Kocher Neil J, Canes David, Bensalah Karim, Roupret Morgan, Lallas Costas, Margulis Vitaly, Shariat Shahrokh, Colin Pierre, Matin Surena, Tracy Chad, Xylinas Evanguelos, Wagner Andrew, Roumiguie Mathieu, Kassouf Wassim, Klatte Tobias, Raman Jay D
Department of Surgery, Penn State Health Milton S. Hershey Medical Center, Hershey, PA, USA.
Department of Urology, Lahey Clinic Hospital and Medical Center, Burlington, MA, USA.
Transl Androl Urol. 2020 Aug;9(4):1786-1793. doi: 10.21037/tau.2020.01.22.
Radical nephroureterectomy (RNU) is the referent standard for managing bulky, invasive, or high grade upper-tract urothelial carcinoma (UTUC). The UTUC patient population, however, generally harbor medical comorbidities thereby placing them at risk of surgical complications. This study reviews a large international cohort of RNU patients to define the risk of major complications and preoperative factors associated with their occurrence.
Patients undergoing RNU at 14 academic medical centers between 2002 and 2015 were retrospectively reviewed. Preoperative clinical, demographic, operative, and comorbidity indices were recorded. The modified Clavien-Dindo index was used to grade complications occurring within 30 days of surgery. The association between preoperative variables and major complications occurring after RNU was determined by multivariable logistic regression.
One thousand two hundred and sixty-six patients (707 men; 559 women) with a median age of 70 years and BMI of 27 kg/m were included. Over three-quarters of the cohort was white, 50.1% had baseline chronic kidney disease (CKD) ≥ stage III, 22.4% had a Charlson comorbidity index (CCI) score >5, and 17.1% had an Eastern Cooperative Oncology Group (ECOG) performance status ≥2. Overall, 413 (32.6%) experienced a complication including 103 (8.1%) with a major event. Specific distribution of major complications included 49 Clavien III, 44 Clavien IV, and 10 Clavien V. On univariate analysis, patient age (P=0.006), hypertension (P=0.002), diabetes mellitus (P=0.023), CKD stage (P<0.001), American Society of Anesthesiologists (ASA) score (P=0.022), ECOG (P<0.001), and CCI (P<0.001) all were associated with major complications. On multivariate analysis, ECOG ≥2 (OR 2.38, 95% CI, 1.46-3.90), P=0.001), CCI >5 (OR 3.45, 95% CI, 1.41-8.33, P=0.007), and CKD stage ≥3 (OR 3.64, P=0.008) were independently associated with major complications.
Major complications following RNU occurred in almost 10% of patients. Impaired preoperative performance status and baseline CKD are preoperative variables associated with these major post-surgical adverse event. These easily measurable indices warrant consideration and discussion prior to proceeding with RNU.
根治性肾输尿管切除术（RNU）是治疗体积较大、浸润性或高级别上尿路尿路上皮癌（UTUC）的参考标准。然而，UTUC患者群体通常存在合并症，因此有发生手术并发症的风险。本研究回顾了一个大型国际RNU患者队列，以确定主要并发症的风险及其发生的术前因素。
对2002年至2015年间在14家学术医学中心接受RNU的患者进行回顾性研究。记录术前临床、人口统计学、手术和合并症指标。采用改良的Clavien-Dindo指数对术后30天内发生的并发症进行分级。通过多变量逻辑回归确定术前变量与RNU术后主要并发症之间的关联。
纳入1266例患者（707例男性；559例女性），中位年龄70岁，BMI为27kg/m。超过四分之三的队列是白人，50.1%有基线慢性肾脏病（CKD）≥III期，22.4%的Charlson合并症指数（CCI）评分>5，17.1%的东部肿瘤协作组（ECOG）体能状态≥2。总体而言，413例（32.6%）发生了并发症，其中103例（8.1%）发生了重大事件。主要并发症的具体分布包括49例Clavien III级、44例Clavien IV级和10例Clavien V级。单因素分析显示，患者年龄（P=0.006）、高血压（P=0.002）、糖尿病（P=0.023）、CKD分期（P<0.001）、美国麻醉医师协会（ASA）评分（P=0.022）、ECOG（P<0.001）和CCI（P<0.001）均与主要并发症相关。多因素分析显示，ECOG≥2（比值比[OR]2.38，95%置信区间[CI]，1.46-3.90，P=0.001）、CCI>5（OR 3.45，95%CI，1.41-8.33，P=0.007）和CKD分期≥3（OR 3.64，P=0.008）与主要并发症独立相关。
RNU术后近10%的患者发生了主要并发症。术前体能状态受损和基线CKD是与这些术后主要不良事件相关的术前变量。在进行RNU之前，这些易于测量的指标值得考虑和讨论。
