Inoue Keiji, Kuno Takahira, Fukuhara Hideo, Hamaguchi Takuya, Fukata Satoshi, Karashima Takashi, Kamada Masayuki, Shuin Taro, Sakakura Naoki, Kasahara Kotaro, Watanabe Hironobu, Kozai Tetsuo, Yasuda Masaharu, Kataoka Shinichi, Tanimura Masanobu, Atsushi Kurabayashi, Furihata Mutsuo
Department of Urology, Kochi Medical School.
Nihon Hinyokika Gakkai Zasshi. 2009 Nov;100(7):661-70. doi: 10.5980/jpnjurol.100.661.
To report our clinical experience regarding transurethral resection of bladder tumor (TUR-Bt) guided by photodynamic diagnosis (PDD) with intravesical instillations of 5-aminolevulinic acid (ALA) and to assess the usefulness of the therapeutic method.
TUR-Bt guided by PDD was performed in 57 patients of which 47 were men and 10 women with a median age of 74.3 years (range 45-90), 36 were primary cases and 21 were recurrent cases with non-muscle invasive bladder cancer. Two to two and half hours prior to endoscopy 1.5 g ALA dissolved in 50 ml of 8.4% sodium hydrogen carbonate (NaHCO3) solution was instilled intravesically. For fluorescence excitation a blue light source (D-LIGHT System, Karl Storz Endoscopy Japan K.K.) was used. The tumorous lesions under white light guidance and the lesion with fluorescent excitation under blue (fluorescence) light guidance were taken by cold cup as a biopsy and also resected sequentially. To evaluate the accuracy of PDD, the levels in images of the ALA-induced fluorescence were compared with the pathological results. To evaluate the availability of TUR-Bt guided by PDD, survival Analysis regarding vesical recurrence was retrospectively examined compared to the cases underwent conventional TUR-Bt under white light guidance. Moreover, in these cases, multivariate analysis using Cox proportional-hazards model was performed to detect the clinico-pathological factor independently contribute to improving prognosis. (Results) In the 301 specimens obtained from 57 patients, the sensitivity and specificity of PDD were 92.5% and 60.1%, whereas the sensitivity and specificity of conventional endoscopic examination under white light guidance were 81.6% and 79.5%, respectively. Median follow-up period was 19.1 (range 8.6-49.9) months in 57 patients underwent TUR-Bt guided by PDD. Eight of 57 patients recurred and recurrence-free survival rate was 88.2 +/- 0.1% (at 12 months) and 76.2 +/- 0.1% (24-48 months). Median follow-up period was 49.9 (5.0-145.0) months in 149 patients underwent conventional TUR-Bt. Ninety-nine of 149 patients recurred and recurrence-free survival rate was 60.3 +/- 0.0% (12 months) and 31.6 +/- 0.0% (24-48 months). There was statistical significance in recurrence-free survival rate between these 2 therapeutic groups (p < 0.001). Moreover, multivariate analysis revealed the independent factor contribute to improving prognosis was only TUR-Bt guided by PDD (hazard ratio 0.279, p = 0.001).
It was suggested that TUR-Bt guided by PDD might reduce the risk of vesical recurrence in the early stage after operation of non-muscle invasive bladder cancer.
报告我们在光动力诊断（PDD）引导下经尿道膀胱肿瘤切除术（TUR-Bt）的临床经验，该诊断方法采用膀胱内灌注5-氨基酮戊酸（ALA），并评估该治疗方法的有效性。
对57例患者进行了PDD引导下的TUR-Bt手术，其中男性47例，女性10例，中位年龄74.3岁（范围45-90岁），36例为原发性病例，21例为非肌层浸润性膀胱癌复发病例。在内镜检查前两到两个半小时，将1.5 g ALA溶解于50 ml 8.4%碳酸氢钠（NaHCO₃）溶液中进行膀胱内灌注。使用蓝色光源（D-LIGHT系统，卡尔史托斯日本内窥镜有限公司）进行荧光激发。在白光引导下的肿瘤病变以及在蓝光（荧光）引导下荧光激发的病变，用冷活检钳进行活检并依次切除。为评估PDD的准确性，将ALA诱导荧光图像中的水平与病理结果进行比较。为评估PDD引导下TUR-Bt的有效性，与白光引导下进行传统TUR-Bt的病例相比，回顾性检查膀胱复发的生存分析。此外，在这些病例中，使用Cox比例风险模型进行多变量分析，以检测独立有助于改善预后的临床病理因素。（结果）在57例患者获得的301个标本中，PDD的敏感性和特异性分别为92.5%和60.1%，而白光引导下传统内镜检查的敏感性和特异性分别为81.6%和79.5%。57例行PDD引导下TUR-Bt的患者中位随访期为19.1（范围8.6-49.9）个月。57例患者中有8例复发，无复发生存率为（12个月时）88.2±0.1%，（24-48个月时）76.2±0.1%。149例行传统TUR-Bt的患者中位随访期为49.9（5.0-145.0）个月。149例患者中有99例复发，无复发生存率为（12个月时）60.3±0.0%，（24-48个月时）31.6±0.0%。这两个治疗组之间的无复发生存率有统计学意义（p<0.001）。此外，多变量分析显示独立有助于改善预后的因素仅为PDD引导下的TUR-Bt（风险比0.279，p=0.001）。
提示PDD引导下的TUR-Bt可能降低非肌层浸润性膀胱癌术后早期膀胱复发的风险。
