二次电切对非肌层浸润性膀胱癌疗效的影响分析

目的 比较常规经尿道膀胱肿瘤电切术（transurethral resection of bladder cancer，TURBT）与经尿道膀胱肿瘤二次电切（repeated-TURBT，Re-TURBT）两种不同手术方式治疗非肌层浸润性膀胱癌的临床疗效，并进一步探讨二次电切的意义及指征。方法 将2011年1月至2017年6月在首都医科大学附属北京朝阳医院接受手术治疗并被确诊为非肌层浸润性膀胱癌的56例患者资料，按照是否行二次电切分为两组。对照组31例：常规行TURBT；观察组25例，该组患者于首次TURBT后8周左右返院行二次电切术。2组患者术后均行术后即刻灌注与维持性灌注化学药物治疗（以下简称化疗），常用化疗药物：表柔比星、吡柔比星等。比较两组患者术后膀胱肿瘤复发率及进展率。两组患者术后均每隔3个月复查一次膀胱镜，同时还需复查血常规、尿常规、生化及肝功指标等，观察两组患者术后复发及进展情况。结果 两组患者性别（χ²=0.144，P>0.05）、年龄（t=-1.03，P>0.05）、肿瘤单发及多发（χ²=0.750，P>0.05）、肿瘤分期（χ²=0.120，P>0.05）、肿瘤分级（χ²=0.002，P>0.05），差异均无统计学意义。两组患者均获随访6~24个月。观察组患者在二次电切术中有3例（12%）发现肿瘤残余，其中Ta期2例，T1期1例，分期均与首次电切病理结果一致。在术后随访中，观察组共有5例（20%）复发，其中Ta期2例，T1期2例，1例于二次电切术后11个月出现进展，由T1期进展为T2。对照组有17例（55%）出现复发，其中Ta期12例，T1期4例，1例于术后18个月由T1期进展为T2期。两种手术方式术后复发率差异有统计学意义（χ²=7.042，P<0.05），二次电切术后复发率低于常规肿瘤电切术。两组患者术中均未发生膀胱穿孔、输尿管口损伤及大出血等严重合并症。结论 TURBT治疗非肌层浸润性膀胱癌容易复发或进展；对于首次电切肿瘤分期≥ T1、高级别肿瘤（G₂及G₃）、肿瘤直径≥ 3 cm或多发肿瘤（≥ 3个）的患者行经尿道膀胱肿瘤二次电切术能早期发现及清除残留的肿瘤，明显降低非肌层浸润性膀胱癌患者的复发率；电切标本要求有平滑肌组织，有助于准确评估肿瘤病理分期。

Analysis of the effect of a second transurethral resection for non-muscle invasive bladder cancer

Objective To investigate the clinical efficacy of the first transurethral resection of bladder tumor (TURBT) vs. repeated TURBT (Re-TURBT) in the treatment of non-muscle invasive bladder cancer and study the clinical significance and indications of Re-TURBT. Methods The 56 cases of non-muscle invasive bladder cancer undergoing surgical treatments in our hospital from January 2011 to June 2017 were divided into two groups:31 patients undergoing conventional TURBT (control group) and 25 cases undergoing Re-TURBT about 8 weeks after the first TURBT (observation group). Both groups of patients received immediate postoperative bladder perfusion and maintain intravesical instillation. Postoperative recurrence rate and progress rate were compared with each other between two groups. Results There was no significant difference in gender(χ²=0.144,P>0.05), age(t=-1.03,P>0.05), number of tumor(χ²=0.750,P>0.05), stage of tumor(χ²=0.120,P>0.05), grade of tumor(χ²=0.002,P>0.05)between two groups. All cases were followed up for 6-24 months. Of the observation group, 3 cases had residual neoplasms, including 2 in Ta and 1 in T1. A total of 5 cases of recurrence in observation group, including 2 cases in Ta and 2 cases in T1, 1 case of progress from T1 to T2 after 11 months of Re-TURBT. There were 17 cases of recurrence in control group, including 12 cases in Ta and 4 cases in T1, and 1 case of progress from T1 to T2 after 18 months of Re-TURBT. There was significant difference in postoperative recurrence rate between two groups(χ²=7.042,P<0.05). No serious complications such as bladder perforation, ureterostoma injury and massive hemorrhage occurred in the two groups. Cystoscopy was re-examined every 3 months after surgery in both groups, and blood routine, urine routine and biochemical liver function were also re-examined to observe postoperative recurrence and progression in the two groups. Conclusion TURBT for non-muscle invasive bladder cancer is prone to recurrence or progression. For the patients with the first TURBT of tumor stage ≥ T1, high grade tumor (G2 and G3), tumor size ≥ 3 cm or multiple tumors (≥ 3 or more), the re-TUBRT can detect and remove the residual tumor at an early stage, and significantly decrease the recurrence rate of non-muscle-invasive bladder cancer. The specimens with smooth muscle tissue are helpful for accurate assessment of tumor pathological staging.