根治性膀胱切除术后早期并发症及危险因素分析

目的:探讨根治性膀胱切除术(RC)后早期并发症(术后90 d内)及其相关的危险因素.方法:收集我院泌尿外科2013年1月至2016年1月期间共185例因膀胱癌行根治性膀胱切除术(RC)的临床资料,术后90天内对患者随访,并应用X2检验和Logistic回归分析术后常见早期并发症的危险因素.结果:术后90天内185位患者中有74位(40.0％)出现了不同的早期并发症,常见并发症依次为肠梗阻、泌尿系感染、切口方面并发症.在回归分析中发现年龄(≥65岁)、肥胖(BMI≥25 kg/m2)、术中输血、手术方式、手术时间、糖尿病是发生RC术后早期并发症的危险因素.结论:根治性膀胱切除术术后早期并发症发生率较高,其中肠梗阻、泌尿系感染、切口方面并发症较常见,正确的围手术期处理及充足的术前准备是降低膀胱癌根治术术后早期并发症的关键.     

选择性膀胱部分切除术对浸润性膀胱癌预后的影响因素

目的探讨选择性膀胱部分切除术对浸润性膀胱癌的治疗效果及相关预后的影响因素.方法回顾性分析2006年5月至2010年5月收治的88例浸润性膀胱癌患者的临床资料,其中行选择性膀胱部分切除术的67例患者作为观察组,行膀胱全切术的21例患者作为对照组,通过Kaplan Meier法比较2种不同手术方式对于患者5年生存率、5年无病生存率的影响.通过单因素分析患者预后生存率与病理特征的关联性.结果观察组患者术后肿瘤复发率略高于对照组,而对照组术后并发症发生率高于观察组.2组患者术后5年生存率、5年无病生存率无明显差异（P〉0.05）.单因素分析结果提示主要影响膀胱癌患者手术预后的主要因素包括肿瘤是否侵犯淋巴、血管,是否行输尿管再植,而与患者的年龄、性别、肿瘤数量、大小意义不大.结论对于膀胱癌患者来说,选择性膀胱部分切除术不仅能够改善患者的预后生活质量,同时对于患者术后肿瘤控制效果满意,延长患者生命,可有选择性地应用.     

保留部分前列腺的全膀胱切除术治疗浸润性膀胱癌

背景与目的：经典的根治性膀胱切除术将膀胱和前列腺全部切除,术后阳痿和尿失禁发生率高。在肿瘤没有累及前列腺的情况下,根治术中保留部分前列腺可改善术后性功能和控尿功能,但对预后是否有影响尚不清楚。本文报告10例保留部分前列腺的改良全膀胱切除术的经验,阐述改良术式对术后性功能、控尿功能和肿瘤控制的影响。方法：对10例男性浸润性膀胱癌患者,先经尿道电切除部分前列腺,全膀胱切除时保留部分前列腺包囊。下尿路重建采用肠道新膀胱术,新膀胱与残留的前列腺包囊吻合。术后随访评价肿瘤控制、尿液控制和性功能情况。结果：术后病理分期均为T2NOM0。随访3～12个月(平均9个月),9例无瘤生存,l例低分化移行细胞癌患者术后2个月出现全身骨骼及淋巴转移;全部患者自主排尿,完全控尿9例,部分控尿l例;术前有性功能的8例中,术后6例保持阴茎勃起功能。结论：保留部分前列腺的改良全膀胱切除术可以较好保留下尿路控尿功能和阴茎勃起功能,但对肿瘤控制的远期影响有待进一步观察。     

输尿管残端冷冻活检在膀胱癌全膀胱切除术中的应用

背景与目的：对于是否需要在膀胱癌全膀胱切除术中常规进行输尿管残端冷冻活检,目前存在争议。本研究探讨输尿管残端冷冻活检在全膀胱切除术中应用的临床意义。方法：回顾性研究我院2002年5月至2006年5月间68例膀胱癌行全膀胱切除术患者的临床病理资料．并将冷冻活检与石蜡切片的结果进行了比较。中位随访时间为2．5年。结果：68例患者中，7例（10．3％）术中冷冻切片证实有一侧输尿管残端异常，其中6例为恶性肿瘤细胞侵润，1例为移行上皮不典型增生：7例患者术中均立即补充切除输尿管残端，并再次送冷冻活检，直到确诊无异常后，再行尿流改道。7例患者的冷冻切片诊断与最终的石蜡切片诊断均相符合。随访中有3例出现肿瘤复发与转移，但均未出现输尿管和肠道吻合口复发。结论：建议在膀胱癌全膀胱切除术中对输尿管残端进行冷冻活检，发现并彻底切除病灶，以改善预后。     

全膀胱切除术治疗高危非肌层浸润性膀胱癌的研究进展

目的非肌层浸润性膀胱癌(NMIBC)主要由三种不同类型的肿瘤组成:乳头状尿路上皮癌局限于黏膜层(Ta),高级别原位癌局限于上皮层(CIS)以及侵犯黏膜下层或固有层的肿瘤(T1).NMIBC的首选治疗方案是彻底的经尿道膀胱肿瘤电切术(TURBT)和(或)膀胱灌注治疗.但是,仍有部分高危患者具有肿瘤进展的风险,因而需要接受...     

膀胱癌根治性全膀胱切除术后行不同尿流改道术对患者生活质量的影响

目的:分析膀胱癌根治性全膀胱切除术后行不同尿流改道术对患者生活质量的影响。方法:选取我院2014年7月至2015年12月期间收治的142例行根治性膀胱全切除及尿道改造术患者的临床资料进行回顾性分析。按照不同改道术将患者分成A组（原位新膀胱术组）（71例,其中原位乙状结肠新膀胱术16例,原位回肠新膀胱术55例）与B组（非原位尿流改道术组）（71例,其中输尿管皮肤造口术10例,回肠通道术61例）,治疗结束后记录并比较2组患者近期临床疗效和生活质量。结果:A组手术时间、住院时间均较B组延长（P＜0.05）。B组患者并发症发生率较A组低,但两组患者并发症发生率比较差异无统计学意义（P=0.370）。两组患者术后生活质量比较均存在差异（P＜0.05）,其中在生理机能、生理职能、社会功能、精神健康及情感职能5个方面两组患者比较差异具有统计学意义（P＜0.05）,且均以A组患者得分较高,而在躯体疼痛、一般健康状况、精力的比较上两组患者差异无统计学意义（P＞0.05）。结论:在根治性膀胱全切除术中采用不同尿流改道术对治疗膀胱癌均具有一定的临床疗效和安全性,但采用原位新膀胱尿流改道的方式更利于提高患者术后生活质量,值得临床上推广使用。     

膀胱全切后改良Indiana膀胱转流术

目的 探讨—种新式改良Indiana新膀胱术的适应证、手术方法并对疗效进行评估。方法 对5例膀胱癌患者施行全膀胱切除术加改良Indiana新膀胱术。结果 5例患者均获得满意的疗效，自行导尿顺利。随访6-30个月，均尿控满意，排尿次数5-6次/昼，1-3次/夜。其中4例行造影，新膀胱呈球形，容量400-500毫升，无输尿管尿液返流。结论 改良Indiana膀胀术具有操作容易，贮尿囊低压容量大，抗返流机制可靠，尿控满意，并发症少的优点，值得在临床推广。     

肌层浸润性膀胱癌患者保留膀胱术后的预后状况研究

目的探究肌层浸润性膀胱癌患者保留膀胱术后的预后状况及其影响因素。方法回顾性分析50例肌层浸润性膀胱癌患者的临床资料,均行膀胱部分切除术配合辅助化疗治疗,COX回归分析影响术后预后复发及生存的因素。结果 5年总生存率为60.00%,5年总复发率为46.00%;经单因素筛选及多因素回归分析后,淋巴血管侵犯、输尿管再植术等均是影响术后无复发率与总生存率的独立危险因素(P<0.05)。结论肌层浸润性膀胱癌患者保留膀胱术后的预后状况,与淋巴血管侵犯、输尿管再植术等因素密切相关,应引起临床重视。     

高龄膀胱癌患者全膀胱切除术的并发症及生存分析

摘 要：［目的］ 探讨高龄膀胱癌患者接受全膀胱切除术的临床病理特点,围手术期并发症和疗效。［方法］ 回顾性分析2012年1月至2016年12月间年龄≥75岁,接受全膀胱切除术的高龄患者,收集患者的临床病理信息,统计学分析患者围手术期并发症及生存情况。［结果］ 57例年龄≥75岁,在我院接受全膀胱切除术的高龄患者,尿流改道方式分别为回肠膀胱术13例和输尿管皮肤造口术44例,无一例患者在围手术期间死亡。22例（38.6%）患者出现围手术期并发症。常见的并发症包括感染、肠梗阻、肾盂输尿管积水等。无复发生存时间（RFS）为11.4个月,中位总生存时间为15.8个月。回肠膀胱术和输尿管皮肤造口术两种尿流改道术式的RFS无统计学差异。［结论］ 肌层浸润或高危复发的高龄膀胱癌患者,全膀胱切除术并发症发生率可以接受。在合适的患者身上,尿流改道应尽可能选用回肠膀胱术。     

腹腔镜下根治性全膀胱切除术应用进展

膀胱癌是泌尿系统最常见的恶性肿瘤,全膀胱切除术是治疗浸润性膀胱癌最有效的方法。1992年Parra等报道了首例腹腔镜全膀胱切除术,2000年Gill等报道2例腹腔镜根治性膀胱切除加回肠通道术,2002年报道首例腹腔镜根治性膀胱切除加原位回肠膀胱术。国内外泌尿外科医生们在腹腔镜下根治性膀胱切除（laparoscopicradicalcystectomy,LRC）及尿路重建方面进行了积极的探索。现就腹腔镜下根治性全膀胱切除术的应用进展作一综述。     

Urinary diversion and morbidity after radical cystectomy for bladder cancer

BACKGROUND:

The rate of continent urinary diversion after radical cystectomy for bladder cancer varies by patient and provider characteristics. Demonstration of equivalent complication rates, independent of diversion type, may decrease provider reluctance to perform continent reconstructions. The authors sought to determine whether continent reconstructions confer increased complication rates after radical cystectomy.

METHODS:

From the Nationwide Inpatient Sample, the authors used International Classification of Disease (ICD‐9) codes to identify subjects who underwent radical cystectomy for bladder cancer during 2001‐2005. They determined acute postoperative medical and surgical complications from ICD‐9 codes and compared complication rates by reconstruction type using the nearest neighbor propensity score matching method and multivariate logistic regression models.

RESULTS:

Adjusting for case‐mix differences between reconstructive groups, continent diversions conferred a lower risk of medical, surgical, and disposition‐related complications that was statistically significant for bowel (3.1% lower risk; 95% confidence interval [95% CI], ?6.8% to ?0.1%), urinary (1.2% lower risk; 95% CI, ?2.3%, to ?0.4%), and other surgical complications (3.0% lower risk; 95% CI, ?6.2% to ?0.4%), and discharge other than home (8.2% lower risk; 95% CI, ?12.1% to ?4.6%) compared with ileal conduit subjects. Older age and certain comorbid conditions, including congestive heart failure and preoperative weight loss, were associated with significantly increased odds of postoperative medical and surgical complications in all subjects.

CONCLUSIONS:

Mode of urinary diversion after radical cystectomy for bladder cancer is not associated with increased risk of immediate postoperative complications. These results may encourage broader consideration of continent urinary diversion without concern for increased complication rates. Cancer 2010. © 2010 American Cancer Society.     

术前营养风险对膀胱癌根治术患者预后的影响

目的:探讨术前营养风险对膀胱癌根治术患者预后的影响。方法:回顾性分析2010年02月至2018年05月我院泌尿外科收治的186例行根治性全膀胱切除术患者的临床资料。术前采用营养风险评估表(NRS-2002)筛查患者营养风险,根据NRS-2002评分结果将患者分为有营养风险组（总评分≥3分）96例和无营养风险组（总评分＜3分）90例。比较两组患者临床资料;采用Kaplan-Meier模型对两组患者的肿瘤无复发生存期(recurrence free survival,RFS)和总生存期(overall survival,OS)进行分析;患者RFS和OS的独立危险因素采用多因素Cox比例风险回归模型分析。结果:有营养风险组和无营养风险组在病理T分期、肿瘤大小、是否淋巴结转移、肾积水方面比较差异有统计学意义(P＜0.05);有营养风险组和无营养风组险5年RFS率分别为29.17％(28/96)、45.56％(41/90),5年OS率分别为43.75％(42/96)、58.89％(53/90);Kaplan-Meier分析结果显示,有营养风险组患者的RFS和OS均短于无营养风险组(P＜0.05);Cox比例风险回归模型显示,术前营养风险是影响膀胱癌根治术患者RFS和OS的独立危险因素(P＜0.05)。结论:术前有营养风险是膀胱癌根治术患者RFS和OS的独立危险因素,有营养风险的患者术后预后更差。     

Urologist referral delay and its impact on survival after radical cystectomy for bladder cancer

Background

Evidence shows that wait times before bladder cancer surgery have been increasing, and wait time can negatively affect survival. We aimed to determine if a long delay caused by an indirect referral before a first urologist visit affects the survival of patients undergoing radical cystectomy for bladder cancer.

Methods

We analyzed data from 1271 patients who underwent surgery for bladder cancer during the decade 2000–2009. The cohort was obtained by linking two administrative databases in the province of Quebec. Patients were considered to have been directly referred to a urologist if they had 5 or fewer visits with a general practitioner before their first urologist visit; otherwise, they were considered to have been indirectly referred. The effect on survival after surgery of a longer delay before a first urologist visit was assessed using Cox regression models.

Results

Median referral delay for the study population was 30 days (56 days for women, 23 days for men; p < 0.0001). Indirect referral was observed for 49% of women and 33% of men. Compared with patients who were directly referred, those who were indirectly referred after first symptoms of bladder cancer experienced poorer survival (hazard ratio: 1.29; 95% confidence interval: 1.10 to 1.52). Women who were indirectly referred had a significant 47% greater risk of death after radical cystectomy. Men who were indirectly referred also experienced decreased survival (adjusted hazard ratio: 1.25; 95% confidence interval: 1.03 to 1.51).

Conclusions

Patients indirectly referred to a urologist had an increased risk of mortality after surgery. Compared with men, women had longer wait times and poorer survival.     

保留膀胱的综合治疗与根治性手术治疗肌层浸润性膀胱癌预后的荟萃分析

目的 比较保留膀胱手术+术后化疗与根治性手术治疗肌层浸润性膀胱癌的预后.方法 检索保留膀胱手术+术后化疗与根治性手术治疗肌层浸润性膀胱癌(muscle-invasive bladder cancer,MIBC)的对照研究,比较两种治疗方案的术后5年生存率,计算合并优势比(OR)和95%CI.结果 共纳入7项研究,累积876例患者.1组研究的OR=1.03,95%CI为1.03(0.52~2.02),4组研究的OR及其95%CI﹤1,2组研究的OR及其95%CI﹥1;7个研究的总OR=1.05,95%CI为1.05(0.53~2.06),跨过"无差异线",故认为根治性膀胱全切术(radical cystectomy,RC)与保留膀胱的综合治疗预后差异无统计学意义(Z=0.13,P=0.89).结论 对于部分肌层浸润性膀胱癌患者,保留膀胱的综合治疗不会降低患者的5年生存率,且能保留患者膀胱的正常功能,提高了患者的生存质量,但适应证需严格把握.     

膀胱癌不同TNM分期对根治性膀胱切除术患者预后的影响

目的:探讨膀胱癌不同TNM分期对根治膀胱切除术患者预后的影响.方法:选取2011年8月至2014年12月在湖北医药学院附属东风医院泌尿外科住院进行诊治的膀胱癌患者92例,CT检查TNM分期中T1期(30例)、T2期(20例)、T3期(32例)和T4期(10例),所有患者都给予腹腔镜下根治膀胱切除术,观察所有患者的预后情况.结果:对比四组分期的手术时间,其差别在统计学上没有意义,然而T3/T4期患者比T1/T2期患者有更多的术后排气时间、住院时间以及术中出血量(P＜0.05).T3/T4期患者术后1个月的切口出血、切口感染、吻合口瘘、肺部感染等并发症发生情况明显高于T1/T2期患者(JP＜0.05).T3/T4期患者的膀胱容量和最大尿流率明显低于T1/T2期患者,而残余尿量明显高于T1/T2期患者,对比差异都有统计学意义(P＜0.05).结论:膀胱癌不同TNM分期能有效预测根治膀胱切除患者的围手术期创伤情况和术后尿动力学状况,值得推广应用.     

Preoperative plasma level of endoglin as a predictor for disease outcomes after radical cystectomy for nonmetastatic urothelial carcinoma of the bladder

Elevated preoperative plasma level of endoglin has been associated with worse oncologic outcomes in various malignancies. The present large-scale study aimed to determine the predictive and prognostic values of preoperative endoglin with regard to clinicopathologic and survival outcomes in patients treated with radical cystectomy (RC) for nonmetastatic urothelial carcinoma of the bladder (UCB). We prospectively collected preoperative blood samples from 1036 consecutive patients treated with RC for UCB. Logistic and Cox regression analyses were undertaken to assess the correlation of endoglin levels with pathologic and survival outcomes, respectively. The AUC and C-index were used to assess the discrimination. Patients with adverse pathologic features had significantly higher median preoperative endoglin plasma levels than their counterparts. Higher preoperative endoglin level was independently associated with an increased risk for lymph node metastasis, ≥pT3 disease, and nonorgan confined disease (NOCD; all p < 0.001). Plasma endoglin level was also independently associated with cancer-specific and overall survival in both pre- and postoperative models (all p < 0.05), as well as with recurrence-free survival (RFS) in the preoperative model (p < 0.001). The addition of endoglin to the preoperative standard model improved its discrimination for prediction of lymph node metastasis, ≥pT3 disease, NOCD, and RFS (differential increases in C-indices: 10%, 5%, 5.8%, and 4%, respectively). Preoperative plasma endoglin is associated with features of biologically and clinically aggressive UCB as well as survival outcomes. Therefore, it seems to hold the potential of identifying UCB patients who may benefit from intensified therapy in addition to RC such as extended lymphadenectomy or/and preoperative systemic therapy.