摘要目的 比较扩大淋巴结清扫(extended pelvic lymph node dissection,ePLND)和标准淋巴结清扫(standard pelvic lymph node dissection,sPLND)在开放根治性膀胱切除术中的疗效差异.方法 回顾性分析我院2007年1月至2017年1月收治的139例膀胱癌患者的临床资料.男117例,女22例.年龄20～84岁,平均(64.6±11.7)岁.139例均由同一组术者行开放根治性膀胱切除术+盆腔淋巴结清扫.根据淋巴结清扫范围分为ePLND组91例(65.5％),男74例,女17例;平均年龄(64.7±11.7)岁;体重指数(BMI)(23.4±3.2) kg/m2;53例有吸烟史;41例(45.1％)伴贫血.sPLND组48例(34.5％),男43例,女5例;平均年龄(65.1±12.7)岁;BMI(22.8±3.7) kg/m2;27例有吸烟史;24例(50.0％)伴贫血.两组比较差异均无统计学意义(P＞0.05).ePLND组清扫范围:上至髂总动脉和腹主动脉下段(未达肠系膜下动脉),外侧界至生殖股神经,远端达髂血管腹股沟处旋髂血管水平,后界至髂内血管和闭孔神经,包含两侧之间的骶前淋巴结.sPLND组清扫范围在髂总动脉分叉水平以下,其余范围与ePLND相同.比较两组的手术时间、术中出血量、术中输血量、术中及术后并发症、术后进食时间、术后下地活动时间、术后排气时间、术后住院时间、胃管留置时间、盆腔引流管留置时间、淋巴结阳性率、淋巴结密度,以及患者的无病生存率等.结果 本研究139例手术均顺利完成.ePLND组和sPLND组的手术时间分别为(351.2±79.5) min和(342.5±69.3) min,术中出血量分别为(314.6±120.6)ml和(298.3±126.3)ml,术中输血量分别为(702.9±645.7) ml和(936.9 ±818.1)ml,差异均无统计学意义(P＞0.05).两组患者均未出现术中并发症.ePLND组和sPLND组的术后并发症分别为29例(31.9％)和18例(37.5％),术后进食时间分别为(5.4±1.9)d和(4.8±2.1)d,术后下地活动时间分别为(2.1±0.9)d和(1.9±0.8)d,术后排气时间分别为(3.8±0.9)d和(3.6±1.0)d,术后住院时间分别为(14.9±7.8)d和(15.5 ±6.9)d,胃管留置时间分别为(4.8±2.6)d和(4.5±1.9)d,盆腔引流管留置时间分别为(11.1±4.9)d和(10.9±4.9)d,差异均无统计学意义(P＞0.05).139例手术共清扫淋巴结2 359枚,ePLND组和sPLND组每例患者清扫淋巴结数量分别为(20.3±3.8)枚和(10.6±3.1)枚(P＜0.01),阳性淋巴结数量分别为(0.6±1.3)枚和(0.3±1.0)枚(P =0.034),淋巴结阳性患者分别为33例(36.3％)和9例(18.8％)(P=0.026),淋巴结密度分别为7.9％(146/1 848)和4.1％ (21/511) (P ＜0.05),差异均有统计学意义.139例术后切缘均为阴性.ePLND组肿瘤分级低级别35例,高级别56例;病理分期T1期4例(4.4％),T2期73例(80.2％),T3期13例(14.3％),T4期1例(1.1％).sPLND组肿瘤分级低级别21例,高级别27例;病理分期T2期34例(70.8％),T3期13例(27.1％),T4期1例(2.1％).两组病理结果比较差异均无统计学意义(P＞0.05).ePLND组和sPLND组术后1、2、3、4、5年的无病生存率分别为94.5％和70.5％、91.0％和63.5％、84.4％和57.8％、81.1％和51.4％、75.3％和41.1％,差异均有统计学意义(P ＜0.001).结论 开放根治性膀胱切除术中,ePLND和sPLND具有相似的手术安全性,但ePLND可以提高患者的无病生存率,可以通过扩大阳性淋巴结清扫范围来改善患者的预后.

abstractsObjective To compare the efficacy of extended pelvic lymph node dissection (ePLND) and standard pelvic lymph node dissection (sPLND) in open radical cystectomy.Methods We retrospectively analyzed the clinical data of 139 patients with bladder cancer cases in our hospital from January 2007 to January 2017,who underwent open radical cystectomy and pelvic lymph node dissection performed by the same group of surgeons.There were 117 males and 22 females,aged from 20 to 84 years old,with an average of (64.6 ± 11.7) years,91 patients were underwent ePLND group and 48 patients were underwent sPLND group.The preoperative anemia-free patients was compared between the ePLND group and the sPLND group [24 (50.0％)] vs.58 (54.9％),respectively],the patients with anemia were [24 (50.0％) vs.41 (45.1％)].The range of ePLND is:sway to the common iliac artery and the lower aortic (unreaching the inferior mesenteric artery);the lateral boundary to the reproductive femoral nerve;the distal end of the iliac artery at the groin level,the posterior border to the iliac vessels and closure,which contains the anterior tibial lymph nodes between the two sides.The range of sPLND is below the level of the common iliac artery bifurcation,and the rest of the range is the same as ePLND.The average operative time,average intraoperative blood loss,intraoperative blood transfusion,intraoperative and postoperative complications,postoperative eating time,postoperative activity time,postoperative exhaust time,postoperative hospital stay,mean gastric tube indwelling time,average pelvic drainage tube indwelling time,lymph nodes positive rate,lymph node density,and cancer-free survival were evaluated.Results All 139 patients underwent surgery successfully.The average operative time in the ePLND group and the sPLND group were [(351.2 ±79.5)min vs.(342.5 ± 69.3) min],average intraoperative blood loss [(314.6 ± 120.6) ml vs.(298.3 ± 126.3)ml],intraoperative blood transfusion [(702.9 ± 645.7) ml vs.(936.9 ± 818.1) ml],no intraoperative complications,postoperative complications [29 cases (31.9 ％) vs.18 cases (37.5 ％)],postoperative eating time [(5.4 ± 1.9) d vs.(4.8 ± 2.1) d],postoperative activity time [(2.1 ± 0.9) d vs.(1.9 ± 0.8) d],postoperative exhaust time [(3.8 ± 0.9) d vs.(3.6 ± 1.0) d],postoperative hospital stay [(14.9 ± 7.8) d vs.(15.5 ± 6.9) d],average gastric tube indwelling time [(4.8 ± 2.6) d vs.(4.53 ± 1.9) d],average pelvic drainage tube indwelling time [(11.1 ± 4.9) d vs.(10.9 ± 4.9) d],the difference was not statistically significant (P ＞ 0.05).A total of 2 359 lymph nodes were dissected from the two groups.The number of lymph nodes dissected in each of the ePLND group and the sPLND group was [(20.3 ± 3.8) vs.(10.6 ± 3.1),P ＜ 0.01],and the average number of positive lymph nodes was [(0.6 ± 1.3) vs.(0.3 ±1.0),P =0.034],the ratio of lymph node positive patients was [33 (36.3％) vs.9 (18.8％),P =0.026],and the lymph node density was [7.9％ (146/1848) vs.4.1％ (21/511)],the difference was statistically significant (P ＜ 0.05).In regard to prognosis,the disease-free survival rate (DFS) of ePLND group was 94.5％,91.0％,84.4％,81.1％,75.3％ at 1,2,3,4 and 5 years follow-up respectively.The other group was 70.5％,63.5％,57.8％,51.4％,41.1％ respectively.DFS of ePLND group tended to be higher than that of sPLND group in lymph node positive subgroups.The difference between the two groups was statistically significant (P ＜ 0.001).Conclusions In open radical cystectomy,ePLND and sPLND have similar surgical safety,but expanded lymph node dissection can improve disease-free survival in patients and improve the prognosis by increasing the detection range of positive lymph nodes.