Helfand Alexander M, Beach Rebekah, Hadj-Moussa Miriam, Krishnan Naveen, He Chang, Montgomery Jeffrey S, Morgan Todd M, Weizer Alon Z, Hafez Khaled, Lee Cheryl T, Stoffel John T, Skolarus Ted A
Department of Urology, University of Michigan Health System, Ann Arbor, MI; Dow Division of Health Services Research, Department of Urology, University of Michigan Health System, Ann Arbor, MI.
Department of Urology, University of Michigan Health System, Ann Arbor, MI.
Urol Oncol. 2017 Jan;35(1):33.e1-33.e9. doi: 10.1016/j.urolonc.2016.07.018. Epub 2016 Aug 29.
To examine whether long-term renal function and overall survival outcomes vary according to management approach for ureteral anastomotic stricture (UAS) after cystectomy and urinary diversion.
We conducted a retrospective cohort study of patients with benign UAS following cystectomy and urinary diversion using our institutional database. We compared time to stricture, renal function, rates of renal loss, and overall survival between patients undergoing ureteral reimplantation vs. those undergoing nonoperative management (nephrostomy tube or ureteral stent). A multivariable Cox proportional hazard model was used to determine whether reimplantation was independently associated with overall survival.
We identified 87 UAS in 69 patients. Reimplantation was performed in 26 patients (37.7%), and 43 patients (62.3%) were managed nonoperatively. The interval between cystectomy and stricture diagnosis was similar in the reimplanted and nonoperative groups (3.06 vs. 4.34mo, P = 0.42). The differences between baseline and follow-up creatinine levels (+0.40 vs.+0.40mg/dl, P = 0.72) and estimated glomerular filtration rate (-25.0 vs.-18.9ml/min/1.73m, P = 0.66) were similar between groups, as were rates of renal loss (34.6% vs. 39.5%, P = 0.68); however, mortality was significantly higher in the nonoperative group. After multivariable adjustment, overall survival remained significantly higher among UAS patients who underwent reimplantation (adjusted hazard ratio [aHR] for risk of death = 0.32, 95% CI: 0.13-0.80).
Reimplantation was associated with improved overall survival but not with improved long-term renal functional outcomes compared with nonoperative management. Nonrenal complications of nonoperative UAS management may play an important role in reducing longevity.
探讨膀胱切除术后尿流改道输尿管吻合口狭窄（UAS）的处理方式是否会影响长期肾功能及总体生存结局。
我们利用机构数据库对膀胱切除术后尿流改道的良性UAS患者进行了一项回顾性队列研究。我们比较了输尿管再植术患者与接受非手术治疗（肾造瘘管或输尿管支架）患者的狭窄发生时间、肾功能、肾丢失率及总体生存率。采用多变量Cox比例风险模型确定再植术是否与总体生存独立相关。
我们在69例患者中识别出87例UAS。26例患者（37.7%）接受了再植术，43例患者（62.3%）接受了非手术治疗。再植术组和非手术治疗组膀胱切除与狭窄诊断之间的间隔相似（3.06个月对4.34个月，P = 0.42）。两组间基线和随访时肌酐水平的差异（+0.40对+0.40mg/dl，P = 0.72）以及估计肾小球滤过率的差异（-25.0对-18.9ml/min/1.73m²，P = 用0.66）相似，肾丢失率也相似（34.6%对39.5%，P = 0.68）；然而，非手术治疗组的死亡率显著更高。多变量调整后，接受再植术的UAS患者总体生存率仍显著更高（死亡风险调整后风险比[aHR]=0.32，95%CI：0.13 - 0.80）。
与非手术治疗相比，再植术与总体生存率提高相关，但与长期肾功能改善无关。非手术治疗UAS的非肾脏并发症可能在降低寿命方面起重要作用。
