标本经阴道取出的3D腹腔镜根治性膀胱切除术的可行性和疗效分析

The feasibility and efficacy of 3D laparoscopic radical cystectomy with transvaginal natural orifice specimen extraction surgery

目的:探讨3D腹腔镜根治性膀胱切除术+经阴道自然腔道标本取出术(NOSES)的安全性、可行性及术后临床效果。方法:回顾性分析2014年11月至2018年12月收治的17例行3D腹腔镜根治性膀胱切除术+经阴道NOSES患者的临床资料。平均年龄70(49~84)岁。4例有腹部手术史,其中2例有子宫全切术史。平均体质指数25.4(22.0~31.2)kg/m 2。平均Charlson合并症指数(CCI)评分3(2~5)分。平均美国麻醉医师协会(ASA)评分2(1~3)分。术前盆底功能障碍问卷(PFDI-20)评分(8.5±1.8)分。17例术前均行膀胱镜活检,病理结果:肌层浸润性膀胱癌12例,非肌层浸润性膀胱癌3例(高危或反复复发),原位癌1例,腺癌1例。所有患者术前影像学检查均未发现远处转移。手术均采用全麻,患者取截石位。建立气腹,置入5个套管。17例均行3D腹腔镜根治性膀胱切除术+经阴道NOSES,其中12例行女性前盆腔脏器切除术,标本切除后经阴道放入阴道保护套,将标本通过保护套取出;3例保留子宫、双附件,在膀胱与子宫及阴道前壁之间游离切除膀胱,切开阴道后穹窿黏膜约2 cm,在腹腔镜直视下置入5 mm套管,经套管置入EndoCatch袋,将标本放入EndoCatch袋后经阴道取出。用2-0可吸收倒刺线缝合阴道。17例尿流改道分别为原位回肠新膀胱3例,回肠通道11例,输尿管皮肤造口术2例;1例因尿毒症行腹腔镜双肾双输尿管膀胱根治性切除术和子宫附件切除术。记录患者围手术期数据(手术时间、出血量、输血率、术后住院时间和术后疼痛等)、术后并发症及肿瘤预后相关临床资料。采用疼痛视觉模拟评分(VAS)评估患者术后疼痛情况。围手术期并发症采用Clavien-Dindo分级。结果:本组17例手术均顺利完成,无中转开放手术。平均总手术时间(309.8±55.7)min,平均NOSES时间(14.0±5.2)min.平均术中失血量(260.0±233.2)ml,2例输血。术后平均正常饮食恢复时间2(1~4)d。17例均未发生术中并发症。6例术后≤30 d发生Clavien-Dindo 1~2级并发症,分别为低白蛋白血症3例、疼痛2例、发热伴疼痛1例;1例术后>90 d发生Clavien-Dindo 1级并发症,为轻微肾盂积水。术后第1、2、3天VAS中位值分别为2、2、1分。术后平均随访时间(35.0±10.9)(34~60)个月。术后3、6个月PFDI-20评分分别为(9.8±1.9)分和(9.3±1.2)分,与术前比较差异均无统计学意义(P=0.06,P=0.15)。1例术后1年发生肾脏转移,1例术后2年发生淋巴结转移;1例术后1年因肿瘤复发死亡。结论:3D腹腔镜根治性膀胱切除术+NOSES是可行的,具有减少术后腹壁疼痛,利于腹壁恢复美观等优势,对患者的盆底功能无明显影响。

Objective To explore the safety,feasibility and clinical effect of transvaginal specimen extraction in 3D laparoscopic surgery for bladder cancer.Methods A retrospective analysis was made of 17 patients who underwent 3D laparoscopic radical cystectomy with NOSES from November 2014 to December 2018.Mean age was 70 years(range 49-84 years),and mean CCI was 3(range 2-5),and mean ASA was 2(range 1-3).Four patients(23.5%)had a history of abdominal surgery.Pelvic floor distress inventory-short form 20(PFDI-20)before surgery was(8.5±1.8).Pathological biopsy after cystoscopy:12 cases MIBC,3 cases NMIBC(high-risk or recurrent),1 case carcinoma in situ and 1 case of adenocarcinoma.Surgical method:Under general anesthesia,the patient was positioned in the lithotomy position.A 5-port transperitoneal approach was used.Under 3D laparoscopic radical cystectomy,if female reproductive organs were excised,they should be excised the bladder and female reproductive organs together.If the female reproductive organs were decided to preserve,the dissection was performed along the space between bladder and uterus or vagina.Cut open the mucosa of the posterior vaginal fornix.And then the specimen was placed in the EndoCatch bag,and completely removed visually through the posterior vaginal fornix incision.The incision of the posterior vaginal fornix was closed with 2-0 absorbable barb thread.According to the patients’situation,4 cases of controllable urinary diversion and 13 cases of uncontrolled urinary diversion were selected.The basic clinical data,perioperative related data,perioperative complications,postoperative complications,and oncologic outcomes were recorded.Result The surgery was successfully completed in 17 patients,and none of them was converted to open surgery.Mean total operative time was(309.8±55.7)min.Mean NOSES time was(14.0±5.2)min.Estimated blood loss was(260.0±233.2)ml.The median time of flatus was 2 days(range 1-4 days).There were no intraoperative complications,6 cases(35.3%)within 30 days complications,and 1 case(5.9%)>90 days complications.The median VAS score on post-op day 1,2,and 3 were respectively 2,2,and 1.At a mean follow up of(35.0±10.9)months(ranged from 34-60 months),0 patient had recurrences,2(11.8%)had metastasis,and 1(5.9%)died.Post-PFDI-20 was(9.8±1.9)after 3 months(compared with pre-PFDI-20,P=0.06),and was(9.3±1.2)after 6 months(compared with pre-PFDI-20,P=0.15).Conclusion Transvaginal specimen extraction in 3D laparoscopic surgery for bladder cancer could be safe and feasible.It could reduce postoperative abdominal wall pain,and hardly affects the pelvic floor function.