微创泌尿外科杂志2024，Vol.13Issue(4) ：265-272.DOI:10.19558/j.cnki.10-1020/r.2024.04.009

机器人辅助腹腔镜根治性膀胱切除术+体内或体外尿流改道术后的肾功能变化及其危险因素分析

Analysis of renal function changes and associated risk factors following robot assisted radical cystectomy with intracorporeal or extracorporeal urinary diversion

王昊 王文帝 方昌华 赵康康 陈天一 张成伟 张士伟 郭宏骞 张古田
微创泌尿外科杂志2024，Vol.13Issue(4) ：265-272.DOI:10.19558/j.cnki.10-1020/r.2024.04.009
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机器人辅助腹腔镜根治性膀胱切除术+体内或体外尿流改道术后的肾功能变化及其危险因素分析

Analysis of renal function changes and associated risk factors following robot assisted radical cystectomy with intracorporeal or extracorporeal urinary diversion

王昊 1王文帝 2方昌华 1赵康康 1陈天一 2张成伟 1张士伟 1郭宏骞 1张古田1
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作者信息

  • 1. 南京大学医学院附属鼓楼医院泌尿外科,南京 210008
  • 2. 东南大学医学院南京鼓楼医院泌尿外科,南京 210003
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摘要

目的:评估膀胱癌患者行机器人辅助腹腔镜根治性膀胱切除术(RARC)+体内或体外尿流改道(UD)术后的肾功能变化及其危险因素.方法:回顾性分析2016年5月至2021年8月在南京大学医学院附属鼓楼医院行RARC+UD的266例膀胱癌患者的临床资料,其中男232例,女34例,平均年龄(67.4±9.4)岁,原位新膀胱 84例,回肠膀胱 182例.通过估算的肾小球滤过率(eGFR)评估患者术后长期肾功能变化.采用Logistic回归评估肾功能损伤的危险因素.结果:根据尿流改道过程中肠管处理的手术入路不同,将 266例患者分为体外尿流改道(ECUD)组(79例)和体内尿流改道(ICUD)组(187例).ECUD组与ICUD组的平均手术时长比较差异无统计学意义(P=0.080);ICUD组平均手术估计失血量[(303.5±116.5)ml]少于ECUD组[(379.8±233.2)ml],差异有统计学意义(P=0.007).ECUD 组术后第 1、2、3 年的平均 eGFR 分别为(92.3±26.5)、(90.4±26.5)、(88.1±28.3)ml/(min·1.73m2),ICUD 组分别为(98.9±23.3)、(97.3±23.3)、(95.7±23.5)ml/(min·1.73m2),两组比较差异均有统计学意义(P值分别为0.042、0.034、0.037).随访期内共有112例(42.1%,112/266)患者出现长期肾功能损伤,其中12例(4.5%,12/266)进展至慢性肾脏病(CKD)3B期及以上,ECUD组9例(11.4%)、ICUD组3例(1.6%),两组比较差异有统计学意义(P<0.001).根据术后随访期间是否发生长期肾功能损伤将患者分为肾损伤组和未发生肾损伤组,对两组患者的临床资料进行单因素分析,年龄(P=0.007)、手术入路(P<0.001)、输尿管肠吻合口狭窄(P<0.001)、病理分期T3期及以上(P<0.001)、术后肾积水(P=0.006)、估计出血量(P=0.007)因素差异均有统计学意义;多因素分析显示不同手术入路(OR=0.24,95%CI:0.12～0.46,P<0.001)、输尿管肠吻合口狭窄(OR=4.37,95%CI:1.32～14.45,P=0.016)、病理分期T3期及以上(OR=6.21,95%CI:3.20～12.07,P<0.001)为术后发生长期肾功能损伤的独立危险因素.随访期内共30例(11.3%)患者发生急性肾损伤(AKI),其中ECUD组6例(7.6%),ICUD组24例(12.8%),两组比较差异无统计学意义(P=0.217).结论:急性和长期肾功能损伤是膀胱癌根治术后的常见并发症.患者的肿瘤病理分期、输尿管肠吻合口狭窄、尿流改道过程中对肠管处理的入路(ECUD和ICUD),是患者长期肾功能损伤的独立危险因素.术前精准评估、选择合适手术入路和长期随访,对于保护膀胱癌患者术后肾功能具有重要意义.

Abstract

Objective:To analyze renal function changes and associated risk factors in bladder cancer patients un-derwent robot assisted radical cystectomy(RARC)with intracorporeal or extracorporeal urinary diversion(UD).Methods:The clinical data of 266 patients with bladder cancer who underwent RARC+UD in Drum Tower Hospi-tal Affiliated to Nanjing University Medical School from May 2016 to August 2021 were retrospectively analyzed.There were 232 males and 34 females,the average age were(67.4±9.4)years,84 cases of orthotopic neobladder(ON)and 182 cases of ileal conduit(IC).Long-term changes in renal function postoperatively were assessed via esti-mated glomerular filtration rate(eGFR).Logistic regression was utilized to identify risk factors for renal function inju-ry.Results:The patients were divided into extracorporeal urinary diversion(ECUD)group and intracorporeal urinary diversion(ICUD)group based on different surgical approaches to bowel handling during urinary diversion.The aver-age operative duration between the two groups had no significant difference(P=0.080),with less average estimated blood loss in the ICUD group[(303.5±116.5)ml]than that in the ECUD group[(379.8±233.2)ml],the difference was statistically significant(P=0.007).The eGFR at 1,2 and 3 years postoperatively in the ECUD group were(92.3±26.5),(90.4±26.5)and(88.1±28.3)ml/(min·1.73 m2),respectively;and in the ICUD group were(98.9±23.3),(97.3±23.3)and(95.7±23.5)ml/(min·1.73 m2),respectively,and there were all statistically sig-nificant differences between the two groups(P=0.042,0.034,0.037).During the follow-up period,a total of 112 pa-tients(42.1%,112/266)experienced long-term renal function injury,with 12 cases(4.5%,12/266)progressing to chronic kidney disease(CKD)3B or above,including 9 cases(11.4% )in the ECUD group and 3 cases(1.6% )in the ICUD group,showing statistically significant difference(P<0.001).Patients were categorized into renal injury group and non-renal injury group based on the presence or absence of long-term renal function injury during the follow-up pe-riod.Univariate analysis comparing clinical data between the two groups revealed statistically significant differences in age(P=0.007),surgical approach(P<0.001),ureteroenteric anastomotic stricture(P<0.001),pathological stage T3 or above(P<0.001),postoperative hydronephrosis(P=0.006),and blood loss(P=0.007).By the multivariate analysis,different surgical approaches(OR=0.24,95% CI:0.12-0.46,P<0.001),ureteroenteric anastomotic stric-ture(OR=4.37,95% CI:1.32-14.45,P=0.016),and pathological stage T3 or above(OR=6.21,95% CI:3.20-12.07,P<0.001)were identified as independent risk factors for long-term renal function injury after surgery.A total of 30 patients(11.3% )developed acute kidney injury(AKI)during the follow-up period,including 6 cases(7.6% )in the ECUD group and 24 cases(12.8% )in the ICUD group,and the difference between the two groups was not statis-tically significant(P=0.217).Conclusion:Postoperative AKI and chronic kidney injury are common complications following radical resection in bladder cancer patients.Tumor characteristics(pathological stage),ureteroenteric anas-tomotic strictures and the choice of surgical approach(ECUD and ICUD)were independent risk factors of long-term renal function injury.Therefore,precise preoperative assessment,selection of appropriate surgical approaches and long-term follow-up are of paramount importance in preserving renal function in bladder cancer patients.

关键词

膀胱癌/机器人辅助腹腔镜根治性膀胱切除术/尿流改道/急性肾损伤/慢性肾脏病

Key words

bladder cancer/robot assisted radical cystectomy/urinary diversion/acute kidney injury/chronic kidney disease

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出版年

2024
微创泌尿外科杂志
解放军总医院

微创泌尿外科杂志

CSTPCD
影响因子：0.777
ISSN：2095-5146
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