Résumé
Objective:To explore the predictors of upper tract urothelial carcinoma (UTUC) invading muscle.Methods:The preoperative clinical data of 169 patients with UTUC who underwent radical nephroureterectomy (RNU) in the Department of Urology, Second Hospital of Tianjin Medical University from August 2019 to September 2021 were retrospectively collected. The average age of the patients was (67.7±8.3)years. There were 95 male cases (56.2%).15 cases (15.8%) were with diabetes, 46 cases (48.4%) with hypertension, 68 cases (71.6%) with hematuria, 44 cases (46.3%) with renal pelvis tumor, 74 cases (77.9%) with hydronephrosis and 8 cases (8.4%) with multifocality. There were 15 (20.3%), with diabetes, 40(54.1%) with hypertension, 58(78.4%)with hematuria, 32(43.2%) with renal pelvis tumor, 60(81.1%) with hydronephrosis and 2(2.7%) with multifocality among 74 female patients(43.8%), respectively. Patients’ body mass index (BMI) was (24.2±3.2) kg/m 2.The tumor diameter was (3.4±1.8) cm. The average count of neutrophil (NEU) was (4.2±1.7) ×10 9/L, with monocyte (MON) (0.4±0.2) ×10 9/L, platelet (PLT) (237.8±75.3) ×10 9/L and lymphocyte (LYM) (1.7±0.5) ×10 9/L. Neutrophil-to-lymphocyte ratio (NLR) was 2.7±1.4. Mmonocyte-to-lymphocyte ratio (MLR) was 0.3±0.1 and platelet-to-lymphocyte ratio (PLR) was 151.1±59.6. The concentrations of hemoglobin (Hb) and fibrinogen (FIB) were (127.1±18.3) g/L and(3.5±1.0) g/L. Univariate logistic regression analysis was performed on all preoperative data, and a nomogram was established to predict UTUC invading muscle by stepwise regression combined with multivariate logistic analysis. Concordance index (C-index) was used to evaluate the accuracy of the model, and Hosmer-Lemeshow test was used to check the fit. Using 1000 bootstrap resampling to validate the model and draw calibration plot. Receiver operating characteristics (ROC) curves were used to determine the most appropriate cut-off point of the model to predict tumor invasion and evaluate its sensitivity and specificity. Results:In this study, there were 169 cases. Postoperative pathological results showed that 18 cases (10.6%) were of low grade and 151 cases (89.4%) were of high grade. There were 2 patients (1.2%) with pT a stage, 44 patients (26.0%) with pT 1 stage, 37 patients (21.9%) with pT 2 stage, 81 patients (47.9%) with pT 3 stage and 5 patients (3.0%) with pT 4 stage. According to tumor stage, 46 patients were included into non-muscle invasive disease (NMID, pT a/T is/T 1) group and 123 patients were included into muscle invasive disease (MID, pT 2/T 3/T 4) group. Univariate analysis showed that hydronephrosis ( OR=2.919, 95% CI 1.332-6.387, P=0.007) was significantly correlated with MID. Tumor location in ureter ( OR=1.898, 95% CI 0.960-3.800, P=0.067), higher NLR value ( OR=1.313, 95% CI 0.9901.832, P=0.082) and FIB concentration ( OR=1.436, 95% CI 1.008-2.125, P=0.056) might have potential association with MID. Stepwise regression method was used to screen out PLT, FIB and hydronefrosis as the optimal combination for MID prediction. multivariate analysis suggested that PLT decreasing ( OR=0.727, 95% CI 0.548-0.955, P=0.023), FIB increasing ( OR=1.629, 95% CI 1.084-2.552, P=0.025) and hydronephrosis ( OR=2.500, 95% CI 1.111-5.601, P=0.026) were independent predictors of MID.The C-index of the model constructed by the three factors was 0.682, and the P-value of the goodness of fit was 0.778. The ROC curve showed that the optimal cut-off point for the prediction of high-risk MID by the nomogram was 0.627, achieving 39.1% specificity, 88.6% sensitivity and 0.682 area under the curve (AUC). Conclusions:Preoperative decrease of PLT, increase of FIB and hydronephrosis were independent factors for predicting UTUC invading muscle.
Résumé
Ureteroscopy plays an important role in the diagnosis and treatment of upper tract urothelial carcinoma (UTUC). Conventional ureteroscopy (URS) can not only identify the location, appearance and size of a tumor, but also assess tumor grade by biopsy. The continued development of electronic flexible ureteroscopy and assistive technologies has led to further advances in the diagnosis of UTUC. Ureteroscopic laser ablation can be used to treat low grade malignancy, renal insufficiency, or isolated kidney. However, the use of URS may have potential risks such as delay of radical treatment, increased surgical difficulty, intraoperative or postoperative complications and intravesical recurrence. This article reviews the advantages and disadvantages of ureteroscopy in the diagnosis and treatment of UTUC.
Résumé
【Objective】 To investigate the efficacy and safety of single position transabdominal and extraperitoneal laparoscopic radical nephroureterectomy in the treatment of upper tract urothelial carcinoma (UTUC). 【Methods】 Clinical data of 31 UTUC cases treated in our hospital during Nov.2018 and Jun.2022 were retrospectively analyzed, including 11 tumors in the right side, and 20 in left side. There were 14 cases of renal pelvic carcinoma, 16 cases of ureter carcinoma, and 1 case of renal pelvic carcinoma plus ureter carcinoma. 【Results】 All surgeries were successfully performed without conversion to open surgery. The mean operation time was (81.45±19.80) min, and the estimated blood loss was (69.03±24.13) mL. No serious perioperative complications were observed. The average postoperative hospital stay was (6.13±2.44) d, and the median follow-up was 28 (3.0-49.0) months. At the last follow-up, 2 patients died, 3 had recurrence, but no contralateral recurrence was observed. 【Conclusion】 Single position transabdominal and extraperitoneal laparoscopic radical nephroureterectomy is safe, effective and feasible in the treatment of UTUC. It is worth clinical popularization.
Résumé
【Objective】 To investigate the effects of preoperative ureteroscopy (URS) on the intravesical recurrence (IVR) in patients with upper tract urothelial carcinoma (UTUC) after radical nephroureterectomy (RNU). 【Methods】 The clinical data of 241 UTUC patients treated during May 2012 and Jan.2020 in the Second Hospital of Laozhou University were retrospectively analyzed. The patients were divided into URS before RNU group (URS group) and non-URS before RNU group (non-URS group). The cumulative IVR rate, progression-free survival (PFS) and overall survival (OS) after RNU were compared, and the survival curve was drawn. Cox proportional hazards models were used to assess risk factors affecting IVR. 【Results】 Of the 241 patients, 64 (26.6%) were included in the URS group and 177 (73.4%) in the non-URS group. In the URS group, 49 underwent biopsy and 15 did not. All patients were followed up for a median of 44 (3 to 122) months, with a median time to recurrence of 12 (3 to 56) months. IVR occurred in 18 patients (28.1%) in the URS group and 25 (14.1%) in the non-URS group. Kaplan-Meier survival analysis showed that the cumulative IVR rate was higher in the URS group than in the non-URS group (all P<0.05), regardless of whether patients had a history of bladder cancer (BC) or not, while PFS was lower in the URS group than in the non-URS group (P=0.007). Cox multivariate regression analysis showed that URS (P=0.031) and complicated renal pelvis tumor and ureteral tumor (P=0.004) were independent risk factors for IVR. 【Conclusion】 Preoperative URS increases the incidence of IVR in patients with UTUC, and routine preoperative use of URS is not recommended.
Résumé
【Objective】 To reduce the misdiagnosis rate by analyzing the clinical data of patients with primary upper tract urothelial carcinoma (UTUC) complicated with calculi. 【Methods】 Clinical data of 7 UTUC with calculi patients treated during Sep.2018 and Apr.2022 were retrospectively analyzed, including general data, time from visit to diagnosis, imaging data, urine exudation cytological results, surgical methods, pathological stages and follow-up data. 【Results】 The ratio of male to female was 3∶4, and the mean age was 66.4 (55-72) years. The initiate imaging examination results only showed calculi, but did not indicate suspicious tumor (including 1 case with missing data). The median time from the first visit to diagnosis was 12 months (5-36 months). Of all 7 cases, 2 (2/4) were clinically diagnosed by enhanced CT, 3 (3/4) by MRI, and 2 (2/7) by positive urine exudation cytology. All patients received surgical treatment. Postoperative pathology showed 85.71% (6/7) were high-grade UTUC. Postoperative staging was T1N0M0 in 4 cases, T3N0M0 in 2 cases, and T4N2M0 in 1 case. Adjuvant chemotherapy was conducted in 2 cases. During the median follow-up of 12 months (6-41), 1 case developed multiple systemic metastases in month 9, while the other cases had no recurrence or metastasis. 【Conclusion】 For UTUC patients without obvious filling defect on imaging, especially when ipsilateral calculi were complicated, misdiagnosis should be alerted for timely treatment and better prognosis.
Résumé
Urothelial carcinoma (UC) is the second most common genitourinary tumor, and upper tract urothelial carcinoma (UTUC) accounts for 5% to 10% of UC. Intravesical recurrence (IVR) occurs in 22% to 47% of patients after radical resection. This article reviews the mechanism, characteristics, related risk factors, regular bladder monitoring, diagnosis and treatment, and preventive measures of IVR, hoping to provide reference for clinical work.
Résumé
Objective:We aim to investigate the clinical characteristics and prognosis of upper tract urothelial carcinoma (UTUC) in patients with non-muscle invasive bladder cancer (NMIBC) after renal transplantation.Methods:We retrospectively analyzed the clinical and follow-up information of 13 kidney recipients with NMIBC admitted to our hospital from January 2014 to June 2022 who subsequently underwent complete transperitoneal laparoscopic nephroureterectomy. There were 8 males and 5 females, aged (56.1±11.5), 3 cases with history of smoking and 10 cases without history of smoking, 4 cases with history of Aristolochic acids and 9 cases with no history of Aristolochic acids. Six and seven cases were treated with transurethral resection of bladder tumor for hematuria and bladder tumors detected by ultrasound or imaging respectively. Single and multiple bladder tumors were 9 and 4 cases; bladder tumor size ≤ 3 cm, >3 cm were 9 and 4 cases respectively; low-and high-grade bladder tumors were 3 and 10 cases separately, with; T a and T 1 of 3 and 10 cases respectively; recurrent bladder cancer and non-recurrent bladder cancer were 5 and 8 cases respectively. Follow-up after transurethral resection of bladder tumor showed that 6 cases with imaging evidence of UTUC for 6-52 months after transurethral resection of bladder tumor were treated with ipsilateral laparoscopic nephroureterectomy, including 2 cases of hydronephrosis, 1 case of renal pelvis mass, and 3 cases of ureteral mass, and 7 cases without imaging evidence of UTUC were performed with bilaterally prophylactic laparoscopic nephroureterectomy. The Kaplan-Meier curve and log-rank test were used for survival analysis to evaluate the prognostic effect of UTUC in kidney recipients with NMIBC. Results:Six of 13 patients named UTUC group were diagnosed with UTUC and 7 of 13 patients named no-UTUC group were not detected with UTUC. There was no statistical difference between these two groups in terms of clinical characteristics, including age( P=0.10), sex( P=0.10), smoking( P=0.19), history of Aristolochic acids( P=0.99), number( P=0.56), grade( P=0.19), stage ( P=0.19)and recurrence of bladder tumor number( P=0.10), and radiological findings of UTUC ( P=0.29). However, patients with larger-sized bladder tumors (larger than 3cm) had a higher rate of UTUC compared to patients with equal or smaller than 3 cm ( P=0.29). In addition, two patients with negative radiological findings developed UTUC following the detection of a large bladder tumor size (larger than 3 cm). The median survival of overall survival time and cancer specific survival time after laparoscopic nephroureterectomy were 42(17, 65) months. Two patients died from any cause during follow-up in patients with UTUC, whereas no significant difference between UTUC group and non-UTUC group in overall survival time and cancer specific survival time, as evaluated by the Kaplan-Meier curves and log-rank tests. ( P=0.29). Conclusions:After kidney transplantation, the diameter of the bladder tumor in NMIBC patients with UTUC was significantly larger than that in patients without UTUC, and no significant difference was observed in the remaining clinical features. Considering the non-functioning kidney after kidney transplantation, prophylactic laparoscopic nephroureterectomy can be considered for NMIBC patients with bladder tumor size >3 cm. Survival analysis showed no significant difference between UTUC group and non-UTUC group.
Résumé
Objective:To summarize the preliminary clinical experience of endoscopic treatment of upper urinary tract urothelial carcinoma, and to analyze its indications and efficacy.Methods:The clinical data of 14 patients underwent endoscopic treatment for upper urinary tract urothelial carcinoma in our hospital from December 2014 to December 2019 were retrospectively analyzed. Among them, there were 5 males and 9 females, with a median age of 75.5(44-84) years. There were 11 patients with hematuria, 2 patients with flank pain and one asymptomatic patient. Five patients had a history of bladder cancer and one had a history of contralateral UTUC. There were 4 patients with solitary kidney, 3 patients with renal insufficiency, 1 patient with bilateral renal pelvis carcinoma, 4 patients prohibitory to nephroureterectomy because of poor general condition (American Society of Anesthesiologists score ≥3), and 2 patients were pathologically diagnosed as low-grade non-invasive urothelial carcinoma and requested renal preservation therapy. A total of 15 renal units included. The main tumor sites were renal pelvis in 6 renal units, upper calyx in 4 renal units, middle calyx in 3 renal units, and lower calyx in 2 renal units. The median tumor diameter was 2.0 (0.8-4.0) cm. All patients were diagnosed with urothelial carcinoma by preoperative computed tomography (CT/CTU), magnetic resonance imaging (MRI), and cytological or pathological biopsy. In 13 patients, ultrasond-guided percutaneous renal access and tract dilation were performed to establish a F24 standard tract. The tumor tissues were vaporized by 1470 semiconductor laser (60-80 W) or thulium laser (15-20 W) under nephroscopy, and electrocoagulation was used to coagulate the bleeding when necessary. Two patients were treated with felxible ureteroscope, under which tumor ablation was performed with 200 μm holmium laser fiber, and neodymium laser was used for hemostasis. The range of tumor vaporization ablation included 0.5-1.0 cm normal renal pelvis mucosa around the tumor, deep to the fatty layer of renal sinus. Biopsy was taken again at the base of the wound after vaporization ablation when necessary.Results:In this study, six sites were pathological high grade, 9 sites were pathological low grade tumors. Eight were in pathological T a stage, 5 in T 1 stage, and 2 in T 2 stage. The median blood loss was 20.0 (2-50) ml. There were 5 postoperative complications, including one patient with fever (body temperature >38.5℃) and 4 patients with hemorrhage requiring blood transfusion (postoperative hemoglobin <70 g/L) with 2-4 U suspended red blood cells.No patient underwent embolization. The median follow-up time were 31(11-70)months. Ten patients experienced recurrence, and the median time to recurrence was 11.3 (4-41) months. Four of them received conservative treatment after recurrence, including immunotherapy and radiotherapy in 1 patient, systemic chemotherapy in 1 patient, and watchful waiting in 2 patients. Three of them received repeated endoscopic treatment after recurrence, including 2 patients with percutaneous nephroscopic laser ablation and 1 patient with transurethral resection of bladder tumor, all of them survived during the follow-up period. Three patients underwent full-length nephroureterectomy after recurrence, 2 died and 1 survived during the follow-up period. Six patients eventually died, and the median time of death after surgery was 21(9-33) months. Five of them died from tumor-specific death and one died from gastric perforation. The median tumor-free survival interval were11 (4-41) months during the follow-up period. The 2-year tumor-specific survival rate was 78.6%, 50% for high-grade patients and 100% for low-grade patients. Conclusions:In patients who were in early stage (≤T 2) and intolerant to the nephroureterectomy, or with solitary kidney, renal insufficiency, or bilateral tumors, endoscopic treatment could be used as an alternative treatment approach for upper urinary tract epithelial carcinoma, especially for low-grade non-invasive patients.
Résumé
Nephroureterectomy is the golden standard for surgical treatment of upper urinary tract urothelial carcinoma. With the development of surgical robotics, the number of robot-assisted laparoscopic nephroureterectomy has increased rapidly worldwide. With the advantages of 3D imaging, high-definition camera and flexible joints, this procedure reduces the complexity of approaches in nephroureterectomy such as dissection of distal and intramural ureter as well as suture of the bladder wound, with comparable oncological outcome to open surgery. The present article reviewed the research progress in preoperative preparation, intraoperative technique, perioperative parameters and prognosis of robot-assisted laparoscopic nephroureterectomy.
Résumé
Objective To introduce and discuss the efficacy of a new technique to perform transperitoneal single-docking robot-assisted laparoscopic nephroureterectomy (RNU).Methods A total of 44 patients diagnosed with urothelial neoplasm of the renal pelvis or were investigated from January 2016 to November 2019.RNU was performed by a single surgeon.Among the 44 patients,31 were male,and 13 were female.The median age was 63 (IQR:58-71).The median body mass index (BMI) was 23.08 (IQR:21.55-24.60) kg/m2.All operations were performed with general anesthesia.The patients were positioned 80 degrees flank with the diseased side up,and the head was tilted 10 degrees downwards.The camera port was placed one finger lateral to the umbilicus.For the right-sided tumors,robotic arm 1 was inserted through the trocar on the right pararectus line,8 cm above the umbilicus,and robotic arm 2 was inserted through the trocar on the same line,8 cm below the umbilicus.Assistant trocar 1 was placed where the anterior midline joins the perpendicular bisector of the camera port and robotic 2,and assistant trocar 2 was placed below the xiphoid process.For the left-sided tumors,all trocars were centrosymmetric to that of the right-sided tumors,except that assistant port 2 was placed 3 finger width above the pubic symphysis.The peritoneum was incised along the Toldt line,and the inferior vena cava was isolated (for left sided tumor,the abdominal aorta was isolated instead).The renal artery and vein were clipped with Hem-o-lok and ligated,and the kidney were isolated.The ureter was identified and isolated downwards across the common iliac artery and then clipped distal to the tumor site.The bladder cuff was resected and sutured under the laparoscopy.Results The median operation time was 145 (IQR:130-175) min,with the median console time of 119 (IQR:108.5-136.0) min,the anastomosis of bladder cuff of 12 min,and the median estimated blood loss of 50 (20-100)ml.After the surgery,6 Clavien-Dindo grade 2 complications occurred,including 2 chylous leakage,1 hemostasis,1 blood transfusion,1 deep vein thrombus,and 1 acute coronary syndrome.The median length of stay (LOS) was 8 (IQR:6.5-10.0) d.The median length of follow-up was 12 months.In total,5 patients were dead,including 3 cancer-specific death.Four recurrence occurred and caused 3 death.The 2-year overall survival and progression-free survival were 68.2％ and 77.9％,respectively.Conclusions The technique of RNU with simultaneous bladder cuff excision (BCE).Our technique improved the surgical outcome.The perioperative complication rate was low,and the short-term survival outcomes were satisfactory.
Résumé
Objective The aim of this study was to evaluate the influence of concomitant carcinoma in situ (CCIS) on tumor survival for the upper tract urinary carcinoma (UTUC) through systematic review and meta-analysis.Methods In the light of Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) guidelines,a systematic search of Web of Science,PubMed and EMBASE China National Knowledge Infrastructure (CNKI) and Wanfang database by key words "upper urinary tract urothelial carcinoma"" renal sputum cancer concomitant carcinoma in situ",and "radical ureterectomy" were performed for all reports that included detailed results on the predictors of CCIS.The search deadline is June 2019,and the search terms are English and Chinese.Methodological quality evaluation was performed using the QUIPS tool,and statistical analysis of the relevant data was performed using Stata 12.0 and RevMan 5.3 software.Results Sixteen articles were included in this study and all published between 2012 and 2019.A total of 11 131 patients with UTUC,including 1 774 (15.9％) patients with CCIS.According to our final results,there was a significant correlation of CCIS with worse cancer-specific survival (CSS) (HR =1.10,95％ CI 1.05-1.16,P ＜ 0.001),recurrence-free survival (RFS) (HR =1.15,95％ CI 1.09-1.21,P＜0.001) and overall survival (OS) (HR=1.10,95％CI 1.03-1.17,P=0.003).Begg's bias analysis showed no significant publication bias in CSS (P =0.822),RFS (P =0.348),and OS (P =0.452).Conclusions This study demonstrated that CCIS was associated with poor oncological outcome and could serve as a independent prognostic factor for patient with UTUC after radical nephroureterectomy.
Résumé
This study aimed to further validate the prognostic role of fibrinogen in upper tract urothelial carcinoma (UTUC) in a large Chinese cohort. A total of 703 patients who underwent radical nephroureterectomy were retrospectively identified. Fibrinogen levels of ≥4.025 g l-1 were defined as elevated. Logistic regression analysis was performed to determine the association between fibrinogen and adverse pathological features. Kaplan-Meier analysis and Cox regression models were used to assess the associations of fibrinogen with cancer-specific survival (CSS), disease recurrence-free survival (RFS), and overall survival (OS). Harrell c-index and decision curve analysis were used to assess the clinical utility of multivariate models. The median follow-up duration was 42 (range: 1-168) months. Logistic regression analysis revealed that elevated fibrinogen was associated with higher tumor stage and grade, lymph node involvement, lymphovascular invasion, sessile carcinoma, concomitant variant histology, and positive surgical margins (all P < 0.05). Multivariate Cox regression analysis demonstrated that elevated fibrinogen was independently associated with decreased CSS (hazard ratio [HR]: 2.33; P < 0.001), RFS (HR: 2.09; P < 0.001), and OS (HR: 2.09; P < 0.001). The predictive accuracies of the multivariate models were improved by 3.2%, 2.0%, and 2.8% for CSS, RFS, and OS, respectively, when fibrinogen was added. Decision curve analysis showed an added benefit for CSS prediction when fibrinogen was added to the model. Preoperative fibrinogen may be a strong independent predictor of worse oncologic outcomes in UTUC; therefore, it may be valuable to apply this marker to the current risk stratification in UTUC.
Sujets)
Sujet âgé , Femelle , Humains , Mâle , Adulte d'âge moyen , Marqueurs biologiques tumoraux , Carcinome transitionnel/chirurgie , Chine , Survie sans rechute , Fibrinogène/analyse , Néphro-urétérectomie , Pronostic , Études rétrospectives , Taux de survie , Tumeurs urologiques/chirurgieRésumé
Objective@#The aim of this study was to evaluate the influence of concomitant carcinoma in situ (CCIS) on tumor survival for the upper tract urinary carcinoma (UTUC) through systematic review and meta-analysis.@*Methods@#In the light of Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) guidelines, a systematic search of Web of Science, PubMed and EMBASE China National Knowledge Infrastructure (CNKI) and Wanfang database by key words "upper urinary tract urothelial carcinoma" "renal sputum cancer" "concomitant carcinoma in situ" , and "radical ureterectomy" were performed for all reports that included detailed results on the predictors of CCIS. The search deadline is June 2019, and the search terms are English and Chinese. Methodological quality evaluation was performed using the QUIPS tool, and statistical analysis of the relevant data was performed using Stata 12.0 and RevMan 5.3 software.@*Results@#Sixteen articles were included in this study and all published between 2012 and 2019. A total of 11 131 patients with UTUC, including 1 774 (15.9%) patients with CCIS. According to our final results, there was a significant correlation of CCIS with worse cancer-specific survival (CSS) (HR=1.10, 95%CI 1.05-1.16, P<0.001), recurrence-free survival (RFS) (HR=1.15, 95%CI 1.09-1.21, P<0.001) and overall survival (OS) (HR=1.10, 95%CI 1.03-1.17, P=0.003). Begg′s bias analysis showed no significant publication bias in CSS (P=0.822), RFS (P=0.348), and OS (P=0.452).@*Conclusions@#This study demonstrated that CCIS was associated with poor oncological outcome and could serve as a independent prognostic factor for patient with UTUC after radical nephroureterectomy.
Résumé
This study aimed to further validate the prognostic role of fibrinogen in upper tract urothelial carcinoma (UTUC) in a large Chinese cohort. A total of 703 patients who underwent radical nephroureterectomy were retrospectively identified. Fibrinogen levels of ≥4.025 g l-1 were defined as elevated. Logistic regression analysis was performed to determine the association between fibrinogen and adverse pathological features. Kaplan-Meier analysis and Cox regression models were used to assess the associations of fibrinogen with cancer-specific survival (CSS), disease recurrence-free survival (RFS), and overall survival (OS). Harrell c-index and decision curve analysis were used to assess the clinical utility of multivariate models. The median follow-up duration was 42 (range: 1-168) months. Logistic regression analysis revealed that elevated fibrinogen was associated with higher tumor stage and grade, lymph node involvement, lymphovascular invasion, sessile carcinoma, concomitant variant histology, and positive surgical margins (all P < 0.05). Multivariate Cox regression analysis demonstrated that elevated fibrinogen was independently associated with decreased CSS (hazard ratio [HR]: 2.33; P < 0.001), RFS (HR: 2.09; P < 0.001), and OS (HR: 2.09; P < 0.001). The predictive accuracies of the multivariate models were improved by 3.2%, 2.0%, and 2.8% for CSS, RFS, and OS, respectively, when fibrinogen was added. Decision curve analysis showed an added benefit for CSS prediction when fibrinogen was added to the model. Preoperative fibrinogen may be a strong independent predictor of worse oncologic outcomes in UTUC; therefore, it may be valuable to apply this marker to the current risk stratification in UTUC.
Résumé
Cystatin-C (Cys-C) has been reported as a valuable prognostic biomarker in various malignancies. However, its effect on upper tract urothelial carcinoma (UTUC) patients has not been investigated before. Thus, to explore the impact of Cys-C on survival outcomes in patients undergoing radical nephroureterectomy (RNU), a total of 538 patients with UTUC who underwent RNU between 2005 and 2014 in our center (West China Hospital, Chengdu, China) were included in this study. Kaplan-Meier method and Cox regression analyses were performed to assess the relationship between Cys-C and survival outcomes using SPSS version 22.0. The cutoff value of Cys-C was set as 1.4 mg l-1 using the receiver operating characteristic (ROC) curves and Youden index. The mean age of patients included was 66.1 ± 11.1 years, and the median follow-up duration was 38 (interquartile range: 19-56) months. Overall, 162 (30.1%) patients had elevated Cys-C, and they were much older and had worse renal function than those with Cys-C <1.4 mg l-1 (both P < 0.001). Meanwhile, Kaplan-Meier analysis revealed that the group with elevated Cys-C had worse cancer-specific survival (CSS, P = 0.001), disease recurrence-free survival (RFS, P = 0.003), and overall survival (OS, P < 0.001). Multivariable Cox analysis suggested that the elevated Cys-C was identified as an independent prognostic predictor of CSS (hazard ratio [HR]: 1.997, 95% confidential interval [CI]: 1.331-2.996), RFS (HR: 1.429, 95% CI: 1.009-2.023), and OS (HR: 1.989, 95% CI: 1.366-2.896). In conclusion, our result revealed that the elevated preoperative serum Cys-C was significantly associated with worse outcomes in UTUC patients undergoing RNU.
Sujets)
Sujet âgé , Femelle , Humains , Mâle , Adulte d'âge moyen , Facteurs âges , Marqueurs biologiques tumoraux/sang , Carcinome transitionnel/chirurgie , Chine , Cystatine C/sang , Période préopératoire , Pronostic , Études rétrospectives , Taux de survie , Tumeurs urologiques/chirurgieRésumé
Objective@#To investigate the value of diagnostic digital flexible ureteroscopy in patient with hematuria from unilateral upper urinary tract.@*Methods@#A retrospective analysis was made in consecutive 140 cases, including 94 males and 46 females, who are considered for hematuria from unilateral upper urinary tract in Renmin hospital of Wuhan University from January 2014 to February 2019.Their age ranged from 22 to 89 years, with mean of 62.3 years. The mean BMI was 24.6 kg/m2(ranging 22.1-28.2 kg/m2). All patients complained about the continuously or intermittently gross hematuria. 29 cases (20.7%) complained about the flank pain, as well. All cases were examined by urinary sonography, CTU and voided urine cytology preoperatively. Occupying lesion was found in 47 case by sonography including suspected diagnosis. Upper tract urothelial carcinoma(UTUC) was diagnosed in 63 cases by CTU including suspected diagnosis.Voided cytology was positive in 17 cases. Concomitant bladder or urethral lesions were excluded by cystoscopy. Hematuria was confirmed from left side in 82 cases(58.6%) and from right side in 58 cases(41.4%). Diagnostic digital flexible ureteroscopy were performed under general anethesia strictly according to 'No touch technique’. Biopsy for suspicious lesions as well as selective in situ cytology were acquired during ureteroscopy.@*Results@#All patients accepted the examination successfully. The duration of follow-up ranged from 3 to 37 months, with mean of 13 month. Benign lesions were found in 71 cases(50.7%) while malignant lesions were identified in 69 cases(49.3%). Benign lesions included 39(54.9%)minute venous rupture, 12 (16.9%)hemangioma, 3 (4.2%)varix and 11 (15.5%)no obvious lesion. The overall success rate of ureteroscopic treatment was 66(93.0%) whereas recurrence rate after treatment was 8(11.3%). Malignant lesions including 67(97.1%) cases with UTUC and 2 cases with squamous carcinoma. The radical nephroureterectomy(RNU)and bladder sleeve resection was performed in all cases. To 67 cases with UTUC, the overall identification rate of urinary sonography, CTU, voided urine cytology, selective in situ cytology and diagnostic digital flexible ureteroscopy was 41(61.2%), 61(91.0%), 13(19.4%), 38(56.7%) and 63(94.0%) respectively. Identification rate of selective in situ cytology was superior to voided cytology(P<0.01) while diagnostic digital flexible ureteroscopy was no significant difference compared with CTU. The concordance of pathological grade between biopsy and final resection specimen was 73.1%.The concordance of low grade was 93.3% whereas high grade was 56.8%. Up-grading was found in 16(23.9%) cases while down-grading was found in 2(3.0%) cases. Intravesical recurrence was affirmed in 11(16.4%) cases during follow-up.@*Conclusions@#Diagnostic digital flexible ureteroscopy may not only present qualitative as well as localized evidence for etiological diagnosis of hematuria from unilateral upper urinary tract, but also provides strategy choice for treatment.
Résumé
The aetiology of hematuria from upper urinary tract is sophisticated including benign and malignant lesions. With comprehensive utilization and improvement of flexible ureteroscopy(fURS), especially innovation and elaboration of digital fURS with auxillary armaments, it may present qualitative as well as localized evidence for etiological diagnosis of hematuria from upper urinary tract. Based on the precise decision of individual strategy, flexible ureteroscopic laser ablation gradually turns to be a direction and trend of option in selected cases based. Flexible ureteroscopy plays a critical role in the diagnosis and treatment of hematuria from upper urinary tract.
Résumé
Objective To investigate the value of diagnostic digital flexible ureteroscopy in patient with hematuria from unilateral upper urinary tract.Methods A retrospective analysis was made in consecutive 140 cases,including 94 males and 46 females,who are considered for hematuria from unilateral upper urinary tract in Renmin hospital of Wuhan University from January 2014 to February 2019.Their age ranged from 22 to 89 years,with mean of 62.3 years.The mean BMI was 24.6 kg/m2 (ranging 22.1-28.2 kg/m2).All patients complained about the continuously or intermittently gross hematuria.29 cases (20.7％) complained about the flank pain,as well.All cases were examined by urinary sonography,CTU and voided urine cytology preoperatively.Occupying lesion was found in 47 case by sonography including suspected diagnosis.Upper tract urothelial carcinoma(UTUC) was diagnosed in 63 cases by CTU including suspected diagnosis.Voided cytology was positive in 17 cases.Concomitant bladder or urethral lesions were excluded by cystoscopy.Hematuria was confirmed from left side in 82 cases(58.6％) and from right side in 58 cases(41.4％).Diagnostic digital flexible ureteroscopy were performed under general anethesia strictly according to ‘ No touch technique’.Biopsy for suspicious lesions as well as selective in situ cytology were acquired during ureteroscopy.Results All patients accepted the examination successfully.The duration of follow-up ranged from 3 to 37 months,with mean of 13 month.Benign lesions were found in 71 cases (50.7％) while malignant lesions were identified in 69 cases (49.3％).Benign lesions included 39 (54.9％)minute venous rupture,12 (16.9％)hemangioma,3 (4.2％)varix and 11 (15.5％)no obvious lesion.The overall success rate of ureteroscopic treatment was 66 (93.0％) whereas recurrence rate after treatment was 8 (1 1.3％).Malignant lesions including 67 (97.1％) cases with UTUC and 2 cases with squamous carcinoma.The radical nephroureterectomy(RNU) and bladder sleeve resection was performed in all cases.To 67 cases with UTUC,the overall identification rate of urinary sonography,CTU,voided urine cytology,selective in situ cytology and diagnostic digital flexible ureteroscopy was 41 (61.2％),61 (91.0％),13 (19.4％),38 (56.7 ％) and 63 (94.0％) respectively.Identification rate of selective in situ cytology was superior to voided cytology (P ＜ 0.01) while diagnostic digital flexible ureteroscopy was no significant difference compared with CTU.The concordance of pathological grade between biopsy and final resection specimen was 73.1％.The concordance of low grade was 93.3％ whereas high grade was 56.8％.Up-grading was found in 16(23.9％) cases while down-grading was found in 2(3.0％) cases.Intravesical recurrence was affirmed in 11 (16.4％) cases during follow-up.Conclusions Diagnostic digital flexible ureteroscopy may not only present qualitative as well as localized evidence for etiological diagnosis of hematuria from unilateral upper urinary tract,but also provides strategy choice for treatment.
Résumé
The aetiology of hematuria from upper urinary tract is sophisticated including benign and malignant lesions.With comprehensive utilization and improvement of flexible ureteroscopy (fURS),especially innovation and elaboration of digital fURS with auxillary armaments,it may present qualitative as well as localized evidence for etiological diagnosis of hematuria from upper urinary tract.Based on the precise decision of individual strategy,flexible ureteroscopic laser ablation gradually turns to be a direction and trend of option in selected cases based.Flexible ureteroscopy plays a critical role in the diagnosis and treatment of hematuria from upper urinary tract.
Résumé
Objective To identify risk factors for local recurrence and distant metastasis in patients with upper tract urothelial carcinoma (UTUC) after radical nephroureterectomy (RNU).Methods We retrospectively reviewed 269 patients with UTUC who had performed RNU from 2003 to 2013 in the Affiliated Hospital of Qingdao University.158 were males and 111 were females,aged range from 37 to 86 years old,left side were 144 cases and right side were 125 cases,157 cases occurred in renal pelvis and 112 cases in ureter,the diameter of tumor ＞ 3 cm were 163 cases,≥ pT3 stage were 143 cases,presence of lymphovascular invasion (LVI) were 35 cases,high grade tumors (G3) were 185 cases,presence of hydronephrosis were 185 cases,multifocal tumors were 28 cases,sessile tumors were 86 cases,neutrophil to lymphocyte ratio(NLR) ≥ 2.0 were 109 cases,estimated glomerular filtration rate (eGFR) ＜ 60ml/(min · 1.73 m2) were 62 cases,plasma fibrinogen ≥3.2 g/L were 129 cases.Univariate and multivariate analyses were performed to identify independent prognostic factors for local recurrence-free survival (IRFS) and distant metastasis-free survival (dMFS).Results The median follow-up was 43.8 months (range 4.4-131.8).30 patients had a local recurrence with a median intermittent period of 19.4 months (range 4.3-71.3).35 patients had a distant metastasis with a median intermittent period of 17.7 months (range 4.1-51.4).In univariate analysis,sessile tumor(P =0.041),tumor multifocality (P =0.027),location in ureter (P =0.001),presence of LVI (P＜0.001),≥pT3 stage(P ＜0.001),eGFR ＜60ml/(min · 1.73 m2) (P =0.009) and plasma fibrinogen ≥ 3.2 g/L (P ＜ 0.001) were associated with lRFS.While high-grade tumor (G3) (P =0.012),sessile tumor (P ＜ 0.001),presence of LVI (P ＜ 0.001),presence of hydronephrosis (P =0.046),and NLR ≥2.0 (P =0.002) were associated with dMFS.Multivariate analysis revealed that location in ureter(HR =4.835,95 ％ CI 1.792-13.044,P =0.002),presence of LVI (HR =5.037,95 ％ CI 2.183-11.230,P ＜ 0.001),≥pT3 stage(HR =2.987,95％ CI 1.078-8.283,P =0.035) and plasma fibrinogen ≥3.20g/L (HR =4.281,95 ％ CI 1.454-12.603,P =0.008) were independent factors for lRFS.Sessile tumor (HR =6.097,95％ CI 2.536-14.660,P ＜ 0.001),presence of LVI (HR =4.191,95％ CI 2.035-8.633,P ＜ 0.001),and NLR ≥2.0 (HR =2.741,95％ CI 1.128-6.657,P =0.026) were independent factors for dMFS.We stratified patients into three risk groups of LR and DM based on the results of the multivariate analysis respectively.The 1-year,3-year,5-year lRFS rates were 99.0％,96.8％,95.0％ in the low-risk group;94.5％,91.2％,87.6％ in the intermediate-risk group;and 77.8％,58.8％,58.8％ in the high-risk group.The differences among groups were significant (P ＜ 0.001).The 1-year,3-year,5-year dMFS rates were 98.4％,97.6％,96.0％ in the low-risk group,88.0％,73.8％,71.8％ in the intermediate-risk group,and 63.7％,42.9％,28.5％ in the high-risk group.The differences among groups were significant as well(P ＜ 0.001).Conclusion Location in ureter,presence of LVI,≥ pT3 stageand plasma fibrinogen ≥3.2 g/L were independent factors for lRFS.Sessile tumor,presence of LVI,and NLR ≥ 2.0 were independent factors for dMFS.The risk stratification models may be useful for identifying the patients with high risk of LR/DM after surgery.