腎臟輸尿管及膀胱袖口切除手術術後腎功能之預測因子分析

邱亮維、蔡禮賢、方仁愷、黃志平、張兆祥、楊啟瑞、吳錫金、葉進仲、陳汶吉、謝博帆、連啟舜、陳冠亨、蕭博任、張議徽

中國醫藥大學附設醫院 泌尿部

Predict factors of the renal function after nephroureterectomy with bladder cuff excision

Liang-Wei Chiu, Li-Hsien Tsai, Jen-Kai Fang, Chi-Ping Huang, Chao-Hsiang Chang, Chi-Rei Yang, Hsi-Chin Wu, Chin-Chung Yeh, Wen-Chi Chen, Po-Fan Hsieh, Chi-Shun Lien, Guan-Heng Chen, Po-Jen Hsiao, Yi-Huei Chang

Department of Urology, China Medical University Hospital, Taichung, Taiwan

Purpose: According to National Comprefensive Cancer Network (NCCN) guideline, nephroureterectomy with bladder cuff excision (NUBCE) is one of options for non-metastatic upper urinary tract urothelial carcinoma (UTUC). If no platinum neoadjuvant treatment given to non-organ confined (NOC) upper urinary tract urothelial carcinoma (UTUC) (pT3/pT4 and/or pN+), adjuvant platinum-based chemotherapy should be considered. However, the renal function might be declined after NUBCE. The adjuvant chemotherapy might be precluded. On the other hand, for patients with chronic kidney disease, dialysis might be needed after NUBCE. Therefore, it is important to make a good preoperative evaluation to predict the change of the post-operative (post-OP) renal function.

Materials and Methods: From November 2015 to August 2019, we recruited 100 patients with non-metastatic UTUC undergoing preoperative effective renal plasma flow (ERPF) and NUBCE in China Medical University Hospital. We examined the preoperative (pre-OP) factors and defined the impaired post-OP renal function as estimated glomerular filtration rate (eGFR) less than 30 ml/min/1.73m², and the declined renal function was considered significant if eGFR decreased by > 30%. All the statistical analysis was performed with SPSS 25.0.

Results: Among the patients, the mean age was 69.0 ± 9.9 years, and 49% of patients was male. Before undergoing NUBCE, eGFR was 51.2 ± 26.7 ml/min/1.73m² (range: 11-127 ml/min/1.73m²). Older age (OR=1.063, 95% CI = 1.012-1.116, p = 0.014), lower pre-OP eGFR (OR=0.915, 95% CI = 0.879-0.952, p = 0.0), higher pre-OP creatinine (OR=9, 95% CI = 3.336-25.839, p = 0.0), coronary artery disease (CAD, p = 0.004), chronic kidney disease (CKD, p = 0.0), and lower the split ERPF of contralateral kidney (OR=0.966, 95% CI = 0.952-0.979, p = 0.0) had higher risk that post-OP eGFR was less than 30 ml/min/1.73m². The split ERPF of contralateral kidney 152 ml/min offered an accurate prediction of 88.6% for post-OP eGFR less than 30 ml/min/1.73m² with sensitivity 77.3% and specificity 88.2%. On the other hand, higher pre-OP eGFR (OR= 1.022, 95% CI = 1.005-1.039, p = 0.009), lower pre-OP creatinine (OR= 0.517, 95% CI = 0.281-0.952, p = 0.034), higher pre-OP albumin level (OR= 4.527, 95% CI = 1.222-16.777, p = 0.024), higher the split ERPF of ipsilateral kidney (OR= 1.013, 95% CI = 1.006-1.020, p = 0.0), and lower the split ERPF of contralateral kidney (OR= 0.993, 95% CI = 0.986-0.999, p = 0.031) had higher risk that post-OP eGFR decreased by > 30%. The split ERPF of ipsilateral kidney 78 ml/min offered an accurate prediction of 77.1% for post-OP eGFR decreased by > 30% with sensitivity 82.5% and specificity 68.3%.