Safety and feasibility of early single-dose mitomycin C bladder instillation after robot-assisted radical nephroureterectomy
Safety and feasibility of early single-dose mitomycin C bladder instillation after robot-assisted radical nephroureterectomy
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DOI：
10.1111/bju.15162
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发表时间：
2020-08-09
影响因子：
4.5
通讯作者：
Bex, Axel
中科院分区：
文献类型：
--
作者：
Gulamhusein, Aziz;Silva, Pedro;Bex, Axel
目的评估三级肾癌中心机器人辅助根治性肾输尿管切除术（RARNU）后早期单剂量丝裂霉素C（MMC）膀胱灌注的安全性和可行性。RARNU联合膀胱袖状切除和随后的MMC膀胱灌注以降低复发风险是高危上尿路上皮癌（UUTUC）的“金标准”。我们采用了RARNU技术，精确的远端输尿管分离，膀胱袖状切除和水密性膀胱闭合。患者和方法我们回顾性分析了在我们中心接受RARNU治疗UUTUC的所有患者，这些患者作为标准化经腹膜手术进行，包括：膀胱袖套切除、双层水密闭合和术中膀胱渗漏测试;没有重新对接/重新定位机器人手术系统。根据Clavien-Dindo分类评估患者人口统计学资料、MMC滴注时间、不良事件（手术和潜在MMC相关）和住院时间（LOS）。结果69例患者接受了RARNU联合MMC灌注。中位（四分位距[IQR]）年龄为70（62-78）岁。MMC滴注的中位（IQR）天数为2（1-3）d，中位（IQR）LOS为2（2-4）d，所有病例均在出院当天拔除导尿管。7例患者（10%）仅发生I级Clavien-Dindo并发症; 5例发生肠梗阻，1例发生伤口感染，1例发生自限性谵妄，均采用保守治疗。术后30天内未观察到与MMC滴注潜在相关的不良事件。结论在RARNU术后即刻膀胱灌注MMC是可行的，安全的，术中证实水密性闭合，可确保早期无导管出院，无明显不良事件。对于早期应用MMC的患者，膀胱内复发的潜在减少需要通过纵向随访研究进行评估。
Objectives To assess the safety and feasibility of early single-dose mitomycin C (MMC) bladder instillation after robot-assisted radical nephroureterectomy (RARNU) at a tertiary kidney cancer centre. RARNU with bladder cuff excision and subsequent MMC bladder instillation to reduce recurrence risk is the 'gold standard' for high-risk upper urinary tract urothelial carcinoma (UUTUC). We adapted a RARNU technique with precise distal ureteric dissection, bladder cuff excision and watertight bladder closure. Patients and Methods We retrospectively reviewed all patients undergoing RARNU for UUTUC at our centre performed as a standardised transperitoneal procedure comprising of: bladder cuff excision, two-layer watertight closure and intraoperative bladder leak test; without re-docking/re-positioning of the robotic surgical system. Patient demographics, the timing of MMC instillation, adverse events (surgical and potentially MMC-related) and length of stay (LOS) were assessed according to the Clavien-Dindo classification. Results A total of 69 patients underwent a RARNU with instillation of MMC. The median (interquartile range [IQR]) age was 70 (62-78) years. The median (IQR) day of MMC instillation was 2 (1-3) days and the median (IQR) LOS was 2 (2-4) days, with urethral catheter removal on day of discharge in all cases. Only Grade I Clavien-Dindo complications occurred in seven patients (10%); five had ileus, one a wound infection and one a self-limiting delirium, all managed conservatively. No adverse events potentially related to MMC instillation were noted within 30 days postoperatively. Conclusion The use of intravesical MMC instillation given in the immediate postoperative period appears feasible and safe in patients undergoing RARNU with intraoperative confirmation of a water-tight closure ensuring early catheter-free discharge, with no significant adverse events. The potential reduction in intravesical recurrence in patients receiving early MMC needs to be assessed with longitudinal follow-up studies.