Da Vinci机器人辅助下肝门部胆管癌手术治疗术式选择与改进

目的总结daVinci机器人手术系统在肝门部胆管癌切除手术中的早期应用经验。方法复习第二炮兵总医院2009年1~6月57例机器人辅助的肝胆胰手术病例临床资料,介绍其中6例肝门部胆管癌切除术的临床效果。结果6例中,男5例,女1例;年龄(60±8)岁。Bismuth分型I型1例,Ⅲb型2例,Ⅳ型3例(1例术前行PTCD1个月)。BismuthI型病人实施机器人辅助下根治性胆管癌切除、胆肠吻合术;Ⅲb型病人1例实施左半肝切除术,1例实施肝门部胆管癌切除、胆管外引流术;BismuthⅣ型病人均实施机器人辅助下胆管癌切除、间置胆囊胆道重建术。术后1例进食后发生不全性肠梗阻,禁食1d后缓解;未发生胆漏、腹膜炎等其他并发症。中位随访时间3个月,未见明确肿瘤复发征象。结论daVinci机器人手术系统实施肝门部胆管癌切除术完全可行,具有手术视觉更扩大清晰,深度操作更确切容易,解剖性探查精细灵巧,手术方案可进可退,创伤小恢复快等优点。机器人辅助下肝门部胆管癌手术对病人的远期生存的影响,仍须进一步观察。     

Comparisons of the Perioperative,Functional, and Oncologic Outcomes After Robot-Assisted Versus Pure Extraperitoneal Laparoscopic Radical Prostatectomy

Background

In spite of the increasing use of robot-assisted radical prostatectomy (RALP) worldwide, no level 1 evidence-based benefit favouring RALP versus pure laparoscopic approaches has been demonstrated in extraperitoneal laparoscopic procedures.

Objective

To compare the operative, functional, and oncologic outcomes between pure laparoscopic radical prostatectomy (LRP) and RALP.

Design, setting, and participants

From 2001 to 2011, 2386 extraperitoneal LRPs were performed consecutively in cases of localised prostate cancers.

Intervention

A total of 1377 LRPs and 1009 RALPs were performed using an extraperitoneal approach.

Outcome measurements and statistical analysis

Patient demographics, surgical parameters, pathologic features, and functional outcomes were collected into a prospective database and compared between LRP and RALP. Biochemical recurrence–free survival was tested using the Kaplan-Meier method. Mean follow-up was 39 and 15.4 mo in the LRP and RALP groups, respectively.

Results and limitations

Shorter durations of operative time and of hospital stay were reported in the RALP group compared with the LRP group (p < 0.001) even beyond the 100 first cases. Mean blood loss was significantly lower in the RALP group (p < 0.001). The overall rate and the severity of the complications did not differ between the two groups. In pT2 disease, lower rates of positive margins were reported in the RALP group (p = 0.030; odds ratio [OR]: 0.396) in multivariable analyses. The surgical approach did not affect the continence recovery. Robot assistance was independently predictive for potency recovery (p = 0.045; OR: 5.9). Survival analyses showed an equal oncologic control between the two groups. Limitations were the lack of randomisation and the short-term follow-up.

Conclusions

Robotic assistance using an extraperitoneal approach offers better results than pure laparoscopy in terms of operative time, blood loss, and hospital stay. The robotic approach independently improves the potency recovery but not the continence recovery. When strict indications of nerve-sparing techniques are respected, RALP gives better results than LRP in terms of surgical margins in pathologically organ-confined disease. Longer follow-up is justified to reach conclusions on oncologic outcomes.     

腹腔镜下经腹膜外途径前列腺癌根治术(附2例报告)

目的:探讨腹腔镜下经腹膜外途径前列腺癌根治术的手术方法和临床效果。　方法:2例前列腺癌患者, 腹腔镜下经腹膜外途径分离前列腺,切开膀胱颈部,分离前列腺尖部、游离精囊后顺行将前列腺切除,膀胱颈成形 后与后尿道吻合。　结果:手术时间分别为10、7h,出血量分别为1000、500ml。术后24h恢复肠道功能,3周后 拔除尿管,未出现并发症。　结论:腹腔镜下腹膜外途径前列腺癌根治术创伤小、视野清晰、出血少、恢复快,是早 期前列腺癌根治术的方法之一。     

Periurethral Suspension Stitch During Robot-Assisted Laparoscopic Radical Prostatectomy: Description of the Technique and Continence Outcomes

Background

Several studies have shown that robot-assisted laparoscopic radical prostatectomy (RALP) is feasible, with favorable complication rates and short hospital times. However, the early recovery of urinary continence remains a challenge to be overcome.

Objective

We describe our technique of periurethral retropubic suspension stitch during RALP and report its impact on early recovery of urinary continence.

Design, setting, and participants

We analyze prospectively 331 consecutive patients who underwent RALP, 94 without the placement of suspension stitch (group 1) and 237 with the application of the suspension stitch (group 2).

Surgical procedure

The only difference between the groups was the placement of the puboperiurethral stitch after the ligation of the dorsal venous complex (DVC). The periurethral retropubic stitch was placed using a 12-in monofilament polyglytone suture on a CT-1 needle. The stitch was passed from right to left between the urethra and DVC, and then through the periostium on the pubic bone. The stitch was passed again through the DVC, and then through the pubic bone in a figure eight, and then tied.

Measurements

Continence rates were assessed with a self-administered validated questionnaire (Expanded Prostate Cancer Index Composite [EPIC]) at 1, 3, 6, and 12 mo after the procedure. Continence was defined as the use of no absorbent pads or no leakage of urine.

Results and limitations

In group 1, the continence rate at 1, 3, 6, and 12 mo postoperatively was 33%, 83%, 94.7%, and 95.7%, respectively; in group 2, the continence rate was 40%, 92.8%, 97.9%, and 97.9%, respectively. The suspension technique resulted in significantly greater continence rates at 3 mo after RALP (p = 0.013). The median/mean interval to recovery of continence was also statistically significantly shorter in the suspension group (median: 6 wk; mean: 7.338 wk; 95% confidence interval [CI]: 6.387–8.288) compared to the nonsuspension group (median: 7 wk; mean: 9.585 wk; 95% CI: 7.558–11.612; log rank test, p = 0.02).

Conclusions

The suspension stitch during RALP resulted in a statistically significantly shorter interval to recovery of continence and higher continence rates at 3 mo after the procedure.     

Randomized Controlled Trial of Barbed Polyglyconate Versus Polyglactin Suture for Robot-Assisted Laparoscopic Prostatectomy Anastomosis: Technique and Outcomes

Background

Transperitoneal robot-assisted laparoscopic prostatectomy (RALP) urethrovesical anastomosis is a critical step. Although the prevalence of urine leaks ranges from 4.5% to 7.5% at high-volume RALP centers, urine leaks prolong catheterization and may lead to ileus, peritonitis, and require intervention. Barbed polyglyconate sutures maintain running suture line tension and may be advantageous in RALP anastomosis for reducing this complication.

Objective

To compare barbed polyglyconate and polyglactin 910 (Vicryl, Ethicon, Somerville, NJ, USA) running sutures for RALP anastomosis.

Design, setting, and participants

This was a prospective, randomized, controlled, single-surgeon study comparing RALP anastomosis using either barbed polyglyconate (n = 45) or polyglactin 910 (n = 36) sutures.

Surgical procedure

RALP anastomosis using either barbed polyglyconate or polyglactin 910 sutures was studied.

Measurements

Operative time, cost differential, perioperative complications, and cystogram contrast extravasation by anastomosis suture type were measured.

Results and limitations

Although baseline characteristics and overall operative times were similar, barbed polyglyconate sutures were associated with shorter mean anastomosis times of 9.7 min versus 9.8 min (p = 0.014). In addition, anastomosis with barbed polyglyconate rather than polyglactin 910 sutures was associated with more frequent cystogram extravasation 8 d postoperatively (20.0% vs 2.8%; p = 0.019), longer mean catheterization times (11.1 d vs 8.3 d; p = 0.048), and greater suture costs per case ($51.52 vs $8.44; p < 0.001). After 8 of 29 (27.6%) barbed polyglyconate anastomosis sites demonstrated postoperative day 8 cystogram extravasation, we modified our technique to avoid overtightening, reducing cystogram extravasation to 1 (6.3%) of 16 subsequent barbed polyglyconate anastomosis sites. Potential limitations include small sample size and the single-surgeon study design.

Conclusions

Compared to traditional sutures, barbed polyglyconate is more costly and requires technical modification to avoid overtightening, delayed healing, and longer catheterization time following RALP.     

经腹膜外途径腹腔镜前列腺癌根治术(附5例报告)

目的:探讨经腹膜外途径腹腔镜前列腺癌根治术的临床体会。方法:采用经腹膜外途径对5例确诊为局限性前列腺癌的患者施行腹腔镜前列腺癌根治术,手术切除前列腺、精囊、输精管的壶腹以及膀胱颈的一部分,后行膀胱尿道吻合。结果:5例手术均获得成功,手术时间270~420 m in,平均350 m in,术中出血量250~600 m l,平均480 m l,术后48 h内胃肠功能恢复,术后2~3 d下床活动,术后住院7~12 d,平均8.5 d。术后随访3~8个月,无尿失禁,3例术前性功能正常的患者,2例术后可有满意的性生活。1例出现膀胱尿道吻合口狭窄,定期尿道扩张,排尿通畅。结论:经腹膜外途径腹腔镜前列腺癌根治术创伤小、对肠道无干扰、患者术后恢复快,可以成为治疗局限性前列腺癌的较好方法。     

经腹膜外腹腔镜下前列腺癌根治术（附151例报告）

目的：探讨经腹膜外腹腔镜下前列腺癌根治术（ELRP）的手术技巧和疗效。方法：回顾分析2006年1月～2011年1月,行ELRP151例患者的临床资料。术前均经病理检查确诊,患者平均年龄69（53～78）岁,盆腔CT、MRI和核素全身骨扫描无盆腔淋巴结、精囊和骨转移。结果：术前TPSA平均16．40（3．27～165．00）μg／L,Gleason评分〈7分63例（41．7％）,7分58例（38．4％）,〉7分30例（19．9％）。平均手术时间178（60～390）min,平均出血量260（20～1000）ml,术中输血5例（3．3％）。直肠损伤1例（0．67％）,术后病理检查切缘阳性14例（9．3％）,局部闭孔淋巴结转移5例（3．3％）。术后留置导尿平均13．5（6～69）天,平均住院时间14．4（4～74）天。术后随访平均27（4~62）个月,不同程度尿失禁31例（20．5％）。尿道狭窄2例（1．3％）,均行尿道狭窄冷刀切开。单侧腹股沟斜疝2例（1．3％）,出现生化复发15例（9．9％）。结论：ELRP是安全可行的,创伤小,术后恢复快。镜下吻合技术和控制出血是手术成功的关键。     

经腹膜外腹腔镜前列腺癌根治术（附7例报告）

目的：探讨经腹膜外腹腔镜前列腺癌根治术的手术方法和疗效.方法：对7例局限性前列腺癌患者实施经腹膜外前列腺癌根治术.结果：7例手术均成功完成,手术时间145～250 min,平均175 min.估计术中出血量200～600 ml,平均300 ml,其中3例患者输400 ml红细胞悬液,术中无腹膜破裂、直肠输尿管损伤、膀胱损伤等病例;术后病理均报告切缘阴性,无淋巴结转移,留置导尿14～23天,平均18.2天;术后1～3天肠道功能恢复,平均1.6天.术后发牛尿漏2例,6天后尿漏消失.随访3～10个月,平均6个月,术后拔除尿管出现轻度尿失禁3例（43%）,1周内完全恢复尿控率71.4%（5/7）,第1、3、6个月完全恢复控尿率分别为71.4%（5/7）、85.7%（6/7）、100%（7/7）,术后3个月检查血清PSA＜0.2 μg/L,随访期间末出现生化复发.结论：腹腔镜下腹膜外途径前列腺癌根治术创伤小、并发症少、恢复快,是局限性前列腺癌安全有效的外科治疗方法.     

Complete Periprostatic Anatomy Preservation During Robot-Assisted Laparoscopic Radical Prostatectomy (RALP): The New Pubovesical Complex-Sparing Technique

Background

Puboprostatic ligament preservation has been proposed as a method to accelerate continence recovery after radical prostatectomy (RP). However, these ligaments present anatomic continuity with the bladder, and there must be interruption at some point to expose the prostatourethral junction.

Objectives

To describe the surgical steps of pubovesical complex (PVC)–sparing robot-assisted laparoscopic RP (RALP) and present the preliminary results of our technique.

Design, setting, and participants

Thirty PVC-sparing RALP procedures were performed in patients <60 yr with clinically localised prostate cancer between 2007 and 2009 by the same surgeon.

Surgical procedure

The principles of bladder neck preservation, tension and energy-free dissection of the bundles as well as seminal vesicle sparing are applied. Ventrally, a plane of dissection is developed between the detrusor apron and the prostate. The soft connective tissue between Santorini's plexus and the prostate is blandly dissected, leaving the plexus intact and in place.

Measurements

The rates and location of positive surgical margins (PSM) as well as functional outcomes are presented.

Results and limitations

Three of 30 patients (10%) had a PSM (two apical margins and one on the left posterolateral side). At catheter removal, 24 of 30 patients (80%) were dry (0 pads), and 6 of 30 patients (20%) needed one security pad. After 3 mo, 22 of 30 patients (73%) presented an International Index of Erectile Function score >17 (with or without phosphodiesterase type 5 inhibitors). Thirteen of 22 potent patients had an Erection Hardness Score of 3, and 9 of 22 patients had a score of 4. Small sample size, low mean age of enrolled patients (52 yr), and the absence of diseases that could impair the continence and potency recovery are some of the limitations of the study. Moreover, it is difficult to quantify the effect of each applied continence-sparing technique.

Conclusions

The holistic preservation of the PVC during RALP is technically feasible. It leads towards an absolute preservation of the periprostatic anatomy that may enhance early functional outcomes. Further studies are needed to confirm our results.     

Current Status of Salvage Robot-Assisted Laparoscopic Prostatectomy for Radiorecurrent Prostate Cancer

Radiation therapy (RT) is one of the treatment options for prostate cancer (PCa). Transperineal low-dose rate brachytherapy (BT) is another safe and effective technique for low-risk PCa. Recurrence after RT for localized PCa can be defined by a PSA value of 2 ng/mL above the nadir after RT, and biochemical recurrence (BCR) rate after RT is 40-60 %. In case of radiorecurrent PCa, treatment options include salvage radical prostatectomy (RP), cryotherapy, high-intensity focused ultrasound (HIFU), and salvage BT. Only salvage RP has cancer control results for over 10-year follow-up in a substantial portion of patients (30-40 %). However, salvage RP is technically demanding, and experienced surgeons are needed; in fact, RT-induced cystitis, fibrosis, and tissue plane obliteration can lead to significant complications, such as rectal injuries, anastomotic stricture, and urinary incontinence. This review describes indications, oncologic and functional outcomes, surgical techniques, and complications of salvage robot-assisted RP.     

Comparing the Approach to Radical Prostatectomy Using the Multiport da Vinci Xi and da Vinci SP Robots: A Propensity Score Analysis of Perioperative Outcomes

BackgroundUse of the single-port da Vinci SP robotic platform for various urological procedures has been described by several groups. However, the comparative performance of the SP robot in relation to earlier models such as the da Vinci Xi is still unclear.ObjectiveTo compare intraoperative and short-term postoperative outcomes between the da Vinci Xi and SP robots for patients undergoing radical prostatectomy (RP) in a referral center.Design, setting, and participantsData were prospectively collected for patients undergoing RP from June 2019 to April 2020 in a single center. The da Vinci SP was used for 71 patients and the da Vinci Xi for 875 patients. After propensity score (PS) matching, two groups of 71 patients were selected for the comparative study.InterventionRP via a transperitoneal approach using the same technique steps and anatomy access with both robot consoles.Outcome measurements and statistical analysisA PS analysis was performed using the covariates age, body mass index, Charlson comorbidity index, Sexual Health Inventory for Men score, American Urological Association symptom score, prostate size, prostate-specific antigen levels, Gleason score, D’Amico risk group, and degree of nerve-sparing. Intraoperative performance and short-term functional (continence and potency) and oncological outcomes were compared between the groups.Results and limitationsMedian follow-up was 4.4 mo (interquartile range [IQR] 1.6–7.2) for the SP group and 3.2 mo (IQR 1.6–4.8) for the Xi group (p = 0.2). The median total operative time and median console time were both significantly higher in the SP group, with median differences of 14 min (95% confidence interval [CI] 9–19) and 5 min (95% CI 0–5), respectively. The proportion of patients with blood loss of >100 ml was significantly lower in the SP group (difference of 27%, 95% CI 12–42%). No intra- or postoperative complications were reported in either group. There were no significant differences in pain scores at 6, 12, and 18 h or in positive surgical margin rates between the groups. The SP group had a significantly higher percentage of extraprostatic extension than the Xi group (difference of 16%, 95% CI 4.6–27%). None of the patients experienced biochemical recurrence during follow-up. The difference in continence rates at 45 d between the SP and Xi groups was 11% (95% CI ?5.6% to 28%) and the difference in potency rates at 45 d was ?7.3% (95% CI ?21% to 6.2%). The short-term follow-up for comparison of functional and oncological outcomes is a limitation.ConclusionsDespite differences in trocar placement and technology between the two da Vinci consoles, the SP has satisfactory intraoperative performance compared to the Xi. SP surgery can be performed safely and effectively during the initial learning phase. However, longer-term follow-up is needed to provide further evidence on the impact of SP implementation on functional and oncological outcomes.Patient summaryWe compared intraoperative and short-term postoperative outcomes for patients who underwent radical prostatectomy using two different robots, the da Vinci Xi and the single-port da Vinci SP. We found that operative time was longer for the Single Port console. Studies with long-term follow-up are needed to compare the functional and oncological outcomes.     

腹膜外径路腹腔镜前列腺癌根治术(附65例报告)

目的:探讨腹膜外径路腹腔镜PCa根治术的初步体会。方法:经腹膜外径路进行腹腔镜PCa根治术65例。结果:64例(98.5%)成功,手术时间100～440min,平均172min。出血量150～800ml,平均340ml,7例(10.8%)患者输红细胞悬液2～4U。1例术中发生直肠损伤,2例术后发生尿外渗。6例(9.2%)患者术后病理提示切缘阳性。58例(89.2%)患者术后3个月尿控良好。结论:腹膜外径路腹腔镜PCa根治术是安全、可行的。且因避免了术中、术后对腹腔内肠管的干扰,降低了手术并发症,利于术后患者的恢复,值得在临床推广应用。     

Oncologic Outcome after Extraperitoneal Laparoscopic Radical Prostatectomy: Midterm Follow-up of 1115 Procedures

Background

Although the first laparoscopic radical prostatectomy was performed in 1997, few midterm oncologic data have been published for the extraperitoneal procedure.

Objective

To determine the oncologic outcome of extraperitoneal laparoscopic radical prostatectomy (ELRP).

Design, setting, and participants

From 2000 to 2007, 1115 consecutive patients underwent ELRP for a localized prostate cancer at our department. Follow-up was scheduled and standardized for all patients and recorded into a prospective database. Median postoperative follow-up was 35.6 mo.

Intervention

All ELRP were performed by three surgeons at the Department of Urology, Hospital Henri Mondor, Créteil, France.

Measurements

Biochemical recurrence was defined by prostate-specific antigen level ≥0.2 ng/ml.

Results and limitations

In pN0/pNx cancers, postoperative stage was pT2 in 664 patients (59.5%), pT3 in 350 patients (31.4%), and pT4 in 77 patients (6.9%). Positive lymph nodes were reported in 24 patients (2.2%). Margins were positive in 16.1% and 34.6% of pT2 and pT3 cancers, respectively. Final Gleason score was <7 in 288 men (25.8%), =7 in 701 men (62.9%), and >7 in 126 men (11.3%). Overall prostate-specific antigen (PSA) recurrence-free survival was 83% at 5 yr. The 5-yr progression-free survival rates were 93.4% for pT2, 74.5% for pT3a, and 55.0% for pT3b tumors, respectively. Multivariate Cox model showed that PSA, Gleason score, pT category, nodal status, and surgical margins were significant independent predictors of biochemical recurrence-free survival.

Conclusions

This assessment of oncologic results demonstrates that ELRP is a safe and effective procedure. On the basis of midterm follow-up data, the prognostic factors of PSA after ELRP failure are the same as those described previously in transperitoneal or open retropubic approaches. The oncologic results of ELRP also are in line with those reported with the use of the retropubic or the transperitoneal laparoscopic approaches.     

Quality of Evidence to Compare Outcomes of Open and Robot-Assisted Laparoscopic Prostatectomy

Robot-assisted laparoscopic radical prostatectomy (RALP) has gained widespread acceptance in the treatment of prostate cancer. While it increasingly is becoming the surgical approach of choice in many centers, limited data exist directly comparing it to radical retropubic prostatectomy (RRP). This review examines the evidence comparing RALP to RRP. The outcomes evaluated are arranged into perioperative, oncologic, and functional outcomes. Of the 21 publications meeting our selection criteria, Level II, III, and IV evidence were found in 9, 1, and 11 articles, respectively. Overall, RALP was associated with lower blood loss, transfusion rates, length of stay, and higher cost when compared to RRP. Definitive conclusions regarding complications and oncologic and functional outcomes are not yet possible, and will require longer-term follow-up and well-designed randomized controlled trials.