RARC+体内或体外回肠通道术的并发症和预后比较

Robot-assisted radical cystectomy with total intracorporeal ileal conduit:comparative analysis with extracorporeal ileal conduit

目的比较机器人辅助根治性膀胱切除术(RARC)+体内回肠通道术(ICUD)或体外回肠通道术(ECUD)的并发症和预后结果。方法回顾性分析2016年3月至2019年6月南京大学医学院附属鼓楼医院收治的95例膀胱癌患者的病例资料,患者均行RARC,其中行ICUD 37例,行ECUD 58例。ICUD组男32例,女5例;年龄(68.0±7.8)岁;体质指数(24.1±3.4)kg/m^(2);美国麻醉医师协会(ASA)评分1~2分4例(10.8%),3~5分33例(89.2%);术前血红蛋白(126.5±14.2)g/L,白蛋白(39.0±2.2)g/L,C反应蛋白4.0(2.0~8.5)mg/L。ECUD组男53例,女5例;年龄(67.5±9.0)岁;体质指数(24.2±3.6)kg/m^(2);ASA评分1~2分16例(27.6%),3~5分42例(72.4%);术前血红蛋白(129.0±12.4)g/L,白蛋白(38.2±3.1)g/L,C反应蛋白4.9(3.1~14.4)mg/L。两组术前资料比较差异均无统计学意义(P>0.05)。两组的RARC和盆腔淋巴结清扫方法相同,ICUD组在完全腔镜下行回肠通道术,ECUD组经下腹正中切口直视下完成回肠通道术。ICUD组和ECUD组术中行扩大盆腔淋巴结清扫术分别为32例(86.5%)和46例(79.3%),差异无统计学意义(P=0.374)。根据Clavien-Dindo分级系统对并发症进行分级。比较两组的围手术期并发症和预后。结果ICUD组和ECUD组的手术时间分别为(430±63)min和(410±69)min(P=0.163),估计失血量分别为(435±233)ml和(388±277)ml(P=0.182),术中输血分别为10例(27.0%)和12例(20.7%)(P=0.475),差异均无统计学意义。ICUD组和ECUD组术后白蛋白分别为(31.5±2.4)g/L和(31.0±2.8)g/L(P=0.387),C反应蛋白分别为30.9(10.4~52.1)mg/L和29.5(14.4~58.5)mg/L(P=0.655),血红蛋白分别为(110.0±13.8)g/L和(113.7±13.4)g/L(P=0.187),术后进食时间分别为4(3~5)d和4(3~5)d(P=0.752),术后住院时间分别为13(10~19)d和13(11~18)d(P=1.000),差异均无统计学意义。ICUD组和ECUD组术后病理检查结果显示,T_(a)/T_(1)/Tis期分别为17例(45.9%)和19例(32.8%),T_(2)期分别为12例(32.4%)和18例(31.0%),T_(3)期分别为5例(13.5%)和19例(32.8%),T_(4)期分别为3例(8.1%)和2例(3.4%),差异均无统计学意义(P=0.166);切除淋巴结数量分别为(18.2±6.7)枚和(16.5±7.9)枚(P=0.178),淋巴结阳性分别为6例(16.2%)和11例(19.0%)(P=0.733),两组均无切缘阳性,差异均无统计学意义。ICUD组和ECUD组术后30 d内并发症发生例数分别为14例(37.8%)和21例(36.2%),差异无统计学意义(P=0.872);术后90 d内并发症发生例数分别为14例(37.8%)和24例(41.4%),差异无统计学意义(P=0.731);Clavien-DindoⅢ~Ⅴ级并发症均为1例,差异无统计学意义(P=0.849),其中ICUD组1例肠吻合口瘘和ECUD组1例机械性肠梗阻行再次手术。ICUD组术后90 d内再次入院率低于ECUD组[3例(8.1%)与11例(19.0%)],但差异无统计学意义(P=0.090)。ICUD组和ECUD组中位随访时间分别为19个月和31个月,1年生存率分别为91.9%和91.4%,两组的生存曲线差异无统计学意义(P=0.746)。术后3、6个月及1年复查泌尿系CT或B超,共13例(20侧)发生输尿管扩张合并肾积水,ICUD组和ECUD组输尿管扩张并肾积水发生率分别为4.1%(3/74侧)和14.7%(17/116侧),差异有统计学意义(P=0.020)。结论与RARC+ECUD相比,RARC+ICUD不会增加术后90 d内并发症发生率,且可降低上尿路扩张的发生风险。

Objective To compare the perioperative complications and prognosis of intracorporeal and extracorporea lileal conduit urinary diversion(ICUD or ECUD)following robot-assisted radical cystectomy(RARC).Methods The data of 95 patients who underwent RARC treatment in Nanjing Drum Tower Hospital from March 2016 to June 2019 were retrospectively analyzed.Among them,37 underwent ICUD and 58 underwent ECUD.In the ICUD group,there were 32 males and 5 females,aged(68.0±7.8)years,body mass index(BMI)of(24.1±3.4)kg/m^(2),American Society of Anesthesiologists(ASA)score of 1-2 in 4 cases(10.8%),ASA score of 3-5 in 33 cases(89.2%),preoperative hemoglobin of(126.5±14.2)g/L,albumin of(39.0±2.2)g/L,and C-reactive protein of 4.0(2.0-8.5)mg/L.In the ECUD group,there were 53 males and 5 females,aged(67.5±9.0)years,BMI of(24.2±3.6)kg/m^(2),ASA score of 1-2 in 16 cases(27.6%),ASA score of 3-5 in 42 cases(72.4%),preoperative hemoglobin of(129.0±12.4)g/L,albumin(38.2±3.1)g/L,and C-reactive protein of 4.9(3.1-14.4)mg/L.There was no significant difference in preoperative data between the two groups(P>0.05).The two groups underwent RARC and pelvic lymph node dissection similarly.The ICUD group underwent a total intracorporeal ileal conduit and the ECUD group underwent extracorporeal ileal conduit with direct vision through a median incision in the lower abdomen.There were 32 cases(86.5%)and 46 cases(79.3%)undergoing expanded pelvic lymph node dissection in the ICUD group and the ECUD group respectively,and the difference was not statistically significant(P=0.374).The complications were graded according to the Clavien-Dindo grading system.The perioperative complications and prognosis of the two groups were compared.Results The operation time of the ICUD group and the ECUD group were(430±63)min vs.(410±69)min,respectively(P=0.163).The estimated blood loss were(435±233)ml vs.(388±277)ml,respectively(P=0.182).Intraoperative blood transfusion were 10 cases(27.0%)and 12 cases(20.7%)(P=0.475).None of the above differences were statistically significant.Postoperative albumin of the ICUD group and the ECUD group were(31.5±2.4)g/L vs.(31.0±2.8)g/L(P=0.387),postoperative C-reactive protein were 30.9(10.4-52.1)mg/L vs.29.5(14.4-58.5)mg/L(P=0.655)and postoperative hemoglobin were(110.0±13.8)g/L vs.(113.7±13.4)g/L(P=0.187).The postoperative feeding recovery were 4(3-5)d vs.4(3-5)d(P=0.752)and the postoperative hospital stay were 13(10-19)d vs.13(11-18)d(P=1.000).There was no statistically significant difference in perioperative data.The postoperative pathological examination results of ICUD group and ECUD group showed that there were 17 cases(45.9%)vs.19 cases(32.8%)in T_(a)/T_(1)/Tis stage,12 cases(32.4%)vs.18 cases(31.0%)in T_(2) stage,5 cases(13.5%)vs.19 cases(32.8%)in T_(3) stage,3 cases(8.1%)vs.2 cases(3.4%)in T_(4) stage,respectively and the difference was not statistically significant(P=0.166).The number of lymph nodes removed were(18.2±6.7)vs.(16.5±7.9)(P=0.178)and the number of patients with positive lymph nodes were 6(16.2%)vs.11(19.0%),respectively(P=0.733).None of the patients had positive margins.There was no statistically significant difference in pathological examination overall.There were 14 cases(37.8%)in the ICUD group and 21 cases(36.2%)in the ECUD group experiencing complications within 30 days after operation and the difference was not statistically significant(P=0.872).The complications within 90 days after operation were 14 cases(37.8%)vs.24 cases(41.4%)respectively and the difference was not statistically significant(P=0.731).Clavien-Dindo gradeⅢ-Ⅴcomplications in the two groups were 1 case(2.7%)vs.1 case(1.7%)respectively,with no significant difference(P=0.849).One patient in the ICUD group developed an intestinal anastomotic leakage and underwent reoperation for repairing and 1 patient in the ECUD group developed mechanical intestinal obstruction and underwent reoperation.The rate of readmission within 90 days after operation of the ICUD group was lower than that of the ECUD group,but the difference was not statistically significant[3 cases(8.1%)vs.11 cases(19.0%),P=0.090].Postoperative follow-up was 13-53 months and the median follow-up of ICUD group and ECUD group were 19 months and 31 months respectively.There was no significant difference in the survival curve between the two groups(P=0.746).The 1-year survival rate was 91.9%in the ICUD group and 91.4%in the ECUD group.Routine re-examination of urinary system CT or B-ultrasound was performed 3 months,6 months and 1 year after surgery.The incidence of ureteral dilatation/hydronephrosis in the ICUD group was lower than that of the ECUD group,with 4.1%(3 sides)vs.14.7%(17 sides)(P=0.020).Conclusion Compared with RARC+ECUD,RARC+ICUD does not increase the incidence of complications within 90 days after surgery and may reduce the risk of upper urinary tract dilatation.