摘要
目的探讨非肌层浸润性膀胱癌(NMIBC)行二次电切术的临床意义及膀胱肿瘤术后复发、进展的危险因素。方法回顾性分析2015年7月至2018年12月收治的171例NMIBC患者的病例资料,男134例,女37例。单次电切组95例,年龄(64.4±10.7)岁;体质指数(BMI)(23.5±3.0)kg/m^2;肿瘤直径(24.7±8.8)mm;肿瘤分期Ta期67例,T1期28例;肿瘤分级低级别44例,高级别51例。二次电切组76例,年龄(66.0±9.2)岁,BMI(23.7±3.0)kg/m^2,肿瘤直径(25.3±9.3)mm;肿瘤分期Ta期44例,T1期32例;肿瘤分级低级别41例,高级别35例。两组比较差异无统计学意义(P>0.05)。手术采用全麻,患者取截石位。首次电切采用标准电切法,切除肿瘤及周围1~2 cm范围黏膜,记录肿瘤大小、位置、数量。术后2~12周行二次电切,二次电切时依次切除原肿瘤基底部位、原肿瘤周围黏膜炎性水肿区域和其他可疑肿瘤部位。两组均于术后24 h内采用表柔比星或吉西他滨行即刻膀胱灌注化疗。术后第1周开始持续膀胱灌注,方案为每周1次,共8次;之后每月1次至术后1年。采用单因素和多因素分析首次电切后膀胱肿瘤残留的相关因素以及术后复发、进展的相关危险因素。分析行二次电切手术的时机。采用Kaplan-meier法绘制生存曲线,分析二次电切对膀胱肿瘤患者生存的影响。结果二次电切时发现17例肿瘤残留,分别为Ta期9例和T1期8例,其中Ta期5例升级为T1期,余12例病理分期无变化。Ta期与T1期残留率(11.8%与10.5%,P>0.05)差异无统计学意义。多因素分析结果显示,肿瘤数量(OR 4.255,95%CI 1.186~16.124,P=0.034)、肿瘤大小(OR 7.800,95%CI 1.852~32.841,P=0.005)、病理分级(OR 3.764,95%CI 0.947~14.968,P=0.006)是肿瘤残留的危险因素。单因素分析结果显示,是否行二次电切、BMI、肿瘤大小、病理分期、病理分级均为膀胱肿瘤复发、进展的影响因素(P<0.05)。多因素分析结果显示,单次电切(OR 0.25,95%CI 0.135~0.561,P=0.000)、肿瘤直径≥30 mm(OR 3.548,95%CI 1.899~6.629,P=0.000)、病理分级高级别(OR 2.62,95%CI 1.026~4.990,P=0.043)是肿瘤复发的独立危险因素,单次电切(OR 0.114,95%CI 0.033~0.391,P=0.001)、肿瘤直径≥30 mm(OR 4.026,95%CI 1.628~9.956,P=0.003)、病理分期T1期(OR 5.623,95%CI 1.818~17.385,P=0.003)是肿瘤进展的独立危险因素。首次电切和二次电切间隔时间≤6周组和>6周组分别为47例和29例,两组的无复发生存时间分别为22.6个月和17.8个月(P<0.05),无进展生存时间分别为23.4个月和22.3个月(P>0.05)。171例的随访时间为3~31个月,平均16.7个月。单次电切组与二次电切组无复发生存时间分别为19.4个月和23.8个月(P<0.05)。25例出现肿瘤进展,单次电切组22例,二次电切组3例,两组无进展生存时间分别为22.1个月和24.7个月(P<0.05)。结论二次电切术可以减少经尿道膀胱肿瘤电切术后的肿瘤残留率,延缓患者术后的复发及进展,改善患者预后。
Objective To investigate the clinical significance of second transurethral resection of bladder tumor and analyze the related risk factors of recurrence and progression of bladder tumor.Methods A retrospective analysis of 171 patients including 134 males and 37 females.95 patients were enrolled in single TURBT group.The patients were(64.4±10.7)years old.Their mean body mass index(BMI)was(23.5±3.0)kg/m^2 and mean tumor diameter was(24.7±8.8)mm.67 cases were diagnosed with Ta stage and 28 cases were diagnosed with T1 stage.There were 44 cases diagnosed with low grade tumor and 51 cases with high grade tumor.76 patients were enrolled in second TURBT group.The patients were(66.0±9.2)years old.Their mean BMI was(23.7±3.0)kg/m^2 and mean tumor diameter was(25.3±9.3)mm.44 cases were diagnosed with Ta stage and 32 cases were diagnosed with T1 stage.There were 41 cases diagnosed with low grade tumor and 35 cases with high grade tumor.There was no significant difference between the two groups(P>0.05).General anesthesia was used for the operation,and the patient was in lithotomy position.For the first TURBT,the standard transurethral resection method was used to resect the tumor and the surrounding mucosa 1-2 cm far from tumor.The tumor size,location and number were recorded.The second resection was performed 2 to 12 weeks after the operation,and the basal part of the original tumor,the inflammatory edema mucosa around the original tumor and other suspicious tumor sites were sequentially removed.Both groups received immediate intravesical instillation chemotherapy with epirubicin or gemcitabine within 24 hours after surgery.The perfusion protocol was started once a week for 8 times;then once a month upto 1 year after surgery.Univariate and multivariate analysis were used to analyze the related factors of bladder tumor residual after first TURBT and the related risk factors of postoperative recurrence and progression.The time of second TURBT was analyzed.The Kaplan-meier method was used to draw the survival curve and analyze the effect of secondary resection on the survival of patients with bladder tumor.Results 17 cases of residual tumor were found in the second TURBT group,including 9 cases with Ta stage and 8 cases with T1 stage.Among them,5 cases in Ta stage were upgraded to T1 stage,and the remaining 12 cases keep the same pathological stage.There was no significant difference in the residual rate between Ta and T1(11.8%vs.10.5%,P>0.05).Multivariate analysis showed that the number of tumors(OR 4.255,95%CI 1.186-16.124,P=0.034),tumor size(OR 7.800,95%CI 1.852-32.841,P=0.005),and pathological grade(OR 3.764,95%CI 0.947-14.968,P=0.006)were risk factors for residual tumor.Univariate analysis showed that secondary TURBT,BMI,tumor size,clinical stage,and pathological grade were the influencing factors of bladder tumor recurrence and progression(P<0.05).Multivariate analysis showed that single TURBT(OR 0.25,95%CI 0.135-0.561,P=0.000),tumor diameter≥30 mm(OR 3.548,95%CI 1.899-6.629,P=0.000),high grade tumor(OR 2.62,95%CI 1.026-4.990,P=0.043)are independent risk factors for tumor recurrence.Single TURBT(OR 0.114,95%CI 0.033-0.391,P=0.001),tumor diameter≥30 mm(OR 4.026,95%CI 1.628-9.956,P=0.003),clinical stage T1(OR 5.623,95%CI 1.818-17.385,P=0.003)are independent risk factors for tumor progression.The recurrence-free survival time of the first and second resection intervals≤6 weeks and>6 weeks was 22.6 months and 17.8 months,respectively(P<0.05),and the progression-free survival time was 23.4 months and 22.3,respectively(P>0.05).The follow-up period was 3 to 31 months with an average of 16.7 months.The recurrence-free survival time of the single TURBT group and the second TURBT group was 19.4 months and 23.8 months,respectively(P<0.05).Tumor progression occurred in 25 patients with 22 in the single TURBT group and 3 in the second TURBT group.The progression-free survival time was 22.1 months and 24.7 months,respectively(P<0.05).Conclusions Second transurethral resection of bladder tumor can reduce postoperative residual tumor,postpone postoperative recurrence and progression,and improve prognosis of the patients.
作者
杨诚
陈伟
梁朝朝
Yang Cheng;Chen Wei;Liang Chaozhao(Department of Urology,the First Affiliated Hospital of Anhui Medical University,Hefei 230022,China)
出处
《中华泌尿外科杂志》
CAS
CSCD
北大核心
2019年第7期498-502,共5页
Chinese Journal of Urology
基金
国家自然科学基金项目(81700662)
安徽省自然科学研究青年科学基金项目(1708085QH203).
关键词
膀胱癌
二次电切
非肌层浸润性膀胱癌
Bladder cancer
Secondary resection
Non-muscle invasive bladder cancer
