经腹膜外途径单孔机器人辅助根治性前列腺切除术的学习曲线分析

Learning curve analysis of extraperitoneal single-port robot-assisted radical prostatectomy

目的分析经腹膜外途径单孔机器人辅助根治性前列腺切除术(spRARP)的学习曲线。方法回顾性分析上海交通大学医学院附属仁济医院自2020年9月—2022年4月开展经腹膜外途径spRARP初始阶段收治的148例连续患者的病例资料。根据手术先后顺序将所有患者分为先手术组(50例)与后手术组(98例)。比较两组患者的年龄、BMI、术前前列腺特异性抗原(PSA)水平、前列腺体积(PV)等指标。进一步根据不同术者、患者BMI、患者PV分组,分别绘制spRARP手术时间(即机械臂操作时间)、术中估计出血量的学习曲线,并进行分析。结果所有手术均顺利完成,无中转行开放手术等情况。两组患者均未发生ClavienⅢ级及以上并发症。两组患者年龄、BMI、术前PSA水平、PV、术后Gleason评分≥8分患者占比的差异均无统计学意义(P值均>0.05),后手术组机械臂操作时间显著短于先手术组(P<0.001),两组间术中估计出血量、术后住院天数和切缘阳性率的差异均无统计学意义(P值均>0.05)。不同术者手术的学习曲线分析结果:术者1(完成78例手术)和术者2(完成67例手术)分别在经过30、40例手术后,机械臂操作时间的学习曲线达到平台期;随着手术例数的增加,两位术者术中估计出血量的学习曲线均呈持续下降趋势,术者2下降更为明显。针对不同BMI患者,术者手术的学习曲线分析结果:针对BMI≥25.0kg/m^(2)的患者,术者机械臂操作时间的学习曲线下降较为明显,术者经过20例手术后,学习曲线达到平台期;针对BMI<25kg/m^(2)的患者,术者机械臂操作时间下降较平缓。随着手术例数的增加,针对BMI<25kg/m^(2)的患者,术者术中估计出血量的学习曲线呈持续下降趋势,而针对BMI≥25.0kg/m^(2)的患者,术者无明确的学习曲线。针对不同PV患者,术者手术的学习曲线分析结果:针对PV≥50mL与PV<50mL患者,术者机械臂操作时间的学习曲线相似,均在约40例手术后到达平台期;随着手术例数的增加,针对PV<50mL的患者,术者术中估计出血量的学习曲线呈下降趋势,而针对PV≥50mL的患者,术者无明确的学习曲线。结论经腹膜外途径spRARP是一种安全、高效的手术方式,在30~40例患者的积累后,手术达到学习曲线的平台期,可以获得较为稳定的手术时间和术中出血量。

Objective To investigate the learning curve of extraperitoneal single-port robot-assisted radical prostatectomy(spRARP).Methods The clinical data of 148 consecutive patients who received extraperitoneal spRARP at Renji Hospital from September 2020 to April 2022 were retrospectively analyzed.The patients were categorized into the prior surgery group(n=50)and posterior surgery group(n=98)according to the sequence of surgery.Age,body mass index(BMI),preoperative prostate-specific antigen(PSA),and prostate volume(PV)were compared between the two groups.The learning curves of spRARP operation time and estimated intraoperative bleeding were plotted and analyzed according to different operators,patients’BMI,and patients’PV grouping.Results All the operations were successfully completed and there was no conversion to open surgery.No postoperative complications of Clavien gradeⅢor higher occurred.There were no significant differences in the age,BMI,preoperative PSA,preoperative PV,or the proportion of patients with postoperative Gleason score≥8 between the two groups(P>0.05).The operating time of the robotic arm in the posterior surgery group was significantly shorter than that in the prior surgery group(P<0.001).There were no significant differences in the estimated intraoperative bleeding,hospital stay after surgery,or the rate of positive margins between the two groups(P>0.05).The learning curves of robotic arm operation time reached a plateau after 30 surgeries for operator 1(who had completed 78 surgeries)and 40 surgeries for operator 2(who had completed 67 surgeries).The learning curves of estimated intraoperative bleeding volume of the two operators showed a continuous downward trend as the number of surgeries increased,and the decrease was more obvious in operator 2.The learning curve of robotic arm operation time decreased significantly in patients with BMI≥25.0 kg/m^(2),and the learning curve reached a plateau after 20 surgeries in both operators.The decline of robotic arm operation time in patients with BMI<25 kg/m^(2)was moderate.As the number of surgeries increased,the learning curves for estimated intraoperative bleeding volume in patients with BMI<25 kg/m^(2)showed a continuous downward trend,whereas there was no clear learning curve in patients with BMI≥25.0 kg/m^(2).The learning curve of robotic arm operation time in patients with PV≥50 mL was similar to that in patients with PV<50 mL,and both reached a plateau after about 40 surgeries.With the increase of the number of surgeries,there was a decreasing trend in the learning curves of estimated intraoperative bleeding volume in patients with PV<50 mL,while there was no clear learning curve in patients with PV≥50 mL.Conclusion Extraperitoneal spRARP is a safe and efficient surgical method.After the accumulation of 30-40 patients,the operation reaches the plateau of the learning curve,and a relatively stable operation time and estimated blood loss can be obtained.