机器人手术在子宫内膜癌分期手术中安全性与有效性的荟萃分析

Comparison of robotic surgery with laparoscopy for surgical staging of endometrial cancer： a meta-analysis

目的分析机器人手术在子宫内膜癌分期手术中的安全性与有效性。方法计算机检索Cochrane图书馆数据库、Embase数据库、PubMed数据库、Web of Science数据库等英文数据库，中国知网（CNKI）数据库、万方医学网数据库、中文科技期刊（CSTJ）数据库等中文数据库；手工检索国际肿瘤学杂志、实用妇产科杂志、中华妇产科杂志等中文期刊。检索2000年1月至2016年10月发表的相关文献。（1）采用Newcastle—Ottawa Scale（NOS）文献质量评价表由两位研究者独立进行文献质量评价，满分为9颗星，得到0～4颗星者为低质量文献、5-9颗星者为高质量文献；（2）采用Cochrane图书馆数据库提供的RevMan5．3软件进行荟萃分析，先对各入选文献进行异质性检验，根据检验结果选用不同的效应模型（包括随机效应模型和固定效应模型），对机器人手术和腹腔镜手术患者的围手术期相关指标进行合并分析。结果（1）最终纳入13篇文献，均为英文文献，共1554例患者，其中行机器人手术（RS组）739例，行腹腔镜手术（LPS组）815例。13篇文献均为队列研究，包括前瞻性的队列研究4篇，回顾性的队列研究9篇；NOS量表评价文献质量均在5颗星以上，均为高质量文献。（2）荟萃分析结果显示，与LPS组患者比较，RS组患者的术中出血量少[标准差（SD）=-72．31ml，95％CI：-107．29～-37．33，P〈0．01]、住院时间短（SD=-0．29d，95％CI：-0．46—-0．13，P=0．001）、输血率低[风险比（RR）：0．57，95％CI：0．33～0．97，P=0．0401、中转开腹率低（RR=0．41，95％CI：0．26～0．65，P=0．000）、术中并发症发生率低（RR=0．43，95％CI：0．24～0，76，P=．004），0两组间上述指标分别比较，差异均有统计学意义；而手术时间（SD=10．26min，95％CI：-13．62～34．13，P=0．400）、盆腔淋巴结切除数（SD=0．48个，95％CI：-1．76～2．71，P=0．680）、腹主动脉旁淋巴结切除数（SD=0．46个，95％CI：-1．42～2．34，P=0．630）、淋巴结切除总数（SD=-0．04个，95％CI：-3．99～3．91，P=0．980）、术后并发症发生率（RR=0．87，95％CI：0．67～1．12，P=0．280）在两组中分别比较，差异均无统计学意义。结论与腹腔镜手术相比，机器人手术有术中出血量少、输血率低、中转开腹率低、术中并发症发生率低、住院时间短等优势，但因其费用昂贵而使临床应用受到一定的限制。

Objective To evaluate the safety and effectiveness of robotic surgery in surgical staging of endometrial cancer. Methods Searched English and Chinese databases, including Cochrane library, PubMed, Embase, Web of Science, China National Knowledge Internet, data base of Wanfang, China Science and Technology Journal （CSTJ）, and relevant journals and magazines by hand from Jan. 2000 to Oct. 2016. （1） In accordance with the inclusion criteria, two independent investigators screened databases and extracted the relevant data respectively, then evaluated the quality of including studies in Newcastle- Ottawa Scale （NOS）. （2） Meta-analysis was performed with RevMan 5.3 software. Heterogeneity inspection was done for each study and different effect model included the random effect model and fixed effect model was chose according to the results of the inspection. At last, the related parameters of the robotic surgery and laparoscopic surgery was analysed. Results （1） Thirteen articles were ultimately included. All of them were written in English and included a total of 1 554 patients, included 739 cases of robotic surgery and 815 cases of laparoscopic surgery. Thirteen articles were all cohort study, four of them were prospective cohort study, while others were retrospective cohort study. After quality assessment, all studies had more than 5 stars and illustrated the higher quality. （2） Meta-analysis results showed： compared with laparoscopic surgery in surgical staging of endometrial cancer, robotic surgery had less estimated blood loss [standard deviation （SD）=-72.31 ml, 95%CI：-107.29 to-37.33, P 〈 0.01], less time for hospital stay （SD=-0.29 days, 95%CI： -0.46 to -0.13, P=0.001）, less need for blood transfusion [risk ratio （RR）=0.57, 95%CI： 0.33 to 0.97, P=0.040], and conversion to open surgery （RR=0.41, 95%Ch 0.26 to 0.65, P=0.000）, less intraoperative complications （RR=0.43, 95%Ch 0.24 to 0.76, P=0.004） in surgical staging of endometrial cancer. There was no statistically significant difference in aspects of operative time （SD=10.26 minutes, 95%CI：- 13.62 to 34.13, P=0.400）, postoperative complications （RR=0.87, 95%CI： 0.67 to 1.12, P= 0.280）, the total number of lymph nodes removed （SD=-0.04, 95%CI：3.99 to 3.91, P=0.980）, the number of pelvic lymph node dissection （SD=0.g8, 95%CI： -1.76 to 2.71, P=0.680） and the number of para-aortic lymph node dissection （SD=0.46, 95%CI： -1.42 to 2.34, P=0.630）. Conclusions Compared the robotic surgery with laparoscopic surgery in surgical staging of endometrial cancer, robotic surgery has less estimated blood loss, less need for blood transfusion and conversion to open surgery, less intraoperative complications and other advantages. While its cost is so expensi,se that restrict clinical application.