Wang Xianjin, Yao Jun, Jin Xingwei, Zhang Xiang, Lu Guoliang, Shao Yuan, Pan Junwei
Department of Urology, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China.
Department of Nursing, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China.
Transl Androl Urol. 2022 May;11(5):607-616. doi: 10.21037/tau-22-270.
Radical nephroureterectomy (RNU) is the principal method for treatment of high-risk upper urinary tract urothelial carcinoma (UTUC). The transperitoneal approach is associated with poor disease progression, but the distal ureter-bladder cuff (DUBC) resection through retroperitoneal laparoscopic approach is difficult. This study proposed a modulated RNU technique, namely, total retroperitoneal laparoscopic radical nephroureterectomy (tRLRNU), with its advantages of DUBC resection and requiring fewer trocars etc. The efficiency, safety, and short-term impacts were retrospectively compared with total transperitoneal laparoscopic radical nephroureterectomy (tTLRNU).
Total of 12 patients who received tRLRNU and 28 patients who received tTLRNU were enrolled. The choice of surgical approach was random and their data were retrospectively analyzed. During tRLRNU, the laparoscope was versed towards the caudal direction and a retroperitoneal laparoscopic ureterectomy was performed. The bladder cuff was entirely transected and the bladder incision was sutured. The tRLRNU cases were compared with the tTLRNU cases in terms of general clinical data, pathologic parameters, peri-operative parameters, adjuvant therapy, and short-term outcomes. The independent samples -tests, chi-square tests, and Fischer exact tests were used to analyze the differences.
There were no significant differences in the basic patient characteristics between the 2 groups. The data were comparable. There were significantly fewer trocars utilized in tRLRNU group compared to tTLRNU group (P=0.0008). tRLRNU group experienced less blood loss (98.33±61.32 versus 170.71±121.32 mL; P=0.017), smaller drainage volume (182.08±163.60 versus 1,924.82±3,370.02 mL; P=0.011), and shorter extubation time (5.67±1.07 versus 8.57±6.96 days; P=0.040) compared to tRLRNU group. There were no statistically differences in the other peri-operative parameters, including whole operation time, transfusion, visceral and vascular injuries, open conversion, post-operative bleeding, recovery time of intestinal function, and discharge time. The patient outcomes in tTLRNU group at 6 months were significantly worse than that of tRLRNU group by comparing progression-free survival, progression survival and mortality (P=0.039).
The tRLRNU was potentially safer, minimally invasive, and more effective compared to the tTLRNU. Due to the small sample size, short follow-up time and no randomization of the study, future comparative studies are warranted to further analyze long-term outcomes of tRLRNU.
根治性肾输尿管切除术（RNU）是治疗高危上尿路尿路上皮癌（UTUC）的主要方法。经腹途径与疾病进展不佳相关，但通过腹膜后腹腔镜途径进行远端输尿管膀胱袖口（DUBC）切除术较为困难。本研究提出了一种改良的RNU技术，即完全腹膜后腹腔镜根治性肾输尿管切除术（tRLRNU），其具有DUBC切除的优势且所需套管针较少等优点。回顾性比较了其与完全经腹腹腔镜根治性肾输尿管切除术（tTLRNU）的效率、安全性和短期影响。
共纳入12例行tRLRNU的患者和28例行tTLRNU的患者。手术方式的选择是随机的，并对他们的数据进行回顾性分析。在tRLRNU过程中，腹腔镜朝向尾侧方向，进行腹膜后腹腔镜输尿管切除术。完全切断膀胱袖口并缝合膀胱切口。比较tRLRNU组和tTLRNU组的一般临床资料﹑病理参数﹑围手术期参数﹑辅助治疗及短期结局。采用独立样本t检验、卡方检验和Fisher确切检验分析差异。
两组患者的基本特征无显著差异。数据具有可比性。与tTLRNU组相比，tRLRNU组使用的套管针明显更少（P = 0.0008）。tRLRNU组的失血量更少（98.33±61.32 vs 170.71±121.3 mL；P = 0.017），引流量更小（182.08±163.6 mL vs 1924.82±337 mL；P = 0.011），拔管时间更短（5.67±1.07天vs 8.57±6.96天；P = 0.040）。在其他围手术期参数方面，包括总手术时间、输血、内脏和血管损伤、中转开放、术后出血、肠功能恢复时间和出院时间，两组无统计学差异。通过比较无进展生存期、进展生存期和死亡率，tTLRNU组6个月时的患者结局明显差于tRLRNU组（P = 0.039）。
与tTLRNU相比，tRLRNU可能更安全、微创且更有效。由于本研究样本量小、随访时间短且未进行随机分组，未来需要进行比较研究以进一步分析tRLRNU的长期结局。
