机器人辅助根治性膀胱切除及Bricker术中体内与体外尿流改道的疗效和并发症比较

Comparison of perioperative result and complications of robot-assisted radical cystectomy with intracorporeal and extracorporeal urinary diversion

目的比较机器人辅助根治性膀胱切除及Bricker术中采用体内与体外尿流改道的疗效和并发症。方法回顾性分析2015年1月至2020年3月浙江省人民医院收治的204例膀胱癌患者的病例资料,患者均接受机器人辅助根治性膀胱切除及Bricker术,其中采用体外尿流改道(ECUD组)82例,采用全腔内尿流改道(ICUD组)122例。ECUD组男67例(81.7%),女15例(18.3%);中位年龄70(61,76)岁;有吸烟史35例(43.2%);既往有高血压病31例(37.5%),糖尿病17例(21.3%),心脏病13例(15.7%),腹部手术史15例(17.8%);中位体质指数(BMI)为26.1(24.3,28.5)kg/m^(2);美国麻醉医师协会(ASA)评分≤2分67例(81.7%),≥3分15例(18.3%);高危非肌层浸润性膀胱癌15例(18.3%),肌层浸润性膀胱癌67例(81.7%);接受新辅助化疗16例(19.5%)。ICUD组男95例(77.9%),女27例(22.1%);中位年龄68(62,75)岁;有吸烟史58例(47.3%);既往有高血压病40例(32.6%),糖尿病33例(22.8%),心脏病28例(26.7%),腹部手术史17例(14.2%);中位BMI 25.6(23.4,27.8)kg/m^(2);ASA评分≤2分105例(86.1%),≥3分17例(13.9%);高危非肌层浸润性膀胱癌29例(24.9%),肌层浸润性膀胱癌93例(75.1%);接受新辅助化疗22例(18.0%)。两组一般资料比较差异均无统计学意义(P>0.05)。ICUD组回肠膀胱制作及输尿管种植方法:距回盲部15 cm处用切割闭合器截取约15 cm回肠制备回肠膀胱通道并恢复回肠的连续性;将取好的回肠膀胱近心端封闭,将双侧输尿管间距3 cm分别种植在回肠膀胱通道上;双侧输尿管内均置入F6单J管引流尿液。ECUD组方法:取脐下5 cm切口,进入腹腔,找到回盲部,将回肠末段提出体外,距盲肠15 cm处切开肠系膜,结扎血管至动脉弓,于回肠上做一小切口;自断端向上15 cm处同法处理肠系膜、肠管;用直线切割吻合器截取所需肠段并恢复延续性,冲洗游离肠段,将双侧输尿管置入单J管并与游离肠管吻合,间距3 cm。比较两组的手术时间、术中出血量、术后排气时间、术后进固体食物时间、术后住院时间、术后切口疼痛(评分>5分)例数、术后再入院率、围手术期死亡率、术后并发症、术后病理检查结果等。结果两组手术均顺利完成,无中转开放或普通腹腔镜手术,无严重术中并发症。ICUD组与ECUD组的手术时间差异无统计学意义[260(230,310)min与235(220,290)min,P=0.078]。ECUD组术中出血量多于ICUD组[300(200,400)ml与150(100,300)ml,P=0.037],但两组输血例数差异无统计学意义[7例(8.6%)与9例(7.4%),P=0.196]。ECUD组的术后排气时间[4(2,6)d与2(1,3)d,P=0.024]和术后进固体食物时间[7(4,9)d与4(3,5)d,P=0.019]长于ICUD组。ECUD组和ICUD组术后住院时间[8(5,11)d与6(5,9)d,P=0.212]差异无统计学意义。ICUD组术后早期(术后<30 d)总并发症发生率[19.6%(24/122)与34.2%(28/82),P=0.029]、早期轻微(Clavien-DindoⅠ~Ⅱ级)并发症发生率[13.9%(17/122)与25.6%(21/82),P=0.007]、晚期(术后30~90 d)严重(Clavien-Dindo≥Ⅲ级)并发症发生率[4.1%(5/122)与10.1%(8/82),P=0.039]明显低于ECUD组;早期严重并发症发生率[5.7%(7/122)与8.5%(7/82),P=0.089]、晚期总并发症发生率[15.6%(19/122)与16.1%(13/82),P=0.345]、晚期轻微并发症发生率[11.5%(14/122)与6.0%(5/82),P=0.085]与ECUD组比较差异无统计学意义。ICUD组与ECUD组的淋巴结清扫数量[21(14,25)枚与19(15,24)枚]、淋巴结阳性率[10.7%(13/122)和10.0%(8/82)]、切缘阳性率[3.3%(4/122)与4.8%(4/82)]和术后病理分期[T_(1)期~Tis期:25例(20.3%)与14例(17.1%);T_(2)期~T_(3)期:97例(79.7%)与68例(82.9%)]差异均无统计学意义(P>0.05)。ICUD组和ECUD组术后切口疼痛分别为43例(35.6%)和46例(56.5%),差异有统计学意义(P<0.05)。ICUD组术后30 d和90 d再入院率分别为1.6%(2/82)和4.9%(6/82),ECUD组术后30 d和90 d再入院率分别为1.2%(1/122)和9.8%(8/122),差异均无统计学意义(P>0.05)。两组围手术期均无死亡病例。结论机器人辅助根治性膀胱切除及体内Bricker术治疗肌层浸润性或高危非肌层浸润性膀胱癌,是安全且可重复的手术方式。腔镜下完全体内重建膀胱切实可行,具有术中出血少、术后肠管功能恢复快、术后早期并发症少的优势。

Objective To explore and compare the perioperative result and complications of robot-assisted radical cystectomy with intracorporeal and extracorporeal urinary diversion.Methods Clinical data of bladder cancer patients undergoing robot-assisted radical cystectomy with ileal conduit in Zhejiang Provincial People's Hospital from January 2015 to March 2020 were retrospectively analyzed.Eighty-two patients underwent extracorporeal urinary diversion(ECUD group),and 122 underwent intracorporeal urinary diversion(ICUD group).In the ECUD group,the median age was 70(61,76)years old,including 67 male(81.7%),the median BMI was 26.1(24.3,28.5),67 cases(81.7%)was ASA score 0-2,15 cases(18.3%)was 3 or higher,15 cases(18.3%)were high risk non-muscular invasive bladder cancer.67 cases(81.7%)were muscular invasive bladder cancer.16 cases(19.5%)received neoadjuvant chemotherapy.Past medical history included smoking in 35 cases(43.2%),hypertension in 31 cases(37.5%),diabetes in 17 cases(21.3%),heart disease in 13 cases(15.7%),and abdominal surgery in 15 cases(17.8%).In the ICUD group,the median age was 68(62,75),95 male(77.9%),the median BMI was 25.6(23.4,27.8)kg/m^(2),105 cases(86.1%)was ASA score 0-2,17 cases(13.9%)was 3 or higher,29 cases(24.9%)were high risk non-muscular invasive bladder cancer,and 93 cases(75.1%)were muscular invasive bladder cancer.There were 22 cases(18.0%)undergoing neoadjuvant chemotherapy.Past medical history included smoking in 58 cases(47.3%),hypertension in 44 cases(32.6%),diabetes in 33 cases(22.8%),heart disease in 28 cases(26.7%),and abdominal surgery in 17 cases(14.2%).No significance was detected in characteristics between the two groups.For ileal bladder making and ureteral implantation method in ICUD group,15 cm ileum was taken using stapler at the 15 cm from ileocecum to make ileal conduit and restore the continuity of the ileum.The proximal end of the ileal conduit was closed.The bilateral ureteral were implanted 3 cm apart on the ileal bladder.F6 single J tube was placed into both of the ureters to drain urine.For ECUD group,the subumbilical 5 cm incision was taken to enter the abdominal cavity.The ileocecum was found and the terminal ileum was taken out of the body.A segment of 15 cm in length ileocecum 15 cm away from the cecum was cut off with a linear cutting stapler and the blood vessels of arterial arch were ligated,then a small opening at the same ileum position was cut.The continuity of the ileocecum was restored.The ileal conduit was irrigated,and the bilateral ureters were placed into a single J tube and anastomosed to the ileal conduit 3 cm apart.The operation time,intraoperative blood loss,postoperative exhaust time,postoperative feeding time,postoperative hospital stay,postoperative incision pain score,postoperative readmission rate,peri-operative mortality,postoperative complications and pathology results were compared between the two groups.Results All cases were successfully performed robotically without conversion or major intraoperative complications.There was no significant difference in operation time between ICUD group and ECUD group[260(230,310)min and 235(220,290)min,P=0.078].The estimated blood loss in ECUD group was more than that in ICUD group[300(200,400)ml and 150(100,300),P=0.037],but there was no difference in blood transfusion rate between the two groups[7(8.6%)and 9(7.4%),P=0.196].The exhaust time[4(2-6)days and 2(1,3)days]and postoperative solid food feeding time[7(4,9)days and 4(3,5)days]in the ECUD group were longer than those in the ICUD group(all P<005).The exhaust time[4(2-6)day and 2(1,3)day]and solid food feeding time[7(4,9)day and 4(3,5)day]in ECUD group were longer than those in ICUD group.There was no significant difference in postoperative hospital stay between ECUD group and ICUD group[8(5,11)day and 6(5,9)day,P=0.212].Clavien-DindoⅠ-Ⅱgrade was defined mild complication,Ⅲgrade or above was defined serious complication,early complication was defined within 30 days after operation,and late complication was defined 30-90 days after operation.The overall early postoperative complication rate were 19.6%(24)and 34.2%(28)(ICUD vs.ECUD),the mild complications rate were 13.9%(17)and 25.6%(21)(ICUD vs.ECUD),and the late severe complication rate were 4.1%(5)and 10.1%(8)(ICUD vs.ECUD).ICUD group were significantly lower than those of ECUD group(all P<0.05).There was no difference in the early severe complication rate[5.7%(7)and 8.5%(7)],the total late complication rate[15.6%(19)and 16.1%(13)],and the late mild complication rate[11.5%(14)and 6.0%(5)](all P>0.05).There was no significant difference between ICUD group and ECUD group,in term of the number of lymph nodes dissected[21(14,25)and 19(15,24)],the positive rate of lymph nodes[10.7%(13)and 10.0%(8)],the positive rate of surgical margin[3.3%(4)and 4.8%(4)]and postoperative pathological stage T_(1)-Tis[25(20.3%)and 14(17.1%)],and T_(2)-T_(3)[97(79.7%)and 68(82.9%)].The number of patients with postoperative incision pain(pain score>5)was 43(35.6%)in ICUD and 46(56.5%)in ECUD(P<0.05).The 30-day and 90-day readmission rates were 1.6%(2/82)and 4.9%(6/82)in ICUD group,and 1.2%(1/122)and 9.8%(8/122)in ECUD group,respectively.There was no peri-operative mortality in both groups.Conclusions Robot-assisted radical cystectomy with ileal conduit is a safe and repeatable method for the treatment of muscular invasive or high-risk non-muscular invasive bladder cancer.Complete intracorporeal bladder reconstruction is feasible and has the advantages of less intraoperative bleeding,faster postoperative intestinal function recovery and less complications.