系统教学模式下无腔镜经验术者实施机器人辅助根治性前列腺切除术的学习曲线分析

Learning curve of robot-assisted radical prostatectomy:impact of a systematic training program on surgeons with no previous laparoscopic experience

目的评估在系统教学模式下无腔镜前列腺切除术经验的术者行机器人辅助根治性前列腺切除术的学习曲线。方法回顾性分析由解放军总医院第三医学中心泌尿外科医学部1名无腔镜经验的术者实施的前120例机器人辅助根治性前列腺切除术患者的资料。术者在术前接受了系统教学指导。本研究按手术实施的先后顺序将患者分为4组,每30例为一组。以手术时间、术中出血量、术后住院天数等作为学习曲线的衡量标准,比较各组间的术后切缘阳性率和并发症发生率以及术后1年的生化复发率和尿控恢复率。结果手术时间90~355 min,平均(186.0±54.7)min;术中出血量50~1000 ml,平均(266.0±186.1)ml;术后住院天数4~21 d,平均(10.0±3.5)d。术后切缘阳性率为27.5%,并发症发生率为20.8%;术后1年生化复发率为15.8%,尿控恢复率为80.8%。随着前30例手术经验的积累,术者到达学习曲线平台期,手术时间、术中出血量、术后住院天数均显著降低(P<0.05);而术者在最后30例渡过了学习平台期,切缘阳性率、并发症发生率、生化复发率和尿控恢复率均显著降低(P<0.05)。结论在系统教学的模式下,无腔镜经验的术者可顺利完成机器人辅助根治性前列腺切除术,并具有明显的学习曲线。术者需要通过90~120例的手术积累以渡过学习曲线的平台期,以获得较满意的肿瘤学和功能学结果。

Objective To evaluate the learning curve of a surgeon without previous experience in laparoscopy performing robot-assisted radical prostatectomy(RARP)after systematic training.Methods A total of 120 patients after RARP in Third Medical Center of Chinese PLA General Hospital were included in the study retrospectively.All of the operations were done by one surgeon without previous laparoscopic experience who had finished a systematic training program.According to the operation sequence,all the cases were divided into four groups,and each group includes 30 patients.The operative time,estimated blood loss and postoperative hospital stay were statistically analyzed.The positive surgical margin rate,complication rate,biochemical recurrence rate and continence rate were compared among each group.Results The mean operative time was(186.0±54.7)min(90-355 min).The mean estimated blood loss was(266.0±186.1)ml(50-1000 ml).The postoperative hospital stay averaged(10.0±3.5)days(4-21 days).The positive surgical margin rate was 27.5%,and the complication rate was 20.8%.The biochemical recurrence rate was 15.8%,and the continence rate was 80.8%.After 30 cases,the surgeon reached the plateau of learning curve,so the operative time,estimated blood loss and postoperative hospital stay all significantly reduced(P<0.05).In addition,the surgeon successfully passed the plateau after 90 cases,so the complication rate,positive surgical margin rate,biochemical recurrence rate and incontinence rate all decreased obviously(P<0.05).Conclusions After systematic training,there is an obvious learning curve in the study process of RARP for surgeons without previous experience in laparoscopy.Satisfactory surgical,oncologic,and functional outcomes could be achieved after an accumulation of approximately 90 to 120 RARP cases.