基于TNM分期常规电切镜经尿道膀胱肿瘤剜除术的研究
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摘要
目的:探讨基于膀胱癌(BC)TNM分期,采用常规电切镜和电切环行经尿道膀胱肿瘤整体剜除术(ERBT)的理论基础和手术方式。方法:2015年1月～2018年12月我院收治的210例非肌层浸润性膀胱肿瘤(NMIBC)患者为研究对象,按手术方式的不同,将其随机分为基于TNM分期常规电切镜经尿道膀胱肿瘤剜除术组(TNM-ERBT组)和常规经尿道膀胱肿瘤切除术组(cTURBT组)。TNM-ERBT组120例,年龄(54.63±12.07)岁;cTURBT组90例,年龄(55.43±11.67)岁。两组均采用常规电切镜和单极电切环进行,TNM-ERBT组的手术方式是从肿瘤基底近端正常黏膜处向肿瘤基底剜除,剜除深度依据肿瘤浸润的深度进行;cTURBT组采用常规手术方式。观察指标包括术前肿瘤临床分期和分级、术中肿瘤分期、术后病理分期和分级及术后6个月的复发率等。结果:TNM-ERBT组和cTURBT组术前临床资料比较差异无统计学意义。术中TNM-ERBT能够按照TNM分期进行肿瘤剜除,准确确定肿瘤浸润深度,正确评估预后。TNM-ERBT组和cTURBT组术后6个月复发率比较差异有统计学意义(13.3%vs.31.8%,P=0.001),且TNM-ERBT组原位复发率显著下降(P<0.05)。结论:基于膀胱癌TNM分期进行ERBT是一种新的手术理念和手术方式。与cTURBT相比,TNM-ERBT能够通过术中分期,即刻明确有无肿瘤残余和预后评估,但尚需大规模临床研究来验证。
Objective: We propose a novel theory and technique of real-time intraoperative staging of bladder tumour by using the ERBT according to tumour, node, metastasis classification(TNM-ERBT). Method: TNM-ERBT and conventional transurethral resection of bladder tumor(cTURBT) were conducted, respectively, in 120 and 90 patients who diagnosed with non-muscle invasive bladder cancer(NMIBC). TNM-ERBT was performed by using continuous flow resectoscope with monopolar electrode loop to coagulate and push form normal mucosa to base of tumour retrogradely according to the depth of tumor infiltration. Patients' clinicopathological characteristics, the data of perioperative tumour stage, intraoperative real-time staging of bladder tumours and follow-up data were observed. Result: Of the 210 patients, 120 underwent TNM-ERBT and 90 underwent cTURBT. Both groups were comparable with the perioperative data. TNM-ERBT could be performed as safely as cTURBT. There was no significant difference in operative time or surgical complications. Although the overall cumulative recurrence of TNM-ERBT and cTURBT were 13.3% and 31.8%, respectively(P=0.001), in situ recurrence significantly reduced in TNM-ERBT group(P<0.05). T_a-T_1tumours do not require detrusor resection, while tumours of stage >T_2 require detrusor resection. Conclusion: TNM-ERBT is a novel technique of real-time intraoperative staging, and it can significantly reduce the in situ recurrence of bladder tumour. However, large-scale clinical verification is needed.
Objective: We propose a novel theory and technique of real-time intraoperative staging of bladder tumour by using the ERBT according to tumour, node, metastasis classification(TNM-ERBT). Method: TNM-ERBT and conventional transurethral resection of bladder tumor(cTURBT) were conducted, respectively, in 120 and 90 patients who diagnosed with non-muscle invasive bladder cancer(NMIBC). TNM-ERBT was performed by using continuous flow resectoscope with monopolar electrode loop to coagulate and push form normal mucosa to base of tumour retrogradely according to the depth of tumor infiltration. Patients' clinicopathological characteristics, the data of perioperative tumour stage, intraoperative real-time staging of bladder tumours and follow-up data were observed. Result: Of the 210 patients, 120 underwent TNM-ERBT and 90 underwent cTURBT. Both groups were comparable with the perioperative data. TNM-ERBT could be performed as safely as cTURBT. There was no significant difference in operative time or surgical complications. Although the overall cumulative recurrence of TNM-ERBT and cTURBT were 13.3% and 31.8%, respectively(P=0.001), in situ recurrence significantly reduced in TNM-ERBT group(P<0.05). T_a-T_1tumours do not require detrusor resection, while tumours of stage >T_2 require detrusor resection. Conclusion: TNM-ERBT is a novel technique of real-time intraoperative staging, and it can significantly reduce the in situ recurrence of bladder tumour. However, large-scale clinical verification is needed.
引文
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8 Mammen S,Krishna S,Quon M,et al.Diagnostic accuracy of qualitative and quantitative computed tomography analysis for diagnosis of pathological grade and stage in upper tract urothelial cell carcinoma[J].J Comput Assist Tomogr,2018,42(2):204-210.
9 Paik M L,Scolieri M J,Brown S L,et al.Limitations of computerized tomography in staging invasive bladder cancer before radical cystectomy[J].J Urol,2000,163(6):1693-1696.
10 Gontero P,Sylvester R,Pisano F,et al.Prognostic factors and risk groups in T1G3 non-muscle-invasive bladder cancer patients initially treated with Bacillus Calmette-Guerin:results of a retrospective multicenter study of 2 451 patients[J].Eur Urol,2015,67(1):74-82.
11 Kramer M W,Bach T,Wolters M,et al.Current evidence for transurethral laser therapy of non-muscle invasive bladder cancer[J].World J Urol,2011,29(4):433-442.
12 Kramer M W,Abdelkawi I F,Wolters M,et al.Current evidence for transurethral en bloc resection of non-muscle-invasive bladder cancer[J].Minim Invasive Ther Allied Technol,2014,23(4):206-213.
13 Kramer M W,Rassweiler J J,Klein J,et al.En bloc resection of urothelium carcinoma of the bladder(EBRUC):a European multicenter study to compare safety,efficacy,and outcome of laser and electrical en bloc transurethral resection of bladder tumour[J].World J Urol,2015,33(4):206-213.
14 Kramer M W,Abdelkawi I F,Wolters M,et al.Current evidence of transurethral en-bloc resection of non muscle invasive bladder cancer[J].Minim Invasive Ther Allied Technol,2014,23(4):206-213.
15 Babjuk M,Oosterlinck W,Sylvester R,et al.EAU guidelines on non-muscle-invasive urothelial carcinoma of the bladder,the 2011 update[J].Actas Urol Esp,2012,36(7):389-402.
16 Divrik R T,Sahin A F,Yildirim U,et al.Impact of routine second transurethral resection on the long-term outcome of patients with newly diagnosed pT1urothelial carcinoma with respect to recurrence,progression rate,and disease-specific survival:a prospective randomised clinical trial[J].Eur Urol,2010,58(2):185-190.
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18 Adiyat K T,Katkoori D,Soloway C T,et al."Complete transurethral resection of bladder tumor":are the guidelines being followed?[J].Urology,2010,75(2):365-367.
19 Richterstetter M,Wullich B,Amann K,et al.The value of extended transurethral resection of bladder tumour(TURBT)in the treatment of bladder cancer[J].BJU Int,2012,110(2 Pt 2):E76-E79.
20 Saito S.Transurethral en bloc resection of bladder tumours[J].J Urol,2000,166(6):2148-2150.
21 杨晓峰,张晓静,杨华,等.剥脱式经尿道膀胱肿瘤切除术[J].中华腔镜泌尿外科杂志,2013,7(3):17-20.
22 Hakenberg O W,Linne C,Manseck A,et al.Bladder wall thickness in normal adults and men with mild lower urinary tract symptoms and benign prostatic enlargement[J].Neurourol Urodyn,2000,19(5):585-593.
23 Heney N M,Ahmed S,Flanagan M J,et al.Superficial bladder cancer:progression and recurrence[J].J Urol,1983,130(6):1083-1086.
24 Yaman O,Baltaci S,Arikan N,et al.Staging with computed tomography,transrectal ultrasonography and transurethral resection of bladder tumour:comparison with final pathological stage in invasive bladder carcinoma[J].Br J Urol,1996,78(2):197-200.
25 Cumberbatch M G K,Foerster B,Catto J W F,et al.Repeat transurethral resection in non-muscle-invasive bladder cancer:A systematic review[J].Eur Urol,2018,73(6):925-933.
26 Kawada T,Ebihara K,Suzuki T,et al.A new technique for transurethral resection of bladder tumours:rotational tumour resection using a new arched electrode[J].J Urol,1997,157(6):2225-2226.
2 Humphrey P A,Moch H,Cubilla A L,et al.The 2016 WHO Classification of tumours of the urinary system and male genital organs-Part B:Prostate and bladder tumours[J].Eur Urol,2016,70(1):106-119.
3 Knowles M A,Hurst C D.Molecular biology of bladder cancer:New insights into pathogenesis and clinical diversity[J].Nat Rev Cancer,2015,15(1):25-41.
4 Pietzak E J,Bagrodia A,Cha E K,et al.Next-generation sequencing of nonmuscle invasive bladder cancer reveals potential biomarkers and rational therapeutic targets[J].Eur Urol,2017,72(6):952-959.
5 Brausi M,Collette L,Kurth K,et al.Variability in the recurrence rate at first follow-up cystoscopy after TUR in stage TaT1transitional cell carcinoma of the bladder:a combined analysis of seven EORTC studies[J].Eur Urol,2002,41(5):523-531.
6 Mariappan P,Zachou A,Grigor K M,et al.Detrusor muscle in the first,apparently complete transurethral resection of bladder tumour specimen is a surrogate marker of resection quality,predicts risk of early recurrence,and is dependent on operator experience[J].Eur Urol,2010,57(5):843-849.
7 Mariappan P,Finney S M,Head E,et al.Good quality white-light transurethral resection of bladder tumours(GQ-WLTURBT)with experienced surgeons performing complete resections and obtaining detrusor muscle reduces early recurrence in new non-muscle-invasive bladder cancer:validation across time and place and recommendation for benchmarking[J].BJU Int,2012,109(11):1666-1673.
8 Mammen S,Krishna S,Quon M,et al.Diagnostic accuracy of qualitative and quantitative computed tomography analysis for diagnosis of pathological grade and stage in upper tract urothelial cell carcinoma[J].J Comput Assist Tomogr,2018,42(2):204-210.
9 Paik M L,Scolieri M J,Brown S L,et al.Limitations of computerized tomography in staging invasive bladder cancer before radical cystectomy[J].J Urol,2000,163(6):1693-1696.
10 Gontero P,Sylvester R,Pisano F,et al.Prognostic factors and risk groups in T1G3 non-muscle-invasive bladder cancer patients initially treated with Bacillus Calmette-Guerin:results of a retrospective multicenter study of 2 451 patients[J].Eur Urol,2015,67(1):74-82.
11 Kramer M W,Bach T,Wolters M,et al.Current evidence for transurethral laser therapy of non-muscle invasive bladder cancer[J].World J Urol,2011,29(4):433-442.
12 Kramer M W,Abdelkawi I F,Wolters M,et al.Current evidence for transurethral en bloc resection of non-muscle-invasive bladder cancer[J].Minim Invasive Ther Allied Technol,2014,23(4):206-213.
13 Kramer M W,Rassweiler J J,Klein J,et al.En bloc resection of urothelium carcinoma of the bladder(EBRUC):a European multicenter study to compare safety,efficacy,and outcome of laser and electrical en bloc transurethral resection of bladder tumour[J].World J Urol,2015,33(4):206-213.
14 Kramer M W,Abdelkawi I F,Wolters M,et al.Current evidence of transurethral en-bloc resection of non muscle invasive bladder cancer[J].Minim Invasive Ther Allied Technol,2014,23(4):206-213.
15 Babjuk M,Oosterlinck W,Sylvester R,et al.EAU guidelines on non-muscle-invasive urothelial carcinoma of the bladder,the 2011 update[J].Actas Urol Esp,2012,36(7):389-402.
16 Divrik R T,Sahin A F,Yildirim U,et al.Impact of routine second transurethral resection on the long-term outcome of patients with newly diagnosed pT1urothelial carcinoma with respect to recurrence,progression rate,and disease-specific survival:a prospective randomised clinical trial[J].Eur Urol,2010,58(2):185-190.
17 Herr H W,Donat S M.Quality control in transurethral resection of bladder tumours[J].BJU Int,2008,102(9 Pt B):1242-1246.
18 Adiyat K T,Katkoori D,Soloway C T,et al."Complete transurethral resection of bladder tumor":are the guidelines being followed?[J].Urology,2010,75(2):365-367.
19 Richterstetter M,Wullich B,Amann K,et al.The value of extended transurethral resection of bladder tumour(TURBT)in the treatment of bladder cancer[J].BJU Int,2012,110(2 Pt 2):E76-E79.
20 Saito S.Transurethral en bloc resection of bladder tumours[J].J Urol,2000,166(6):2148-2150.
21 杨晓峰,张晓静,杨华,等.剥脱式经尿道膀胱肿瘤切除术[J].中华腔镜泌尿外科杂志,2013,7(3):17-20.
22 Hakenberg O W,Linne C,Manseck A,et al.Bladder wall thickness in normal adults and men with mild lower urinary tract symptoms and benign prostatic enlargement[J].Neurourol Urodyn,2000,19(5):585-593.
23 Heney N M,Ahmed S,Flanagan M J,et al.Superficial bladder cancer:progression and recurrence[J].J Urol,1983,130(6):1083-1086.
24 Yaman O,Baltaci S,Arikan N,et al.Staging with computed tomography,transrectal ultrasonography and transurethral resection of bladder tumour:comparison with final pathological stage in invasive bladder carcinoma[J].Br J Urol,1996,78(2):197-200.
25 Cumberbatch M G K,Foerster B,Catto J W F,et al.Repeat transurethral resection in non-muscle-invasive bladder cancer:A systematic review[J].Eur Urol,2018,73(6):925-933.
26 Kawada T,Ebihara K,Suzuki T,et al.A new technique for transurethral resection of bladder tumours:rotational tumour resection using a new arched electrode[J].J Urol,1997,157(6):2225-2226.