【探泌】Eur Urol：非肌层浸润性膀胱癌的二次经尿道切除术：一项系统性回顾
编者按
为贯彻落实中华医学会泌尿外科学分会“顶天立地”发展规划，加强国内外学术交流，促进我国泌尿外科事业更好更快发展，学习联盟特推出“探泌”栏目。本栏目秉承“专业，公益，共享，共进”原则，旨在传播学科发展资讯，搭建学术交流平台，更好地为我国广大泌尿外科同道服务。
经尿道膀胱肿瘤切除术（TURBT）是非肌层浸润性膀胱癌（NMIBC）的主要治疗方式，由于肿瘤性质、术者经验等因素影响，存在肿瘤残留、分期偏低等问题。有学者建议在首次术后短期内行二次经尿道切除术（reTUR），但亦有学者认为reTUR并不是必需的。reTUR的有效性及必要性仍存在争议。对此，发表于《European Urology》杂志题为《Repeat Transurethral Resection in Non-muscle-invasive Bladder Cancer: A Systematic Review》[1]的文章对非肌层浸润性膀胱癌的二次经尿道切除术作了系统性回顾。
【Abstract】
Context: Initial treatment for most bladder cancers (BCs) involves transurethral resection (TUR) of tumours. Often more cancer is found after the initial treatment in around half of patients, requiring a second resection. Repeat transurethral resection (reTUR) is recommended for high-risk, non–muscle-invasive bladder cancer (NMIBC) to remove any residual disease and improve cancer outcomes.
背景：多数膀胱癌的初次治疗包括对肿瘤行经尿道切除术（TUR）。在初次治疗后，大约一半的患者由于发现更多的肿瘤需要行二次切除术。对于高危、非肌层浸润性膀胱癌（NMIBC），建议行二次经尿道切除术（reTUR）以去除残留肿瘤，改善预后。
Objective: To systematically review the practice and therapeutic benefit of an early reTUR for high-risk NMIBC.
目的：系统性回顾早期reTUR对高危NMIBC的实践及治疗获益。
Evidence acquisition: A systematic review of original articles was performed using PubMed/Medline and Web of Science databases in December 2016 (initial) and October 2017 (final). We searched the references of included papers.
证据获得：通过PubMed/Medline和Web of Science数据库对发表于2016年12月-2017年10月的论著类文章进行系统性回顾。并检索涉及文章的参考文献。
Evidence synthesis: We screened 15 209 manuscripts and selected 31 detailing 8409 persons with high-grade Ta and T1BC for inclusion. Detrusor muscle was found at initial TUR histology in 30–100% of cases. Residual tumour at reTUR was found in 17–67% of patients following Ta and in 20–71% following T1 cancer. Most residual tumours (36–86%) were found at the original resection site. Upstaging occurred in 0–8% (Ta to ≥T1) and 0–32% (T1 to ≥T2) of cases. Conflicting data report the impact of reTUR on subsequent recurrence and cancer-specific mortality. Recurrence for Ta was 16% in the reTUR group versus 58% in the non-reTUR group. For T1, recurrence ranged from 18% to 56%, but no clear trend was identified between reTUR and control. No clear relationship between reTUR and progression was found for Ta, although for T1 rates were higher in the non-reTUR group in series with control populations (5/6 studies). Overall mortality was slightly reduced in the reTUR group in two studies with controls (22–30% vs 26–36% [no reTUR]).
MIBC.
证据分析：通过筛选15029篇稿件，从中选出31篇涉及高级别Ta期和T1期膀胱肿瘤患者共8409例。30-100%的病例在初次TUR标本中发现逼尿肌。Ta期和T1期肿瘤接受reTUR后，残留肿瘤检出率分别为17-67%和20-71%。多数残留肿瘤（36-86%）位于初次切除部位。Ta期升级为T1期以上的病例占0-8%。T1期升级为T2期以上的病例占0-32%。关于reTUR影响术后复发和肿瘤特异性死亡率的数据并不一致。Ta期肿瘤复发率在reTUR组和非reTUR组分别为16%和58%。T1期肿瘤复发率介于18%-56%，但在reTUR组和非reTUR组之间无明显趋势。尽管非reTUR组T1期肿瘤进展率较高，但未发现reTUR与Ta期肿瘤进展有明确关系。在两项对照研究中，总体死亡率在reTUR组较非reTUR组略有下降（22-30% vs 26-36%）。
Conclusions: Residual tumour is common after TUR for high-risk NMIBC. The reTUR helps in the diagnosis of this residual cancer and may improve outcomes for cancers initially staged as T1.
MIBC.
结论：肿瘤残留在高危NMIBC TUR后常见。reTUR有利于残留肿瘤的诊断，可能会改善初次分期为T1期肿瘤的预后。
译者评述
有研究表明，大约70-80%的非肌层浸润性膀胱癌（NMIBC）患者通过经尿道膀胱肿瘤切除术（TURBT）联合膀胱灌注化疗或免疫治疗，能够有机会获得治愈。然而，对于T1期和高级别肿瘤，初次TURBT后存在肿瘤残留和（或）肿瘤分期偏低的风险，其中肿瘤残留的风险高达50-70%，分期偏低的风险高达20-30%。故有学者强调在上述特定情况下需要reTUR对残留肿瘤进行切除（repeat resection）和分期（restaging）。EAU专家委员会建议对所有T1期，或高级别肿瘤，或标本不含逼尿肌（Tx）的患者行reTURBT。
亦有研究表明，初次手术标本含有逼尿肌的T1期NMBIC患者在接受reTUR后，其无进展生存期及肿瘤特异性生存率没有改善。故有学者认为，对于初次TURBT标本含有逼尿肌的T1期膀胱癌患者，reTUR并不是必需的。
《中国泌尿外科疾病诊断治疗指南（2014版）》及《非肌层浸润性膀胱癌二次电切中国专家共识》对reTUR指征定义如下：1.首次TURBT不充分；2.首次电切标本中没有肌层组织；3.T1期肿瘤；4.G3（高级别）肿瘤，单纯原位癌除外。并推荐术后2-6周进行reTUR。
总之，做到初次手术彻底切除肿瘤非常重要，确保标本含有肌层组织，切除所有可见的肿瘤。虽然没有绝对证据表明reTUR在预防肿瘤进展和复发方面具有优势，但对于初次分期为T1期肿瘤，reTUR有利于残留肿瘤的诊断，可能会改善预后。
参考文献：
1. Cumberbatch MGK, Foerster B, Catto JWF, et al. Repeat Transurethral Resection in Non-muscle-invasive Bladder Cancer: A Systematic Review. Eur Urol. 2018;73(6):925-933
编译|王冬(陕西中医药大学附属医院)
编辑|榭小仙
审核|王欣
