out the factors that may affect the operation time and blood loss. Logistic multivariate analysis was performed on the selected risk factors, and the risk factors were assigned values according to the characteristics of logistic regression analysis to establish a scoring system. Finally, the receiver operating characteristic (ROC) was used to evaluate the efficacy of the scoring system, and the calibration curve was used to determine its prediction accuracy.Results The anteroposterior diameter of the middle pelvis, the distance from the suprapubic bone to the coccyx, and the diameter of the spinous process of the middle pelvis had a greater impact on the difficulty of surgical operation. The results of ROC curve showed that Y 0.83 could be used as the predictive value to determine the ease of laparoscopic cystectomy, and its sensitivity and specificity were 97.1% and 66.6%, respectively.Conclusion Preoperative CT pelvis measurement can provide a useful index for evaluating the difficulty of laparoscopic radical cystectomy.
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Key words:
- bladder cancer /
- laparoscopy /
- pelvis measurement /
- clinical pathology /
- difficulty of surgery
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表 1 骨盆径线测量及定义
骨盆测量参数/mm 定义 骨盆入口前后径 耻骨联合上缘中点到骶骨岬前缘中点的一条线 中骨盆前后径 耻骨联合下缘中点经坐骨棘连线中点到骶尾交界的距离 骨盆出口前后径 从耻骨联合的正中下方到尾骨顶端的一条线 耻骨联合高度 耻骨联合两端中点的连线 骶尾部距离 从骶角到尾骨尖端的距离 耻骨上端到尾骨距离 从耻骨联合的正中上部到尾骨顶端的一条线 中骨盆棘突直径 中骨盆横径、两侧坐骨棘最内点之间的距离 坐骨结节间径 坐骨结节最内点之间的距离 
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表 2 单因素分析骨盆各径线和基础资料
例(%)，X±S 因素 容易组 困难组 P 年龄/岁 64.89±8.84 65.03±10.49 0.952 BMI 24.20±5.70 24.00±5.50 0.529 有无基础疾病 0.138 无 10(15.9) 16(47.1) 有 26(84.1) 18(52.9) 骨盆入口前后径/mm 110.16±4.34 107.68±4.90 0.028 中骨盆前后径/mm 100.24±5.64 97.12±3.89 0.009 骨盆出口前后径/mm 91.04±7.26 89.09±4.67 0.184 耻骨联合高度/mm 42.60±2.02 43.35±2.73 0.197 耻骨上端到尾骨距离/mm 114.11±6.97 111.02±2.80 0.019 骶尾部距离/mm 117.91±7.13 116.11±3.43 0.187 中骨盆棘突间径/mm 103.45±9.91 93.95±5.83 < 0.001 坐骨结节间径/mm 87.80±9.07 83.48±8.60 0.045
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表 3 单因素分析病理分级及临床分期
例 组别 病理分级 T分期 N分期 低级别 高级别 T1 T2 T3 T4 N0 N1 N2 N3 容易组 14 22 10 9 12 5 35 1 0 0 困难组 13 21 4 15 10 5 30 3 0 1 P 0.955 0.231 0.350
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表 4 多因素分析影响腹腔镜下膀胱癌根除术难度的危险因素
变量 β SE Wald df P Exp(β) 95%CI 骨盆入口前后径 0.504 0.835 0.364 1 0.546 1.655 0.322~8.494 中骨盆前后径 -2.571 1.114 5.322 1 0.021 0.076 0.009~0.679 上耻骨到尾骨距离 -1.529 0.731 4.374 1 0.036 0.217 0.052~0.908 棘突间径 -3.575 1.330 7.224 1 0.007 0.028 0.002~0.380 坐骨结节间径 -1.580 0.865 3.335 1 0.068 0.206 0.038~1.123 常量 11.584 2.987
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表 5 2组在手术时间和出血量之间的差异比较
X±S 组别 中骨盆前后径 上耻骨到尾骨距离 棘突间径 手术时间/min 出血量/mL 手术时间/min 出血量/mL 手术时间/min 出血量/mL 较短组 129.46±13.24 218.80±42.70 129.31±13.82 219.23±43.61 130.96±13.33 225.32±40.48 较长组 118.25±10.10 185.00±35.61 122.42±11.90 196.45±40.21 116.65±6.72 176.09±27.76 P 0.001 0.003 0.031 0.028 ＜0.001 ＜0.001
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表 6 各危险因素和模型函数Y的ROC曲线下面积
参数 AUC SE P 95%CI 中骨盆前后径 0.703 0.063 0.004 0.578~0.827 上耻骨到尾骨距离 0.686 0.064 0.008 0.560~0.812 棘突间径 0.839 0.048 < 0.001 0.746~0.933 函数Y 0.871 0.044 < 0.001 0.785~0.958
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