机器人辅助腹腔镜肾部分切除术与传统腹腔镜肾部分切除术适应证选择及临床疗效对比研究

Conventional laparoscopy and da Vinci robot-assisted technique for partial nephrectomy: comparison of indications and clinical outcomes

目的通过对比分析机器人辅助腹腔镜肾部分切除术和传统腹腔镜肾部分切除术患者的临床资料,探讨机器人辅助腹腔镜肾部分切除术的临床优势和应用价值。方法 2011年1月至2012年12月,共完成机器人辅助腹腔镜肾部分切除术24例,传统腹腔镜肾部分切除术43例。两组患者术前临床分期均为T1N0M0。收集两组术前基线资料,采用单因素分析和logistic回归模型分析机器人辅助腹腔镜肾部分切除术适应证选择的主要影响因素。根据主要影响因素进行11配对后,收集纳入患者各项术中、术后及随访资料,比较两组间各项指标的差异。结果单因素和多因素logistic回归模型分析显示,各术前参数中,只有肾肿瘤DAP评分是选择机器人辅助腹腔镜肾部分切除术的独立预测因子(β=1.987,P=0.022,95%CI:1.34～39.79)。按DAP评分配对后,两组各纳入19例患者,除了术前估算肾小球滤过率(eGFR)外,两组间各项基线资料均平稳。机器人辅助腹腔镜肾部分切除术组1例因术中出血,经输血并中转开放手术完成;传统腹腔镜肾部分切除术组均顺利完成。两组患者在术中出血、术后禁食天数、术后住院期间最高一次疼痛视觉模拟评分、术后住院时间、并发症发生率及输血率方面差异均无统计学意义(P>0.05)。两组患者的手术时间分别为(249.5±49.6)min和(212.9±57.1)min,热缺血时间分别为(27.0±5.3)min和(34.2±7.3)min,差异均有统计学意义(P<0.05)。两组患者手术切缘均为阴性,平均随访(5.6±2.2)个月和(6.6±2.6)个月,仅有传统腹腔镜手术组出现1例肿瘤复发;末次随访eGFR平均下降百分比分别为(12±8)%和(17±15)%,差异无统计学意义。结论对于具备丰富传统腹腔镜肾部分切除手术经验的医生而言,机器人辅助腹腔镜肾部分切除术学习曲线短,早期即可完成传统腹腔镜手术难以完成的高难度肾肿瘤肾部分切除术,且具有手术安全性高、热缺血时间短的优点,短期疗效确切,临床应用前景广。

Objective To investigate the clinical benefits and role of robot-assisted laparoscopic partial nephrectomy （RAPN） by comparing the clinical data of patients receiving the RAPN or conventional laparoscopic partial nephrectomy （CLPN）. Methods A retrospective analysis was performed for 67 patients who underwent either RAPN （n= 24） or CLPN （n= 43） between January 2011 and December 2012 at our institution. Preoperative clinical stages of both groups were T1 No M0. Univariate analysis and logistic regression model were used to detect factors affecting indication selection in RAPN. The intraoperative parameters and postoperative outcomes were compared between RAPN and CLPN groups matched for DAP score. Results Univariate and multivariate logistic regression analysis revealed that DAP score （β= 1. 987, P=0. 022, 95 CI[-1.34, 39.79]） was the only predictor of RAPN approach in logistic regression analysis. Only 38 DAP matched cases in RAPN （n= 19） and CLPN （n= 19） were included for analysis, and the demographics were comparable between the matched two groups except for the preoperative estimated glomerular filtration rate （eGFR）. One open conversion was required in the RAPN group due to intra-operation bleeding, and all the cases were smoothly completed in the conventional laparoscopic group. There were no significant differences between the matched two groups regarding the estimated blood loss, time off oral-intake, highest visual analog pain scale, length of stay, complication rate or transfusion rate （all P〈0.05）. Patients undergoing RAPN had a significantly shorter warm ischemia time （[27. 0±5. 3] min vs [-34. 2± 7. 3] min, P〈0. 05） and a longer operative time （[-249.5i49.6] min vs E212.9±57.11] min, P〈0.05） compared with CLPN group. The surgical margins were negative in both groups. During a mean follow-up of （5.6±2.2） months and （6.6±2.6） months, only one tumor recurrence was notice in the CLPN group. At the last follow-up, the decrease percentage of eGFR was （12± 8）% in the RAPN group versus （17 ± 15） % in the CLPN group （P〈0.05）. Conclusion RAPN requires a shorter warm ischemia time and provides a more rapid learning curve, good surgical safety and good short-term efficacy. For surgeons with experienced CLPN technique, they can use RAPN to treat high-complexity tumors which are beyond the conventional laparoscopic technique.