女性膀胱癌患者腹腔镜膀胱全切术与开放膀胱全切术的倾向性评分匹配比较
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摘要
目的:比较女性膀胱癌患者腹腔镜膀胱全切术和开放膀胱全切术两种术式的围手术及肿瘤学预后差异。方法:回顾性分析2006—2017年于北京大学第一医院泌尿外科行根治性膀胱全切术的女性膀胱癌患者91例,将腹腔镜膀胱全切患者以1∶1的比例运用倾向性评分匹配(propensity score matching,PSM)方法与开放膀胱全切患者进行匹配,匹配因素包括年龄、体重指数(body mass index,BMI)、美国麻醉医师协会(American Society of Anesthesiologists,ASA)评分、T分期及N分期,比较匹配前后两组患者的围手术及肿瘤学特征,应用Kaplan-Meier法比较匹配前后两组间总生存时间(overall survival,OS)、肿瘤特异生存时间(cancer specific survival,CSS)、无进展生存时间(progression free survival,PFS)。采用COX多因素回归分析校正匹配因素,进行敏感性分析。结果:共纳入行开放膀胱全切术患者65例,腹腔镜膀胱全切患者26例,中位随访时间为38个月(四分位距18～69个月)。与开放膀胱全切组相比,腹腔镜膀胱全切组患者年龄更小(P<0.001),术前ASA评分更低(P=0.018),匹配后,22例开放膀胱全切患者与腹腔镜膀胱全切患者匹配成功。匹配前,腹腔镜膀胱全切组术中失血量更少(P=0.005),术中输血率更低(P<0.001),清扫淋巴结数目更多(P=0.035),围手术期并发症发生率较低(P=0.015),两组间OS(P=0.698)、CSS(P=0.942)、PFS(P=0.837)差异无统计学意义;匹配后,腹腔镜膀胱全切组术中失血量仍较开放膀胱全切组更少(P=0.009),术中输血率更低(P=0.001),围手术期并发症发生率较低(P=0.040),但清扫淋巴结数目两组间差异无统计学意义,两组间OS(P=0.432)、CSS(P=0.429)、PFS(P=0.284)差异亦无统计学意义。COX多因素回归分析显示,手术方式并不是女性膀胱癌患者OS(HR 1.134,95%CI 0.335～3.835,P=0.839)、CSS(HR1.051,95%CI 0.234～4.719,P=0.949)、PFS (HR 0.538,95%CI 0.138～2.095,P=0.371)的独立预测因子。结论:腹腔镜膀胱全切术术中出血量少、术中输血率低、围术期并发症少,但本研究并无证据表明女性膀胱癌患者接受腹腔镜膀胱全切术的预后优于开放膀胱全切术。
Objective:To compare the perioperative and oncologic outcomes of female patients receiving laparoscopic radical cystectomy(LRC) and open radical cystectomy(ORC).Methods:Retrospective review of 91 consecutive female patients with urothelial carcinoma of bladder undergoing radical cystectomy at a single academic institution from 2006 to 2017.Those female patients received open radical cystectomy were matched to the patients who underwent laparoscopic radical cystectomy by using propensity score matching in 1 ∶ 1 ratio.The matching factors included age,body mass index(BMI),American Society of Anesthesiologists(ASA) score,pathologic stage and pathologic nodal stage.The perioperation and oncology characteristics were compared,and Kaplan-Meier method was used to analyze the overall survival(OS),cancer specific survival(CSS) and progression-free survival(PFS) estimates.Finally,we did a sensitive analysis by using multivariable COX regression of all the patients,adjusting for the matching factors.Results:There were 65 ORC and 26 LRC patients identified in this cohort with urothelial carcinoma of bladder,the median follow-up time was 38 months(interquartile range 18-69).The age(P<0.001) and ASA scores(P=0.018) were less for LRC before being matched.There were22 LRC and 22 ORC patients matching successfully.Before being matched,the estimate blood loss(P=0.005),transfusion rate(P<0.001) and total complications rate(P=0.015) were less for LRC,and the lymph nodes yield was greater for LRC,but there were no differences in OS(P=0.698),CSS(P=0.942) and PFS(P=0.837) between the two groups.After being matched,the estimate blood loss(P=0.009),transfusion rate(P=0.001) and total complications rate(P=0.040) were less for LRC,but there was no difference in the lymph nodes yield.Besides,there were no statistic differences in OS(P=0.432),CSS(P=0.429) and PFS(P=0.284) between the two groups.In addition,in multivariable COX regression analysis,surgical approaches(LRC/ORC) were not found to be a predictor of OS(HR 1.134,95% CI 0.335-3.835,P=0.839),CSS(HR 1.051,95% CI 0.234-4.719,P=0.949) and PFS(HR 0.538,95% CI 0.138-2.095,P=0.371) of the female patients with urothelial carcinoma of bladder.Conclusion:It is advantageous for laparoscopic radical cystectomy in terms of estimating blood loss,transfusion rate and complication rate.But there was no evidence that laparoscopic radical cystectomy for female patients with bladder cancer had a better oncologic prognosis than open radical cystectomy from this study.
Objective:To compare the perioperative and oncologic outcomes of female patients receiving laparoscopic radical cystectomy(LRC) and open radical cystectomy(ORC).Methods:Retrospective review of 91 consecutive female patients with urothelial carcinoma of bladder undergoing radical cystectomy at a single academic institution from 2006 to 2017.Those female patients received open radical cystectomy were matched to the patients who underwent laparoscopic radical cystectomy by using propensity score matching in 1 ∶ 1 ratio.The matching factors included age,body mass index(BMI),American Society of Anesthesiologists(ASA) score,pathologic stage and pathologic nodal stage.The perioperation and oncology characteristics were compared,and Kaplan-Meier method was used to analyze the overall survival(OS),cancer specific survival(CSS) and progression-free survival(PFS) estimates.Finally,we did a sensitive analysis by using multivariable COX regression of all the patients,adjusting for the matching factors.Results:There were 65 ORC and 26 LRC patients identified in this cohort with urothelial carcinoma of bladder,the median follow-up time was 38 months(interquartile range 18-69).The age(P<0.001) and ASA scores(P=0.018) were less for LRC before being matched.There were22 LRC and 22 ORC patients matching successfully.Before being matched,the estimate blood loss(P=0.005),transfusion rate(P<0.001) and total complications rate(P=0.015) were less for LRC,and the lymph nodes yield was greater for LRC,but there were no differences in OS(P=0.698),CSS(P=0.942) and PFS(P=0.837) between the two groups.After being matched,the estimate blood loss(P=0.009),transfusion rate(P=0.001) and total complications rate(P=0.040) were less for LRC,but there was no difference in the lymph nodes yield.Besides,there were no statistic differences in OS(P=0.432),CSS(P=0.429) and PFS(P=0.284) between the two groups.In addition,in multivariable COX regression analysis,surgical approaches(LRC/ORC) were not found to be a predictor of OS(HR 1.134,95% CI 0.335-3.835,P=0.839),CSS(HR 1.051,95% CI 0.234-4.719,P=0.949) and PFS(HR 0.538,95% CI 0.138-2.095,P=0.371) of the female patients with urothelial carcinoma of bladder.Conclusion:It is advantageous for laparoscopic radical cystectomy in terms of estimating blood loss,transfusion rate and complication rate.But there was no evidence that laparoscopic radical cystectomy for female patients with bladder cancer had a better oncologic prognosis than open radical cystectomy from this study.
引文
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[14]孟一森,王宇,范宇,等.根治性膀胱全切手术及尿流改道方式对高龄患者围手术期并发症的影响[J].北京大学学报(医学版),2016,48(4):632-637.
[15]Shabsigh A,Korets R,Vora KC,et al.Defining early morbidity of radical cystectomy for patients with bladder cancer using a standardized reporting methodology[J].Eur Urol,2009,55(1):164-174.
[16]Stein JP,Lieskovsky G,Cote R,et al.Radical cystectomy in the treatment of invasive bladder cancer:long-term results in 1 054patients[J].J Clin Oncol,2001,19(3):666-675.
[17]Studer UE,Burkhard FC,Schumacher M,et al.Twenty years experience with an ileal orthotopic low pressure bladder substitute:lessons to be learned[J].J Urol,2006,176(1):161-166.
[18]Parra RO,Andrus CH,Jones JP,et al.Laparoscopic cystectomy:initial report on a new treatment for the retained bladder[J].JUrol,1992,148(4):1140-1144.
[19]Aboumarzouk OM,Hughes O,Narahari K,et al.Safety and feasibility of laparoscopic radical cystectomy for the treatment of bladder cancer[J].J Endourol,2013,27(9):1083-1095.
[20]Biondi-Zoccai G,Romagnoli E,Agostoni P,et al.Are propensity scores really superior to standard multivariable analysis?[J].Contemp Clin Trials,2011,32(5):731-740.
[21]焦明旭,张晓,刘迪,等.倾向性评分匹配在非随机对照研究中的应用[J].中国卫生统计,2016,33(2):350-352.
[22]王永吉,蔡宏伟,夏结来,等.倾向指数匹配法与Logistic回归分析方法对比研究[J].现代预防医学,2011,38(12):2217-2219.
[23]Challacombe BJ,Bochner BH,Dasgupta P,et al.The role of laparoscopic and robotic cystectomy in the management of muscleinvasive bladder cancer with special emphasis on cancer control and complications[J].Eur Urol,2011,60(4):767-775.
[24]Rios GE,Lopez-Tello GJ,Martinez-Pineiro LL.Laparoscopic radical cystectomy[J].Clin Transl Oncol,2009,11(12):799-804.
[25]Chade DC,Laudone VP,Bochner BH,et al.Oncological outcomes after radical cystectomy for bladder cancer:open versus minimally invasive approaches[J].J Urol,2010,183(3):862-869.
[26]Liedberg F,Mansson W.Lymph node metastasis in bladder cancer[J].Eur Urol,2006,49(1):13-21.
[27]Dotan ZA,Kavanagh K,Yossepowitch O,et al.Positive surgical margins in soft tissue following radical cystectomy for bladder cancer and cancer specific survival[J].J Urol,2007,178(6):2308-2312.
[28]Hadjizacharia P,Stein JP,Cai J,et al.The impact of positive soft tissue surgical margins following radical cystectomy for high-grade,invasive bladder cancer[J].World J Urol,2009,27(1):33-38.
[2]Pang C,Guan Y,Li H,et al.Urologic cancer in China[J].Jpn J Clin Oncol,2016,46(6):497-501.
[3]Tang K,Li H,Xia D,et al.Laparoscopic versus open radical cystectomy in bladder cancer:A systematic review and metaanalysis of comparative studies[J].PLo S One,2014,9(5):e95667.
[4]Esquinas C,Alonso JM,Mateo E,et al.Prospective study comparing laparoscopic and open radical cystectomy:Surgical and oncological results[J].Actas Urol Esp,2018,42(2):94-102.
[5]Guillotreau J,Game X,Mouzin M,et al.Radical cystectomy for bladder cancer:morbidity of laparoscopic versus open surgery[J].J Urol,2009,181(2):554-559.
[6]Ha US,Kim SI,Kim SJ,et al.Laparoscopic versus open radical cystectomy for the management of bladder cancer:Mid-term oncological outcome[J].Int J Urol,2010,17(1):55-61.
[7]Haber GP,Crouzet S,Gill IS.Laparoscopic and robotic assisted radical cystectomy for bladder cancer:A critical analysis[J].Eur Urol,2008,54(1):54-62.
[8]Hemal AK,Kolla SB.Comparison of laparoscopic and open radical cystoprostatectomy for localized bladder cancer with 3-year oncological followup:a single surgeon experience[J].J Urol,2007,178(6):2340-2343.
[9]Porpiglia F,Renard J,Billia M,et al.Open versus laparoscopyassisted radical cystectomy:Results of a prospective study[J].JEndourol,2007,21(3):325-329.
[10]Wang SZ,Chen LW,Zhang YH,et al.Comparison of handassisted laparoscopic and open radical cystectomy for bladder cancer[J].Urol Int,2010,84(1):28-33.
[11]Lin T,Fan X,Zhang C,et al.A prospective randomised controlled trial of laparoscopic vs.open radical cystectomy for bladder cancer:perioperative and oncologic outcomes with 5-year follow-up T Lin et al[J].Br J Cancer,2014,110(4):842-849.
[12]Dobruch J,Daneshmand S,Fisch M,et al.Gender and bladder cancer:a collaborative review of etiology,biology,and outcomes[J].Eur Urol,2016,69(2):300-310.
[13]Stenzl A.Cystectomy:technical considerations in male and female patients[J].EAU Update Series,2005,3(3):138-146.
[14]孟一森,王宇,范宇,等.根治性膀胱全切手术及尿流改道方式对高龄患者围手术期并发症的影响[J].北京大学学报(医学版),2016,48(4):632-637.
[15]Shabsigh A,Korets R,Vora KC,et al.Defining early morbidity of radical cystectomy for patients with bladder cancer using a standardized reporting methodology[J].Eur Urol,2009,55(1):164-174.
[16]Stein JP,Lieskovsky G,Cote R,et al.Radical cystectomy in the treatment of invasive bladder cancer:long-term results in 1 054patients[J].J Clin Oncol,2001,19(3):666-675.
[17]Studer UE,Burkhard FC,Schumacher M,et al.Twenty years experience with an ileal orthotopic low pressure bladder substitute:lessons to be learned[J].J Urol,2006,176(1):161-166.
[18]Parra RO,Andrus CH,Jones JP,et al.Laparoscopic cystectomy:initial report on a new treatment for the retained bladder[J].JUrol,1992,148(4):1140-1144.
[19]Aboumarzouk OM,Hughes O,Narahari K,et al.Safety and feasibility of laparoscopic radical cystectomy for the treatment of bladder cancer[J].J Endourol,2013,27(9):1083-1095.
[20]Biondi-Zoccai G,Romagnoli E,Agostoni P,et al.Are propensity scores really superior to standard multivariable analysis?[J].Contemp Clin Trials,2011,32(5):731-740.
[21]焦明旭,张晓,刘迪,等.倾向性评分匹配在非随机对照研究中的应用[J].中国卫生统计,2016,33(2):350-352.
[22]王永吉,蔡宏伟,夏结来,等.倾向指数匹配法与Logistic回归分析方法对比研究[J].现代预防医学,2011,38(12):2217-2219.
[23]Challacombe BJ,Bochner BH,Dasgupta P,et al.The role of laparoscopic and robotic cystectomy in the management of muscleinvasive bladder cancer with special emphasis on cancer control and complications[J].Eur Urol,2011,60(4):767-775.
[24]Rios GE,Lopez-Tello GJ,Martinez-Pineiro LL.Laparoscopic radical cystectomy[J].Clin Transl Oncol,2009,11(12):799-804.
[25]Chade DC,Laudone VP,Bochner BH,et al.Oncological outcomes after radical cystectomy for bladder cancer:open versus minimally invasive approaches[J].J Urol,2010,183(3):862-869.
[26]Liedberg F,Mansson W.Lymph node metastasis in bladder cancer[J].Eur Urol,2006,49(1):13-21.
[27]Dotan ZA,Kavanagh K,Yossepowitch O,et al.Positive surgical margins in soft tissue following radical cystectomy for bladder cancer and cancer specific survival[J].J Urol,2007,178(6):2308-2312.
[28]Hadjizacharia P,Stein JP,Cai J,et al.The impact of positive soft tissue surgical margins following radical cystectomy for high-grade,invasive bladder cancer[J].World J Urol,2009,27(1):33-38.