单一术者连续118例腹腔镜膀胱癌根治术学习曲线分析
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摘要
目的:回顾性分析我院单一术者连续行腹腔镜膀胱癌根治术(LRC)患者的临床资料,评估学习曲线的影响。方法:我院2014年2月～2018年3月接受LRC患者118例,男98例,女20例;其中90例行回肠膀胱术,21例行输尿管皮肤造口术,7例行原位回肠新膀胱术。按时间顺序将病例分为3组(第1组第1～40例,第2组第41～80例,第3组第81～118例),比较3组的手术时间、术中出血等方面的差异。结果:3组患者平均手术时间为(295.59±56.59)min;平均术中出血为(353.64±163.19)ml。第1组、第2组和第3组的平均手术时间分别为(338.00±50.00)min、(283.50±50.55)min和(263.68±40.63)min,第1组与第2组比较差异有统计学意义(P<0.05),第2组与第3组比较差异无统计学意义(P>0.05)。第1组、第2组和第3组的平均出血量分别为(448.00±224.38)ml、(327.25±107.63)ml和(282.11±57.43)ml,术中出血量逐渐下降,而手术时间在40例后呈稳定趋势。结论:LRC治疗膀胱肿瘤是安全有效的,学习曲线相对陡峭。当达到40例手术的积累后,熟练程度明显提高。
Objective:To evaluate our experience and results of laparoscopic radical cystectomy(LRC)and assess the impact of learning curve on perioperative outcomes with LRC by a single-surgeon's experience in Peking Union Medical College Hospital.Method:Between February 2014 and March 2018,aprospective study in a single institute on patients with bladder cancer who underwent LRC was conducted.One hundred and eighteen patients(98 men and 20 women)underwent LRC during the 4-year study period.Ninety patients were submitted to ileal conduits,21 patients to ureterocutaneostomies,and 7 to neobladders.The patients were divided into 3 groups according to the time of operation.Operative parameters and perioperative complications were evaluated including operative time,blood loss and perioperative complications.Result:The mean operative time was(295.59±56.59)min,and the mean blood loss was(353.64±163.19)ml.The operative time was(338.00±50.00),(283.50±50.55)and(263.68±40.63)minutes,respectively,for each group.The intraoperative blood loss was(448.00±224.38),(327.25±107.63)and(282.11±57.43)ml,respectively,for each group.The intraoperative blood loss was gradually lowered from group one to group three.Significant decline of operative time occurred after every40 cases of LRC(P<0.05).Conclusion:LRC is a safe and efficient modality of treatment of bladder cancer.However,it comes with a steep learning curve.This report helps to define the learning curve for LRC and demonstrates an acceptable level of proficiency by the 40 th case.
Objective:To evaluate our experience and results of laparoscopic radical cystectomy(LRC)and assess the impact of learning curve on perioperative outcomes with LRC by a single-surgeon's experience in Peking Union Medical College Hospital.Method:Between February 2014 and March 2018,aprospective study in a single institute on patients with bladder cancer who underwent LRC was conducted.One hundred and eighteen patients(98 men and 20 women)underwent LRC during the 4-year study period.Ninety patients were submitted to ileal conduits,21 patients to ureterocutaneostomies,and 7 to neobladders.The patients were divided into 3 groups according to the time of operation.Operative parameters and perioperative complications were evaluated including operative time,blood loss and perioperative complications.Result:The mean operative time was(295.59±56.59)min,and the mean blood loss was(353.64±163.19)ml.The operative time was(338.00±50.00),(283.50±50.55)and(263.68±40.63)minutes,respectively,for each group.The intraoperative blood loss was(448.00±224.38),(327.25±107.63)and(282.11±57.43)ml,respectively,for each group.The intraoperative blood loss was gradually lowered from group one to group three.Significant decline of operative time occurred after every40 cases of LRC(P<0.05).Conclusion:LRC is a safe and efficient modality of treatment of bladder cancer.However,it comes with a steep learning curve.This report helps to define the learning curve for LRC and demonstrates an acceptable level of proficiency by the 40 th case.
引文
1 Takada N,Abe T,Shinohara N,et al.Peri-operative morbidity and mortality related to radical cystectomy:a multi-institutional retrospective study in Japan[J].BJU Int,2012,110(11Pt B):E756-E764.
2 章小平,黄新冕,王呈.机器人辅助技术在膀胱癌治疗中的应用和评价[J].临床泌尿外科杂志,2017,32(8):571-574.
3 杨小明,易成智,李帅,等.299例膀胱全切术后早期并发症及危险因素分析[J].临床泌尿外科杂志,2016,31(6):513-518.
4 Sim A,Balbay D,Todenh9fer T,et al.Robot-assisted radical cystectomy and intracorporeal urinary diversionsafe and reproducible?[J].Cent European J Urol,2015,68(1):18-23.
5 Challacombe B J,Bochner B H,Dasgupta P,et al.The role of laparoscopic and robotic cystectomy in the management of muscle-invasive bladder cancer with special emphasis on cancer control and complications[J].Eur Urol,2011,60(4):767-775.
6 Bochner B H,Dalbagni G,Marzouk K H,et al.Randomized Trial Comparing Open Radical Cystectomy and Robot-assisted Laparoscopic Radical Cystectomy:Oncologic Outcomes[J].Eur Urol,2018.
7 Di Pierro G B,Wirth J G,Ferrari M,et al.Impact of a Single-surgeon Learning Curve on Complications,Positioning Injuries,and Renal Function in Patients Undergoing Robot-assisted Radical Prostatectomy and Extended Pelvic Lymph Node Dissection[J].Urology,2014,84(5):1106-1011.
8 Juan H C,Yeh H C,Li C C,et al.Complications of laparoscopic radical prostatectomy-a single institute experience[J].Kaohsiung J Med Sci,2012,28(10):550-554.
9 Ou Y C,Yang C K,Chang K S,et al.The surgical learning curve for robotic-assisted laparoscopic radical prostatectomy:experience of a single surgeon with 500cases in Taiwan,China[J].Asian J Androl,2014,16(5):728-734.
10 马潞林,张帆,黄毅,等.学习曲线对腹腔镜下根治性前列腺切除术围手术期并发症的影响:单中心连续200例经验总结[J].中华泌尿外科杂志,2015,36(8):611-614.
11 Hayn M H,Hussain A,Mansour A M,et al.The learning curve of robot-assisted radical cystectomy:results from the International Robotic Cystectomy Consortium[J].Eur Urol,2010,58(2):197-202.
12 Guru K A,Perlmutter A E,Butt Z M,et al.The learning curve for robot-assisted radical cystectomy[J].JSLS,2009,13:509-514.
13 Aboumarzouk O M,Drewa T,Olejniczak P,et al.Laparoscopic radical cystectomy:a 5-year review of a single institutes operative data and complications and a systematic review of the literature[J].Int Braz J Urol,2012,38(3):330-340.
14 郑卫,吴鑫,张雷,等.腹腔镜膀胱全切手术:单中心60例学习曲线结果分析[J].北京大学学报(医学版),2012,44(4):558-562.
15 Touijer K,Kuroiwa K,Saranchuk J W,et al.Quality improvement in laparoscopic radical prostatectomy for pT2prostate cancer:impact of video documentation review on positive surgical margin[J].J Urol,2005,173(3):765-768.
16 Cathcart P,Sridhara A,Ramachandran N,et al.Achieving Quality Assurance of Prostate Cancer Surgery During Reorganisation of Cancer Services[J].Eur Urol,2015,68(1):22-29.
17 Pierorazio P M,Patel H D,Feng T,et al.Robotic-assisted Versus Traditional Laparoscopic Partial Nephrectomy:Comparison of Outcomes and Evaluation of Learning Curve[J],Urology,2011,78(4):813-819.
2 章小平,黄新冕,王呈.机器人辅助技术在膀胱癌治疗中的应用和评价[J].临床泌尿外科杂志,2017,32(8):571-574.
3 杨小明,易成智,李帅,等.299例膀胱全切术后早期并发症及危险因素分析[J].临床泌尿外科杂志,2016,31(6):513-518.
4 Sim A,Balbay D,Todenh9fer T,et al.Robot-assisted radical cystectomy and intracorporeal urinary diversionsafe and reproducible?[J].Cent European J Urol,2015,68(1):18-23.
5 Challacombe B J,Bochner B H,Dasgupta P,et al.The role of laparoscopic and robotic cystectomy in the management of muscle-invasive bladder cancer with special emphasis on cancer control and complications[J].Eur Urol,2011,60(4):767-775.
6 Bochner B H,Dalbagni G,Marzouk K H,et al.Randomized Trial Comparing Open Radical Cystectomy and Robot-assisted Laparoscopic Radical Cystectomy:Oncologic Outcomes[J].Eur Urol,2018.
7 Di Pierro G B,Wirth J G,Ferrari M,et al.Impact of a Single-surgeon Learning Curve on Complications,Positioning Injuries,and Renal Function in Patients Undergoing Robot-assisted Radical Prostatectomy and Extended Pelvic Lymph Node Dissection[J].Urology,2014,84(5):1106-1011.
8 Juan H C,Yeh H C,Li C C,et al.Complications of laparoscopic radical prostatectomy-a single institute experience[J].Kaohsiung J Med Sci,2012,28(10):550-554.
9 Ou Y C,Yang C K,Chang K S,et al.The surgical learning curve for robotic-assisted laparoscopic radical prostatectomy:experience of a single surgeon with 500cases in Taiwan,China[J].Asian J Androl,2014,16(5):728-734.
10 马潞林,张帆,黄毅,等.学习曲线对腹腔镜下根治性前列腺切除术围手术期并发症的影响:单中心连续200例经验总结[J].中华泌尿外科杂志,2015,36(8):611-614.
11 Hayn M H,Hussain A,Mansour A M,et al.The learning curve of robot-assisted radical cystectomy:results from the International Robotic Cystectomy Consortium[J].Eur Urol,2010,58(2):197-202.
12 Guru K A,Perlmutter A E,Butt Z M,et al.The learning curve for robot-assisted radical cystectomy[J].JSLS,2009,13:509-514.
13 Aboumarzouk O M,Drewa T,Olejniczak P,et al.Laparoscopic radical cystectomy:a 5-year review of a single institutes operative data and complications and a systematic review of the literature[J].Int Braz J Urol,2012,38(3):330-340.
14 郑卫,吴鑫,张雷,等.腹腔镜膀胱全切手术:单中心60例学习曲线结果分析[J].北京大学学报(医学版),2012,44(4):558-562.
15 Touijer K,Kuroiwa K,Saranchuk J W,et al.Quality improvement in laparoscopic radical prostatectomy for pT2prostate cancer:impact of video documentation review on positive surgical margin[J].J Urol,2005,173(3):765-768.
16 Cathcart P,Sridhara A,Ramachandran N,et al.Achieving Quality Assurance of Prostate Cancer Surgery During Reorganisation of Cancer Services[J].Eur Urol,2015,68(1):22-29.
17 Pierorazio P M,Patel H D,Feng T,et al.Robotic-assisted Versus Traditional Laparoscopic Partial Nephrectomy:Comparison of Outcomes and Evaluation of Learning Curve[J],Urology,2011,78(4):813-819.