开放、腹腔镜及机器人根治性膀胱切除术的疗效及围术期并发症比较(附325例报告)

Comparative study on curative effect and complication rate among open,laparoscopic and robotic radical cystectomy:report of 325 cases

目的:比较开放、腹腔镜及机器人三种根治性膀胱切除术的手术疗效及围术期并发症。方法:回顾性分析2013年1月~2015年12月于本中心因膀胱恶性肿瘤行根治性膀胱切除术患者围术期的临床资料:共计325例,男282例,女43例,中位年龄66岁,其中开放根治性膀胱切除术(open radical cystectomy,ORC)226例(男194例,女32例),腹腔镜手术(laparoscopic radical cystectomy,LRC)61例(男54例,女7例),机器人手术(robot-assisted radical cystectomy,RARC)38例(男34例,女4例),收集三组患者年龄、性别组成、体质指数(BMI值)、ASA评分、既往手术史、肿瘤分期和分级、膀胱切除时间、出血量、术中输血率、术后住院天数、二次手术率、围术期并发症的发生率及死亡率等指标,比较各组手术疗效及围术期并发症差异。结果:325例手术均顺利完成,腔镜手术均未中转开放。三组患者的年龄及性别组成、BMI、ASA评分、既往手术史、肿瘤分期及分级之间的差异无统计学意义(P>0.05)。ORC、LRC及RARC的膀胱切除时间分别为(173.4±64.1)min、(224.7±82.5)min、(243.7±96.69)min,差异有统计学意义(P=0.032<0.05,F=14.85);术中出血量分别为(556.2±390.1)ml、(377.1±249.3)ml、(333.9±189.9)ml,差异有统计学意义(P<0.01,F=10.735);术中输血率分别为23.9%、13.8%、10%,差异有统计学意义(P=0.046<0.05,F=12.53);术后住院天数为(13.7±8.71)d、(10.08±4.92)d、(8.40±4.17)d,差异有统计学意义(P=0.042<0.05)。3例因术后粘连性肠梗阻(2例ORC,1例LRC)、2例因切口感染裂开(均为ORC)均行二次手术。围术期并发症发生率分别为25.2%、21.3%、18.4%,差异无统计学意义(P=0.568>0.05,F=1.132),ORC与微创手术(RARC及ORC)相比,ClavienⅡ级以上并发症发生率分别为8.0%、1.6%,差异有统计学意义(P=0.046<0.05)。围术期因感染性休克、失血性休克及心脏基础疾病死亡3例,均为ORC患者。结论:虽然膀胱切除时间较长,但与ORC相比,LRC及RARC的微创优势明显,并发症发生率,尤其是ClavienⅡ级以上并发症比重较低,整体手术疗效优于ORC。

Objective：To compare the operative efficacy and perioperative complications among three kinds of procedures about radical cystectomy.Method：From Jan.2013 to Dec.2015,we retrospectively analyzed the perioperative clinical data of 325 patients with bladder cancer who had undergone radical cystectomy.The median age was 66 years old,and the amount of male was 282,female was 43.Open radical cystectomy（ORC）was performed in 226cases（194males,32females）.Laparoscopic radical cystectomy（LRC）was performed in 61cases（54males,7females）.Robot-assisted radical cystectomy（RARC）was performed in 38cases（34males,4females）.We collected the clinical parameters including age,sex composition,BMI,ASA scores,the history of operation,bladder resection time,blood transfusion rate,tumor grade and stage,postoperative hospital stay,the incidence of perioperative complications and death ratio.Result：The 325 cases were completed successfully,and no minimally invasive surgery had been converted to open surgery.Significant statistically difference was found in bladder resection time,blood transfusion rate and length of hospital stay among ORC,LRC and RARC[（173.4±64.1）min,（224.7±82.5）min,（243.7±96.69）min,P=0.0320.05,F=14.85;23.9%,13.8%,10%,P=0.0460.05,F=12.53;（13.7±8.71）d,（10.08±4.92）d,（8.40±4.17）d,P=0.0420.05].Five cases were performed second operation because of adhesive intestinal obstruction（3cases）and incision splitting with infection（2cases）,and four cases of them derived from ORC.There was no significant difference in perioperative complication rate among the three groups（25.2%,21.3% vs.18.4%,P=0.5680.05）.However,the difference between ORC group and minimally invasive operation group in the rate of complication above Clavien-Ⅱexisted statistically difference（8.0% vs.1.6%,P=0.0460.05）.Three cases who underwent ORC presented perioperative death owing to septic shock,uncontrolled hemorrhagic shock and heart disease,which didn＇t occur in LRC or RARC group.Conclusion：Compared to ORC,LRC and RARC have significant advantages of minimally invasive,lower complication rate especially lower proportion of complications above Clavien-Ⅱ,though patients may experience longer bladder resection time.The overall curative effect of LRC and RARC is superior to that of ORC.