上泌尿道上皮癌術後膀胱內腫瘤復發之預測與預後分析
李允仁、劉忠一、莊正鏗、馮思中、張英勛、虞凱傑、林柏宏、邵翊紘、甘弘成
林口長庚紀念醫院外科部 泌尿科系
Predictors of Intravesical Recurrence after Radical Nephroureterectomy and prognosis in Patients with Upper Tract Urothelial Carcinoma
Yun-Ren Li, Chung-Yi Liu, Cheng-Keng Chuang, See-Tong Pang, Ying-Hsu Chang, Kai-Jie Yu, Po-Hung Lin, I-Hung Shao, Hung-Cheng Kan
Division of Urology, Department of Surgery, Chang Gung Memorial Hospital, Taoyuan, Taiwan
Purpose: We investigate factors that may contribute individually to bladder recurrence and find out the potential candidate to receive postoperative single dose intravesical chemotherapy.
Materials and Methods: A total 217 patients were diagnosed of UTUC underwent radical nephroureterectomy from January 2012 to December 2016 at Linkou Chang Gung Memorial Hospital. The possible risk factor that may contribute to development of bladder recurrence and overall survival were analyzed. In order to find out the relationship between 1st bladder recurrence timing and outcome, we divided the 54 patients with bladder recurrence after RNU into 2 groups, the early and late bladder recurrence group, using the median time of 1st bladder recurrence and confirmed with the“minimum P -value” approach. The primary endpoint was development of relapsing high risk non-muscle invasive bladder cancer (NMIBC). The predictive factors of early recurrence and prognostic factors of survival were also analyzed.
Results: Among 217 patients with UTUC under RNU, the median age was 70(34-90) years and 138(63.6%) patients were female. The median follow up period was 42.0 (1.18-8.34) months. Intravesical recurrence after RNU occurred in 56(25.8%) patients after a median follow up of 35.2(1.18-83.34) months. Preoperative ureter manipulation, contaminate with CIS, positive surgical margin, main tumor>6.7mm seemed to have more bladder recurrences. Preoperative ureter manipulation (p=0.009) was significant predictor for development of bladder tumors. As for overall survival, renal rein invasion (p=0.017), preop neutrophil to lymphocyte ratio (p=0.021) and main tumor size (p=0.015) were significant predictors. For 54 patients who developed bladder recurrence, the optimal cutoff point of early recurrence was determined to be 10 months after surgery (p=0.042). Preoperative ureter manipulation (p=0.012) was identified as independent factors associated with early recurrence. An ERSD history and surgical margin positive patient was tend to have late bladder recurrence.
Conclusion: Bladder recurrence (25.8% in 3 years) was common in UTUC after RNU. Early bladder recurrence (10 months) was associated with more relapsing high-risk NMIBC and preoperative ureter manipulation was identified as independent factors associated with early recurrence. These patients may need more intensive monitoring or to receive prophylactic chemotherapy installation.