经腹途径与经腹膜外途径机器人辅助腹腔镜下根治性前列腺切除术临床疗效的Meta分析

Transperitoneal versus extraperitoneal robot-assisted radical prostatectomy for localized prostate cancer

目的:采用Meta分析的方法比较经腹途径机器人辅助腹腔镜下根治性前列腺切除术(Tp-RALRP)与经腹膜外途径机器人辅助腹腔镜下根治性前列腺切除术(Ep-RALRP)治疗局限性前列腺癌的临床疗效。方法:通过计算机检索Pubmed,EMBASE,Web of science,EBSCO,Cochrane library,万方,中国知网(CNKI),中国生物医学数据库(CBM)(2000年1月~2016年11月),入选文献必须对比Tp-RALRP与Ep-RALRP的疗效,包含手术时间、术中出血量、术后留置导尿时间、术后卧床时间、围手术期并发症发生率、切缘阳性率、与肠道有关的并发症发生率、术后尿道吻合口瘘发生率、术后控尿率等指标中的至少一项,运用Meta分析方法比较两种手术方式在治疗局限性前列腺癌疗效上的差异。统计学软件采用Rev Man 5.3软件。结果:经仔细筛选后共有8篇文献纳入该研究,其中Tp-RALRP组451例,Ep-RALRP组676例。与Tp-RALRP相比,Ep-RALRP具有手术时间短(WMD=21.39,95%CI 7.54~35.24,P=0.002),术后卧床时间短(WMD=0.85,95%CI 0.61~1.09,P<0.001)、与肠道有关的并发症发生率低(RR=9.74,95%CI 3.26~29.07,P<0.001)等优势,差异均有统计学意义(P<0.05)。两种手术方式的术中出血量(WMD=-8.12,95%CI-27.86~11.63,P=0.42)、术后留置导尿时间(WMD=-0.17,95%CI-0.55~0.21,P=0.38)、围手术期并发症发生率(RR=1.34,95%CI-0.97~1.87,P=0.08)、切缘阳性率(RR=1.24,95%CI 0.95~1.61,P=0.12)、术后尿道吻合口瘘发生率(RR=0.98,95%CI 0.46~2.10,P=0.95)、术后3个月控尿率(RR=0.96,95%CI 0.91~1.00,P=0.05)及术后6个月控尿率(RR=1.00,95%CI 0.97~1.02,P=0.82)等方面差异均无统计学意义(P>0.05)。结论:与Tp-RALRP相比,Ep-RALRP具有手术时间短、术后卧床时间短、与肠道有关的并发症发生率低等优点,因此,Ep-RLRP可能是治疗局限性前列腺癌更好的方法。但未来仍然需要开展更多多中心、大样本的随机对照研究进而更好地评估两种手术方式的优劣。

Objective： To compare the clinical effects of transperitoneal （Tp） versus extraperitoneal （Ep） robot-assisted radical prostatectomy （HARP） in the treatment of localized prostate cancer. Methods ： We searched PubMed, EMBASE, Web of Science, EBSCO, Cochrane Library, Wanfang, CNKI, and CBM for the articles comparing the clinical effect Tp-RARP with that of Ep-RARP in the treatment of localized prostate cancer published from January 2000 to November 2016. All the articles must meet the inclusion crite- ria, that is, dealing with at least one of the following aspects： operation time, intraoperative blood loss, postoperative catheterization time, length of bed confinement, perioperative complications, positive surgical margins, bowel-related complications, postoperative anastomotic leakage, and postoperative urinary continence. We subjected the data obtained to statistical analysis using the RevMan5.3 software. Results： Two randomized controlled trials and six case-control studies were included in this meta-analysis, involving 451 cases of Tp-RARP and 676 cases of Ep-RARP. Compared with Tp-RARP, Ep-RARP showed significantly shorter operation time （WMD = 21.39, 95% CI： 7.54-35.24, P = 0.002）, shorter length of bed confinement （WMD = 0.85, 95% CI： 0.61- 1.09, P 〈 0.001 ）, and lower rate of bowel-related complications （ RR = 9.74, 95% CI ： 3.26 - 29.07, P 〈 0.001 ）. However, no statistically significant differences were found between the two strategies in intraoperative blood loss （WMD = - 8. 12, 95% CI： -27.86 - 11.63, P --- 0.42） , postoperative catheterization time （WMD = 0.17, 95% CI： -0.55 -0.21, P = 0.38）, or the rates of perioperative complications （RR = 1.34, 95% CI： -0.97 - 1.87, P = 0.08）, positive surgical margins （RR = 1.24, 95% CI ： 0.95 - 1.61, P = 0.12）, anastomotic leakage （ RR = 0.98, 95% CI： 0.46 - 2.10, P = 0.95）, urinary continence at 3 months （RR = 0.96, 95% CI： 0.91 -1.00, P = 0.05） and urinary continence at 6 months （RR = 1.00, 95% CI： 0.97 - 1.02, P = 0.82 ）. Conclusion ： Ep-RARP has the advantages of shorter operation time, shorter length of bed confinement and lower rate of bowel-related complications over Tp-RARP, and therefore may be a better option for the treatment of localized prostate cancer. However, more multi-centered randomized controlled clinical trials are needed for further evaluation of these two approaches.