386例膀胱癌临床治疗策略分析：从NMIBC到MIBC

发布时间：2018-06-18 13:42

本文选题：非肌层浸润性膀胱癌 + 经尿道膀胱肿瘤电切术　；参考：《华中科技大学》2016年博士论文

【摘要】：目的：研究膀胱肿瘤电切术切缘范围以及术后病理证实切缘是否阳性与术后肿瘤复发以及肿瘤原位复发之间的相关性,藉此探讨更为合理的膀胱肿瘤电切术切缘。方法：回顾性分析2011年1月至2013年6月期间同济医院泌尿外科收治的Ta及T1期非肌层浸润性膀胱癌(NMIBC)患者的资料共143例。按不同手术医生施行手术时的切缘范围分为10mm,15mm和20mm三组,术后按临床及病理分期和危险度行相应的膀胱内药物灌注治疗。每例患者维持24个月的术后随访,观察肿瘤复发及原位复发的情况。采用Log-rank检验法比较三组之间肿瘤复发及原位复发的差异。采用Cox风险回归分析法,以肿瘤复发作为终止事件,对肿瘤大小、本次为原发／复发、病理分级、电切范围、切缘是否为阳性与肿瘤复发、及原位复发之间进行多因素风险分析。采用Kaplan-Meier法,以肿瘤复发为终点,分别对肿瘤复发及原位复发进行生存分析。结果：肿瘤的大小,本次肿瘤为原发/复发,肿瘤病理分级,电切范围,以及手术切缘阳性/阴性的差异均为膀胱肿瘤的复发的影响因素(P0.05)。而对于膀胱肿瘤原位复发率,膀胱肿瘤的大小,肿瘤的病理分级,手术电切的范围,以及手术切缘阳性/阴性的差异均为其影响因素。肿瘤直径3cm,本次肿瘤为复发,电切术后切缘阳性是影响NMIBC复发的独立危险因素。而增加切缘范围是NMIBC复发的独立保护因素。电切术后切缘阳性为NMIBC原位复发的独立危险因素,增加切缘范围是NMIBC原位复发的独立保护因素(p0.05)。与15mm及20mm的患者相比,切缘为10mm.的患者复发率增加(p=0.005)。切缘阳性与阴性患者相比,复发率增高(p0.001)。与15mm及20mm的患者相比,切缘为10mm的患者原位复发率增加(p0.001)。切缘阳性患者与阴性患者相比,其原位复发率增加(p=0.000)。与1Omm及15mm切缘的患者相比,切缘20mm的患者TURBT手术的并发症发生率明显增加(p0.05)。结论：术后病理结果表明,切缘阳性明显增加了膀胱癌患者的复发及原位复发率。将切缘范围定为15mm,可明显降低膀胱癌患者的复发率及原位复发率,同时又不显著增加术后并发症的发生。值得在临床工作中进一步推广研究。目的：对比分析机器人辅助腹腔镜、传统腹腔镜以及开放手术下膀胱根治性切除术+输尿管皮肤造口术的围手术期资料及并发症情况。方法：入组2010年1月-2015年10月我院行膀胱根治性切除术+输尿管皮肤造口术患者共111名,其中行开放手术者73名,行腹腔镜手术者30名,行机器人辅助腹腔镜手术者8名,分析各组手术时间,术中出血量,输血量,进食时间,拔管时间,术后住院时间等围手术期情况和并发症情况。结果：全部手术均顺利完成,三组患者术后进食时间及术后住院时间无差异(p0.05),开放组手术时间为240min (210-300min),低于腹腔镜组手术时间308min(240-431min)(p=0.002),而开放组和机器人组,腹腔镜组和机器人组在手术时间方面无差异。机器人组的术中出血量为200ml (150-300ml)，小于开放组1000m1(600-1900m1)(p=0.001)和腹腔镜组800ml (375-1300ml) (p=0.041),开放组和腹腔镜组出血量无差异。在术中输血方面,腹腔镜组及机器人组输红细胞及血浆均小于开放组(p0.05),腹腔镜组和机器人组两组间术中输红细胞及血浆无差异。三组间TNM分期、淋巴结阳性率及病理分级均无明显差异。三组患者之间的手术并发症差异无统计学意义,以Clavien-Dindo评分对并发症进行分级,三组并发症分级无统计学差异。结论：机器人辅助腹腔镜下根治性膀胱切除术+输尿管皮肤造口术具有创伤小,术中出血少,术后恢复快的优势,是治疗浸润性膀胱癌安全有效的手术方法。目的：比较分析机器人辅助腹腔镜、传统腹腔镜以及开放手术下膀胱根治性切除术+Bricker回肠膀胱术的围手术期资料及并发症情况。方法：入组2010年1月-2015年10月我院行膀胱根治性切除术及Bricker回肠代膀胱术的132例膀胱癌患者,其中行开放手术者69名,行腹腔镜手术者57名,行机器人辅助腹腔镜手术者6名,比较各组手术时间,术中出血量,输血量,进食时间,拔管时间,术后住院时间等围手术期情况和术后并发症情况。结果：全部手术均顺利完成,三组患者在术后进食时间和拔盆腔引流管时间方面无差异。开放组手术时间为398min (360-450min),低于腹腔镜组手术时间435min(390-510min) (p=0.011),而机器人手术时间338min (330-480min)与开放组和腹腔镜组之间无差异。在术中出血量方面,机器人组出血量为300ml (200-375ml),低于腹腔镜组出血量700ml(400-1200ml)(p=0.043)和开放组出血量1200ml(800-2000ml) (p0.001),腹腔镜组出血量低于开放组(p=0.003)。机器人组术中所输红细胞量0U(0-OU)低于开放组6U(4-7.5U)(p=0.001),与腹腔镜组无差异,而腹腔镜组术中输红细胞量2U(0-4U)低于开放组(p0.001)。术中输血浆量三组总体存在差异(p=0.040),但两两比较无差异。在出院时间方面,机器人组术后出院时间11天(10-19.5天),少于开放组术后住院时间19天(14-23天)(p=0.027),腹腔镜组术后住院时间为15天(13-20天),与开放组及机器人组均无差异。三组间肿瘤TNM分期、淋巴结阳性率及病理分级均无明显差异。三组患者之间的手术并发症差异无统计学意义,以Clavien-Dindo评分对并发症进行分级,三组并发症分级无统计学差异。结论：机器人辅助腹腔镜下根治性膀胱切除术+Bricker回肠膀胱术具术中出血少,术中创伤小,术后恢复快的优势,是治疗浸润性膀胱癌安全有效的手术方法。
[Abstract]:Objective: To study the range of cutting edge of bladder tumor resection and the correlation between the positive margin of the resection and the recurrence of tumor and the recurrence of tumor in situ, so as to explore a more reasonable cutting edge of bladder tumor resection. Method: a retrospective analysis of the Ta in Tongji Hospital from January 2011 to June 2013. 143 cases of non myometrium invasive bladder cancer (NMIBC) patients with T1 were divided into 10mm, 15mm and 20mm three groups according to the operation of different surgeons. After operation, the corresponding intravesical infusion therapy was performed according to the clinical and pathological stages and risk. Each case was followed up for 24 months and observed the recurrence and in situ of the tumor. Log-rank test was used to compare the difference of tumor recurrence and in situ recurrence between the three groups. Using the Cox risk regression analysis, the tumor recurrence was used as the termination event, the tumor size, this time was primary / recurrence, the pathological grade, the electric cutting range, the positive margin of the cutting edge and the recurrence of the tumor, and the recurrence of the tumor in situ. Risk analysis. The Kaplan-Meier method was used to analyze the recurrence of tumor and in situ recurrence at the end of tumor recurrence. Results: the size of the tumor was the primary / recurrence of the tumor, the pathological grade of the tumor, the scope of the resection, and the difference of the positive / negative of the surgical margin were the influencing factors of the recurrence of the bladder tumor (P0.05). The recurrence rate of Yu Bangguang's tumor in situ, the size of the bladder tumor, the pathological classification of the tumor, the scope of the surgical resection, and the difference of the positive / negative of the surgical margin were all the factors affecting the tumor. The tumor was 3cm, the tumor was recurrent, and the positive margin of the resection was an independent risk factor for the recurrence of NMIBC. The increase of the margin of cutting margin was the recurrence of NMIBC. Independent protective factors. The positive margin of tangent margin after electrocutting was an independent risk factor for the recurrence of NMIBC in situ. Increasing the margin of cutting edge was an independent protective factor for the recurrence of NMIBC in situ (P0.05). Compared with 15mm and 20mm, the recurrence rate of patients with 10mm. was increased (p=0.005). Compared with negative patients, the recurrence rate increased (p0.001) and 15mm (p0.001). Compared with the patients with 20mm, the recurrence rate of the patients with 10mm was increased (p0.001). The incidence of in situ recurrence was increased (p=0.000) compared with the negative patients (p=0.000). The incidence of TURBT surgery in patients with 20mm was significantly increased (P0.05) compared with those with 1Omm and 15mm margin. Conclusion: the postoperative pathological results showed that the margin Yang of the patients. The recurrence rate and in situ recurrence rate of bladder cancer patients are obviously increased. The margin range is 15mm, which can obviously reduce the recurrence rate and in situ recurrence rate of bladder cancer patients. At the same time, it does not significantly increase the incidence of postoperative complications. The perioperative data and complications of endoscopic and open radical cystectomy plus ureterostomy. Methods: a total of 111 patients were treated with radical cystectomy and ureterostomy in October January 2010 -2015 years, including 73 open operations, 30 laparoscopic surgery, and a robot. 8 patients were assisted by laparoscopy. The operation time, the amount of bleeding, the amount of blood transfusion, the time of feeding, the time of eating, the time of extubation, the postoperative hospitalization time and other complications. Results: all the operations were successfully completed. There was no difference between the three groups after the operation and the time of postoperative hospitalization (P0.05), and the operation time of the open group was 240Min (210-300min) less than 308min (240-431min) (p=0.002) in the laparoscopy group, and there was no difference in the operation time between the open group and the robot group, the laparoscopic group and the robot group. The intraoperative bleeding amount of the robot group was 200ml (150-300ml), less than the open group 1000m1 (600-1900m1) (p=0.001) and the laparoscopy group 800ml (375-1300ml) (p=0.041). In the intraoperative blood transfusion, the transfusion of red cells and plasma in the laparoscopic group and the robot group were less than the open group (P0.05). There was no difference between the two groups in the laparoscopic group and the robot group. There was no significant difference in the TNM staging, the positive rate of lymph nodes and the pathological grade between the three groups. The three groups were between the two groups. There was no statistically significant difference in surgical complications. The complications were graded by Clavien-Dindo score. There was no statistical difference between the three groups. Conclusion: the robot assisted laparoscopic radical cystectomy plus ureterostomy has less trauma, less bleeding and rapid recovery after operation. It is a treatment for invasive bladder cancer. Objective: To compare and analyze the perioperative data and complications of robot assisted laparoscopy, traditional laparoscopy and radical cystectomy for +Bricker ileocystectomy. Methods: radical cystectomy and Bricker ileum cystectomy were performed in October January 2010 -2015. 132 cases of bladder cancer, including 69 open surgery, 57 laparoscopic surgery and 6 robot assisted laparoscopic surgery, compared each group of operation time, intraoperative bleeding, blood transfusion, feeding time, extubation time, postoperative hospital time and other perioperative conditions and postoperative complications. Results: all the operations were finished smoothly. There was no difference between the three groups in the three groups. The operation time in the open group was 398min (360-450min), lower than that of the laparoscopic group, 435min (390-510min) (p=0.011), and there was no difference between the robotic operation time 338min (330-480min) and the open and open group and the laparoscopy group. The amount of hemorrhage in the human group was 300ml (200-375ml), lower than the amount of 700ml (400-1200ml) in the laparoscope group (p=0.043) and the open group, 1200ml (800-2000ml) (p0.001), and the amount of hemorrhage in the laparoscope group was lower than that in the open group (p=0.003). The amount of erythrocyte 0U (0-OU) lost in the operation of the robot group was lower than that in the open group, but there was no difference between the laparoscopy group and the laparoscope group. 2U (0-4U) in endoscopic group was lower than that in open group (p0.001). The total number of blood transfusion in three groups was different (p=0.040), but there was no difference in 22. In the discharge time, the discharge time of the robot group was 11 days (10-19.5 days) after operation, less than 19 days (14-23 days) after the operation of the open group (14-23 days), and the time of hospital stay after the laparoscopy group. There was no difference between the open group and the robot group for 15 days (13-20 days). There was no significant difference in TNM staging, lymph node positive rate and pathological grade between the three groups. There was no statistical difference between the three groups. The complications were graded by Clavien-Dindo score, and there was no statistical difference between the three groups of complications. Conclusion: machine +Bricker ileocystectomy with human assisted laparoscopic radical cystectomy is a safe and effective surgical method for the treatment of invasive bladder cancer with less bleeding, less trauma and quick recovery.
【学位授予单位】：华中科技大学
【学位级别】：博士
【学位授予年份】：2016
【分类号】：R737.14

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