BMI对机器人辅助根治性膀胱切除+腔内尿流改道术围手术期疗效和并发症的影响

Impact of body mass index on perioperative efficacy and complications of robot-assisted radical cystectomy with intracorporeal urinary diversion

目的探讨不同体质量指数(BMI)患者机器人辅助根治性膀胱切除(RARC)+腔内尿流改道术的疗效和并发症。方法回顾性分析2017年1月至2020年1月浙江省人民医院收治的146例膀胱癌患者的病例资料。按BMI将患者分为3组:正常组(<25.0 kg/m2)61例,超重组(25.0~29.9 kg/m2)52例,肥胖组(≥30.0 kg/m2)33例。正常组男45例(73.8%),女16例(26.2%);中位年龄73.6(59,79)岁;吸烟34例(55.7%);既往有高血压病19例(31.1%),糖尿病10例(16.4%),心脏病12例(19.7%),腹部手术史6例(9.8%);美国麻醉医师协会(ASA)评分1~2分51例(83.6%),3~4分10例(16.4%);10例(16.4%)接受新辅助化疗。超重组男38例(73.1%),女14例(26.9%);中位年龄69.7(60,78)岁;吸烟30例(57.7%);既往有高血压病20例(38.5%),糖尿病10例(19.2%),心脏病9例(17.3%),腹部手术史5例(9.6%);ASA评分1~2分25例(48.1%),3~4分27例(51.9%);9例(17.3%)接受新辅助化疗。肥胖组男21例(63.7%),女12例(36.3%);中位年龄69.9(61,78)岁;吸烟18例(54.5%);既往有高血压病17例(51.5%),糖尿病19例(57.6%),心脏病7例(21.2%),腹部手术史4例(12.1%);ASA评分1~2分20例(60.6%),3~4分13例(39.4%);9例(27.3%)接受新辅助化疗。肥胖组和超重组的高血压病、糖尿病比例高于正常组(均P<0.05),3组间其他指标比较差异无统计学意义(均P>0.05)。3组均接受RARC和双侧盆腔淋巴结清扫术,然后行腔内尿流改道。淋巴结清扫范围分为标准范围和扩大范围。尿流改道方式包括原位新膀胱和回肠膀胱。原位新膀胱制作方法:用腔内切割闭合器在距回盲部15 cm处取回肠末段40~50 cm肠管,用切割闭合器在腔内完成U形新膀胱的制作,并将新膀胱与尿道和双侧输尿管吻合。回肠膀胱制作方法: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连续性;将双侧输尿管间距3 cm分别吻合于回肠膀胱通道上。正常组淋巴结清扫范围分别为标准20例(32.8%),扩大41例(67.2%);尿流改道方式分别为原位新膀胱22例(36.1%),回肠膀胱39例(63.9%)。超重组淋巴结清扫范围分别为标准12例(23.1%),扩大40例(76.9%);尿流改道方式分别为原位新膀胱26例(49.1%),回肠膀胱26例(50.9%)。肥胖组淋巴结清扫范围分别为标准7例(21.2%),扩大26例(78.7%);尿流改道方式分别为原位新膀胱7例(21.2%),回肠膀胱26例(78.8%)。3组的淋巴结清扫范围和尿流改道方式比较差异无统计学意义(均P>0.05)。比较3组的手术时间、术中出血量、输血率、术后排气时间、术后进固体食物时间、术后住院时间、术后并发症(Clavien-DindoⅠ~Ⅱ级定义为轻微并发症,≥Ⅲ级定义为严重并发症)、术后肿瘤病理等指标。结果3组手术均顺利完成,无中转开放或普通腹腔镜,术中无严重并发症。正常组、超重组、肥胖组行RARC+原位新膀胱的手术时间分别为250(230,310)min、310(250,350)min、370(310,420)min,差异有统计学意义(P=0.008);行RARC+回肠膀胱的手术时间分别为240(220,290)min、270(220,300)min、280(230,300)min,差异无统计学意义(P=0.256);出血量分别为190(100,350)ml、230(150,450)ml、310(250,600)ml,差异有统计学意义(P=0.011);输血例数分别为5例(8.2%)、4例(7.7%)、2例(6.1%),差异无统计学意义(P=0.663)。正常组、超重组、肥胖组的术后排气时间[2(1,3)d与2(1,4)d与2(1,4)d,P=0.624]、术后进固体食物时间[4(3,5)d与4(3,6)d与4(3,6)d,P=0.618]、术后住院时间[10(5,16)d与10(6,17)d与12(6,20)d,P=0.362]差异无统计学意义。正常组、超重组、肥胖组术后90 d内轻微并发症例数[20例(32.8%)与28例(53.8%)与16例(48.5%),P=0.035]差异有统计学意义,3组间总并发症和严重并发症例数差异无统计学意义(均P>0.05)。正常组、超重组、肥胖组的泌尿系统并发症[18例(29.5%)与21例(40.4%)与26例(78.8%),P=0.019]和切口并发症[2例(3.3%)与3例(5.8%)与6例(18.2%),P=0.037]差异有统计学意义,胃肠道并发症和输尿管吻合口并发症(狭窄或尿漏)差异无统计学意义(P>0.05)。正常组、超重组、肥胖组清扫淋巴结数量[19(10,25)枚与21(14,28)枚与21(14,26),P=0.384],阳性淋巴结例数[9例(14.8%)与7例(13.5%)与6例(18.2%)P=0.541],切缘阳性例数[3例(4.9%)与2例(3.8%)与1例(3.0%),P=0.437],病理分期[T_(is)~T_(1)/T_(2)~T_(3)期:13例(21.3%)/48例(78.7%)与10例(19.2%)/42例(80.8%)与5例(15.1%)/28例(84.9%),P=0.672]差异均无统计学意义。结论BMI不影响RARC+腔内尿流改道术后肠道功能恢复和肿瘤治疗效果,但对超重和肥胖患者行RARC+原位新膀胱存在手术时间长、术中出血量多、增加术后轻微并发症的风险。

Objective To determine the impact of body mass index(BMI)on perioperative and oncological outcomes after robot-assisted radical cystectomy(RARC)with intracorporeal urinary diversion.Methods Clinical data of bladder cancer patients undergoing robot-assisted radical cystectomy with intracorporeal urinary diversion in Zhejiang Provincial People's Hospital from January 2017 to January 2020 were retrospectively analyzed.Patients were divided into three groups according to BMI,including 61 cases in normal group(<25.0 kg/m^(2)),52 cases in overweight group(25.0-29.9 kg/m^(2))and 33 cases in obese group(≥30.0 kg/m^(2)).In the normal group,the median age was 73.6(59,79),including 45 male(73.8%),with 51 cases(83.6%)of ASA score 0-2,10 cases(16.4%)of 3 or higher,and 10 cases(16.4%)undergoing neoadjuvant chemotherapy.Past medical history included smoking in 34 cases(55.7%),hypertension in 19 cases(31.1%),diabetes in 10 cases(16.4%),heart disease in 12 cases(19.7%),and abdominal surgery in 6 cases(9.8%).In the overweight group,the median age was 69.7(60,78),including 38 male(73.1%),with 25 cases(48.1%)of ASA score 0-2,27 cases(51.9%)of 3 or higher,and 9 cases(17.3%)undergoing received neoadjuvant chemotherapy.Past medical history included smoking in 30 cases(57.7%),hypertension in 20 cases(38.5%),diabetes in 10 cases(19.2%),heart disease in 9 cases(17.3%),and abdominal surgery in 5 cases(9.6%).In the obses group,the median age was 69.9(61,78),including 21 male(63.7%),with 20 cases(60.6%)of ASA score 0-2,13 cases(39.4%)of 3 or higher,9 cases(27.3%)undergoing neoadjuvant chemotherapy.Past medical history included smoking in 18 cases(54.5%),hypertension in 17 cases(51.5%),diabetes in 19 cases(57.6%),heart disease in 7 cases(21.2%),and abdominal surgery in 4 cases(12.1%).After statistical comparison among the three groups,it was found that the proportion of patients with hypertension and diabetes in the obesity group and overweight group was higher than that in the normal group(all P<0.05),but there was no significant difference in other factors(all P>0.05).During the surgical process,robot-assisted radical cystectomy and bilateral pelvic lymph node dissection were performed firstly.The scope of lymph node dissection was divided into standard range and expanded range,and the diversion was divided into orthotopic neobladder and ileal bladder.During the orthotopic neobladder process,40-50 cm ileum at the distance of 15 cm away from ileocecum was obtained by stapler,and then the U-shaped neobladder was made,and the new bladder was anastomosed with urethra and bilateral ureter.For ileal bladder,the ileum was cut off 15cm away from the ileocecum with stapler to obtain the 15 cm ileum to prepare the ileal conduit and restore the continuity of the ileum.The bilateral ureteral spacing 3cm was implanted on the ileal conduit.In the normal group,standard range lymphatic dissection was performed in 20 cases(32.8%),enlarged dissection in 41 cases(67.2%),orthotopic neobladder in 22 cases(36.1%),and ileal conduit in 39 cases(63.9%).In the overweight group,standard range lymphatic dissection was performed in 12 cases(23.1%),enlarged dissection in 40 cases(76.9%),orthotopic neobladder in 26 cases(49.1%),and ileal conduit in 26 cases(50.9%).In the obesity group,the standard range of lymphatic dissection was performed in 7 cases(21.2%),enlarged dissection in 26 cases(78.7%),orthotopic neobladder in 7 cases(21.2%),and ileal conduit in 26 cases(78.8%).There was no significant difference among the three groups(all P>0.05).Compared the operation time,intraoperative blood loss,postoperative exhaust time,postoperative time of taking solid food,postoperative hospital stay,postoperative complications(according to the Clavien-Dindo grading system,postoperative complications are reported inⅠ-Ⅱgrade as mild complications and aboveⅢgrade as serious complications)and pathology results in three groups.Results All cases successfully underwent robotically without conversion or major intraoperative complications.The operation time in overweight and obsess group were longer than that of normal group with RARC or orthotopic neobladder[310(250,350)min,370(310,420)min,250(230,310)min,(P<0.05)],but there was no significant difference in RARC and ileal conduit[270(220,300)min,280(230,300)min,240(220,290)min,P>0.05].The estimated blood loss in overweight and obsess group was more than that in normal group[230(150,450)ml,310(250,600)ml,190(100,350)ml,P<0.05],but there was no difference in blood transfusion rate[4(7.7%),2(6.1%),5(8.2%),P>0.05].The exhaust time[2(1,3)days,2(1,4)days,2(1,4)days],postoperative solid food intake time[4(3,5)days,4(3,6)days,4(3,6)days]and the hospital stay[10(5,16)days,10(6,17)days,12(6,20)days]were not different in three groups(all P>0.05).The mild complication rates in 90 days were significant higher in overweight and obsess groups[28(53.8%),16(48.5%),20(32.8%),P<0.05],but the total and severe complication rates were not significantly different.The incidences of urinary system complications and incision complications in obese and overweight patients were significantly higher than those in normal group(P<0.05).There was no significant difference in the incidence of gastrointestinal complications and ureteral anastomosis-related complications(stricture or urinary leakage)(P>0.05).There was no significant difference in the number of dissected lymph node,positive lymph node,positive rate of incisional margin and postoperative pathological stage among three different BMI groups(all P>0.05).Conclusion Robot-assisted radical cystectomy combined with intracorporeal urinary diversion is a safe and effective method for the treatment of overweight,obese and even morbidly obese patients with bladder cancer.The recovery of intestinal function and the oncological results are not affected by body mass index.However,laparoscopic radical cystectomy for overweight and obese patients,especially for orthotopic neobladder,has the risk of long operation time,large amount of intraoperative bleeding and increased risk of minor postoperative complications.