肾输尿管全长切除术两种不同术式的双中心疗效对比
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摘要
目的:比较经腹完全腹腔镜肾输尿管全长切除术(complete transperitoneal laparoscopic nephroureterectomy,CTNU)和传统后腹腔镜肾输尿管全长切除术(traditional retroperitoneoscopic nephroureterectomy,TRNU)治疗上尿路尿路上皮癌(upper urinary tract urothelial carcinoma,UTUC)的手术安全性和疗效。方法:收集2011年1月至2018年12月期间在北京大学第一医院泌尿外科和福建省立医院泌尿外科接受CTNU和TRNU手术治疗的UTUC病例,比较两种手术方式患者在临床资料、围术期参数、术后随访结果等方面的差异。结果:最终共纳入病例266例,其中CTNU组94例,TRNU组172例。与CTNU组相比,TRNU组左侧病变比例更大(P<0.05)。两组患者年龄、性别分布、体重指数(body mass index,BMI)、美国麻醉医师学会评分(American society of anesthesiologists score,ASA score)、肿瘤所在侧别等方面均差异无统计学意义(P>0.05)。所有病例均完成手术,TRNU中有1例因左肾动脉损伤加行开放血管修补术。CTNU组手术时间为(202.9±76.7) min、术中出血量(68.4±73.3) mL、术后引流管留置天数(3.9±1.5) d、引流液总量(181.7±251.5) mL、术后住院天数(7.8±4.1) d; TRNU组手术时间为(203.5±68.7) min、术中出血量(130.2±252.1) mL、术后引流管留置天数(4.3±1.6) d、引流液总量(179.1±167.5) mL、术后住院天数(8.2±3.7) d。CTNU组术中出血量少于TRNU组,且差异有统计学意义(P=0.005)。中位随访时间39个月(1～88个月),TRNU组的5年总体生存率(overall survival,OS)、肿瘤特异性生存率(cancer specific survival,CSS)、无膀胱复发生存率(intra-vesical recurrence free survival,IvRFS)、无病生存率(disease free survival,DFS)分别为75.6%、86.9%、73.8%、57.5%; CTNU组的5年OS、CSS、IvRFS、DFS分别为66.3%、83.5%、75.9%、58.6%,两组间差异均无统计学意义。结论:CTNU手术是一种安全有效的手术治疗方式,但尚需更进一步的前瞻性随机对照研究加以证实。
Objective:To compare the efficacy and safety of complete transperitoneal laparoscopic nephroureterectomy(CTNU) and traditional retroperitoneoscopic nehroureterectomy(TRNU) for the management of upper urinary tract urothelial carcinoma(UTUC).Methods:We retrospectively collected the clinical data of UTUC patients who underwent CTNU or TRNU surgery from January 2011 to December 2018 in Peking University First Hospital and Fujian Provincial Hospital,and compared the clinical characteristics,perioperative parameters,and follow-up results between the CTNU and TRNU surgeries.Results:Finally,a total of 266 cases were included,with 94 cases in the CTNU group and 172 cases in the TRNU group.The proportion of left side lesions was bigger in TRNU group when compared with CTNU group(P<0.05).No significant differences were observed in clinical characteristics,such as age,gender,body mass index(BMI),American society of anesthesiologists score(ASA score) and tumor laterality.All surgery procedures were completed.The vascular resparing was performed by reason that left arteria renalis was injured accidently during surgical operation in one case of TRNU group.No serious complications were observed in both CTNU and TRNU groups.In CTNU group,operating time was(202.9 ± 76.7) min,estimated blood loss was(68.4 ± 73.3) mL,drainage duration was(3.9 ±1.5) d,drainage volume was(181.7 ± 251.5) mL,and postoperative hospital stay was(7.8 ± 4.1) d.In TRNU group,operating time was(203.5 ± 68.7) min,estimated blood loss was(130.2 ± 252.1)mL,drainage duration was(4.3 ± 1.6) d,drainage volume was(179.1 ± 167.5) mL,and postoperative hospital stay was(8.2 ± 3.7) d.The estimated blood loss in CTNU group was significantly less than that in TRNU group(P=0.005).The median follow-up time was 39 months(range:1-88 months).The 5-year overall survival rate(OS),cancer specific survival rate(CSS),intra-vesical recurrence free survival rate(IvRFS),disease free survival rate(DFS) of CTNU group was 75.6%,86.9%,73.8%,57.5%,respectively.The OS,CSS,IvRFS and DFS of TRNU group was 66.3%,83.5%,75.9%,58.6%,respectively.No significant differences were observed in the OS,CSS,IvRFS and DFS between the CTNU and TRNU groups.Conclusion:CTNU technique is a safe and effective surgical option,and further prospective randomized controlled trial is needed for further evaluation.
Objective:To compare the efficacy and safety of complete transperitoneal laparoscopic nephroureterectomy(CTNU) and traditional retroperitoneoscopic nehroureterectomy(TRNU) for the management of upper urinary tract urothelial carcinoma(UTUC).Methods:We retrospectively collected the clinical data of UTUC patients who underwent CTNU or TRNU surgery from January 2011 to December 2018 in Peking University First Hospital and Fujian Provincial Hospital,and compared the clinical characteristics,perioperative parameters,and follow-up results between the CTNU and TRNU surgeries.Results:Finally,a total of 266 cases were included,with 94 cases in the CTNU group and 172 cases in the TRNU group.The proportion of left side lesions was bigger in TRNU group when compared with CTNU group(P<0.05).No significant differences were observed in clinical characteristics,such as age,gender,body mass index(BMI),American society of anesthesiologists score(ASA score) and tumor laterality.All surgery procedures were completed.The vascular resparing was performed by reason that left arteria renalis was injured accidently during surgical operation in one case of TRNU group.No serious complications were observed in both CTNU and TRNU groups.In CTNU group,operating time was(202.9 ± 76.7) min,estimated blood loss was(68.4 ± 73.3) mL,drainage duration was(3.9 ±1.5) d,drainage volume was(181.7 ± 251.5) mL,and postoperative hospital stay was(7.8 ± 4.1) d.In TRNU group,operating time was(203.5 ± 68.7) min,estimated blood loss was(130.2 ± 252.1)mL,drainage duration was(4.3 ± 1.6) d,drainage volume was(179.1 ± 167.5) mL,and postoperative hospital stay was(8.2 ± 3.7) d.The estimated blood loss in CTNU group was significantly less than that in TRNU group(P=0.005).The median follow-up time was 39 months(range:1-88 months).The 5-year overall survival rate(OS),cancer specific survival rate(CSS),intra-vesical recurrence free survival rate(IvRFS),disease free survival rate(DFS) of CTNU group was 75.6%,86.9%,73.8%,57.5%,respectively.The OS,CSS,IvRFS and DFS of TRNU group was 66.3%,83.5%,75.9%,58.6%,respectively.No significant differences were observed in the OS,CSS,IvRFS and DFS between the CTNU and TRNU groups.Conclusion:CTNU technique is a safe and effective surgical option,and further prospective randomized controlled trial is needed for further evaluation.
引文
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[3]刘荣耀,赵鹏举,李学松,等.经腹腔完全腹腔镜肾输尿管全长切除术治疗上尿路尿路上皮癌[J].北京大学学报(医学版),2011,43(4):531-534.
[4]李学松,洪鹏,丁光璞,等.经腹完全腹腔镜肾输尿管全长切除术的关键技术总结(附光盘)[J].现代泌尿外科杂志,2018,23(10):728-731.
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[6]Ni S,Tao W,Chen Q,et al.Laparoscopic versus open nephroureterectomy for the treatment of upper urinary tract urothelial carcinoma:a systematic review and cumulative analysis of comparative studies[J].Eur Urol,2012,61(6):1142-1153.
[7]Ghazi A,Shefler A,Gruell M,et al.A novel approach for a complete laparoscopic nephroureterectomy with bladder cuff excision[J].J Endourol,2010,24(3):415-419.
[8]Mcdonald DF.Intussusception ureterectomy:a method of removal of the ureteral stump at time of nephrectomy without an additional incision[J].Surg Gynecol Obstet,1953,97(5):565-568.
[9]Gill IS,Soble JJ,Miller SD,et al.A novel technique for management of the en bloc bladder cuff and distal ureter during laparoscopic nephroureterectomy[J].J Urol,1999,161(2):430-434.
[10]Gill IS,Sung GT,Hobart MG,et al.Laparoscopic radical nephroureterectomy for upper tract transitional cell carcinoma:the cleveland clinic experience[J].J Urol,2000,164(5):1513-1522.
[11]Tsivian A,Benjamin S,Sidi AA.A sealed laparoscopic nephroureterectomy:a new technique[J].Eur Urol,2007,52(4):1015-1019.
[12]Jarrett TW,Chan DY,Cadeddu JA,et al.Laparoscopic nephroureterectomy for the treatment of transitional cell carcinoma of the upper urinary tract[J].Urology,2001,57(3):448-453.
[13]Yoshino Y,Ono Y,Hattori R,et al.Traditional retroperitoneoscopic nephroureterectomy for transitional cell carcinoma of the renal pelvis and ureter:Nagoya experience[J].Urology,2003,61(3):533-538.
[14]Hsi RS,Saint-Elie DT,Zimmerman GJ,et al.Mechanisms of hemostatic failure during laparoscopicnephrectomy:review of Food and Drug Administration database[J].Urology,2007,70(5):888-892.
[15]Liu P,Fang D,Xiong G,et al.A novel and simple modification for management of distal ureter during laparoscopic nephroureterectomy without patient repositioning a bulldog clamp technique and description of modified port placement[J].J Endourol,2016,30(2):195-200.
[16]Abe T,Shinohara N,Harabayashi T,et al.The role of lymphnode dissection in the treatment of upper urinary tract cancer:a multi-institutional study[J].BJU Int,2008,102(5):576-580.
[17]Kondo T,Tanabe K.Role of lymphadenectomy in the management of urothelial carcinoma of the bladder and the upper urinary tract[J].Int J Urol,2012,19(8):710-721.
[2]Roupret M,Babjuk M,Comperat E,et al.European association of urology guidelines on upper urinary tract urothelial carcinoma:2017 update[J].Eur Urol,2017,73(1):111-122.
[3]刘荣耀,赵鹏举,李学松,等.经腹腔完全腹腔镜肾输尿管全长切除术治疗上尿路尿路上皮癌[J].北京大学学报(医学版),2011,43(4):531-534.
[4]李学松,洪鹏,丁光璞,等.经腹完全腹腔镜肾输尿管全长切除术的关键技术总结(附光盘)[J].现代泌尿外科杂志,2018,23(10):728-731.
[5]Clayman RV,Kavoussi LR,Figenshau RS,et al.Laparoscopic nephroureterectomy:initial clinical case report[J].J Laparoendosc Surg,1991,1(6):343-349.
[6]Ni S,Tao W,Chen Q,et al.Laparoscopic versus open nephroureterectomy for the treatment of upper urinary tract urothelial carcinoma:a systematic review and cumulative analysis of comparative studies[J].Eur Urol,2012,61(6):1142-1153.
[7]Ghazi A,Shefler A,Gruell M,et al.A novel approach for a complete laparoscopic nephroureterectomy with bladder cuff excision[J].J Endourol,2010,24(3):415-419.
[8]Mcdonald DF.Intussusception ureterectomy:a method of removal of the ureteral stump at time of nephrectomy without an additional incision[J].Surg Gynecol Obstet,1953,97(5):565-568.
[9]Gill IS,Soble JJ,Miller SD,et al.A novel technique for management of the en bloc bladder cuff and distal ureter during laparoscopic nephroureterectomy[J].J Urol,1999,161(2):430-434.
[10]Gill IS,Sung GT,Hobart MG,et al.Laparoscopic radical nephroureterectomy for upper tract transitional cell carcinoma:the cleveland clinic experience[J].J Urol,2000,164(5):1513-1522.
[11]Tsivian A,Benjamin S,Sidi AA.A sealed laparoscopic nephroureterectomy:a new technique[J].Eur Urol,2007,52(4):1015-1019.
[12]Jarrett TW,Chan DY,Cadeddu JA,et al.Laparoscopic nephroureterectomy for the treatment of transitional cell carcinoma of the upper urinary tract[J].Urology,2001,57(3):448-453.
[13]Yoshino Y,Ono Y,Hattori R,et al.Traditional retroperitoneoscopic nephroureterectomy for transitional cell carcinoma of the renal pelvis and ureter:Nagoya experience[J].Urology,2003,61(3):533-538.
[14]Hsi RS,Saint-Elie DT,Zimmerman GJ,et al.Mechanisms of hemostatic failure during laparoscopicnephrectomy:review of Food and Drug Administration database[J].Urology,2007,70(5):888-892.
[15]Liu P,Fang D,Xiong G,et al.A novel and simple modification for management of distal ureter during laparoscopic nephroureterectomy without patient repositioning a bulldog clamp technique and description of modified port placement[J].J Endourol,2016,30(2):195-200.
[16]Abe T,Shinohara N,Harabayashi T,et al.The role of lymphnode dissection in the treatment of upper urinary tract cancer:a multi-institutional study[J].BJU Int,2008,102(5):576-580.
[17]Kondo T,Tanabe K.Role of lymphadenectomy in the management of urothelial carcinoma of the bladder and the upper urinary tract[J].Int J Urol,2012,19(8):710-721.