单一术者65例机器人辅助腹腔镜下前列腺癌根治术的学习曲线分析

Analysis of learning curve for robot-assisted laparoscopic radical prostatectomy:a single operator's initial experience in 65 cases

目的探讨单一术者机器人辅助腹腔镜下前列腺癌根治术(RARP)的学习曲线,为拟开展RARP的医师提供参考依据。方法回顾性分析2022年9月-2023年12月上海交通大学医学院附属第六人民医院泌尿外科65例行RARP治疗的前列腺癌患者的相关资料。患者中位年龄为67.5(58.1~82.4)岁,中位总前列腺特异性抗原(PSA)为15.6(6.7~98.4)ng/mL,中位身体质量指数(BMI)为20.8(17.4~27.3),术前肿瘤临床分期T2aN0M0~T3bN1M0。使用累积和方法(CUSUM)对RARP装机时间和手术时间的学习曲线进行拟合,根据曲线的拐点数据,将术者的学习曲线分为不同的学习阶段,并对在不同学习阶段进行手术的患者临床资料进行比较。结果RARP的学习曲线手术例数为12例。65例手术分为3个阶段:1~12例为学习阶段,13~43例为掌握阶段,44~65例为熟练阶段。随着手术例数的增加,3个阶段的中位手术时间[191(100~360)min vs.116(83~165)min vs.90(75~105)min]和中位术中出血量[403(180~900)mL vs.236(180~305)mL vs.94(30~200)mL]均呈逐渐下降的趋势(P<0.05)。学习阶段的中位装机时间明显长于掌握阶段和熟练阶段[25(21~28)min vs.12(11~15)min vs.12(11~14)min](P<0.05)。学习阶段的手术切缘阳性率(PSM)明显高于掌握阶段和熟练阶段(41.7%vs.22.6%vs.22.7%)(P<0.05)。结论对于传统腹腔镜手术经验丰富的术者,RARP的学习曲线手术例数为12例左右,经过43例手术后,手术时间和术中出血量可进一步降低。

Objective To explore the learning curve of single-surgeon robot-assisted laparoscopic radical prostatectomy(RARP),which provides a reference for physicians who intend to carry out RARP.Methods The clinical data of 65 prostate cancer patients who underwent RARP in our hospital during Sep.2022 and Dec.2023 were retrospectively analyzed.The patients median age was 67.5(58.1-82.4)years,median total prostate-specific antigen(PSA)was 15.6(6.7-98.4)ng/mL,median body mass index(BMI)was 20.8(17.4-27.3)and preoperative clinical stage of tumor was T2aN0M0-T3bN1M0.The cumulative sum(CUSUM)method was used to fit the learning curves of machine installation time and operation time.According to the inflection points,the learning curves were divided into different learning stages,and the clinical data of patients at different learning stages were compared.Results The learning curve of RARP was 12 cases.The 65 cases were divided into three stages:1st-12th cases in the learning stage,13rd-43rd cases in the mastery stage,and 44th-65th cases in the proficiency stage.With the increase of the number of surgical cases,the median operation time[191(100-360)min vs.116(83-165)min vs.90(75-105)min]and median intraoperative blood loss[403(180-900)mL vs.236(180-305)mL vs.94(30-200)mL]in the three stages showed a gradual downward trend(P<0.05).The median machines installation time of the learning stage was significantly longer than that in the mastery stage and the proficiency stage[25(21-28)min vs.12(11-15)min vs.12(11-14)min](P<0.05).The positive surgical marginrate(PSM)in the learning stage was significantly higher than that in the mastery stage and proficiency stage(41.7%vs.22.6%vs.22.7%)(P<0.05).Conclusion For surgeons with rich experience in traditional laparoscopic surgery,the learning curve of RARP is about 12 cases,and after 43 cases,the operation time and intraoperative blood loss can be further reduced.