完全腹腔镜根治性膀胱切除加体内改良回肠通道术的学习效果分析

目的分析术者对完全腹腔镜根治性膀胱切除(LRC)+改良回肠通道术(MIC)的学习效果。方法回顾性分析首都医科大学附属北京朝阳医院2014年4月至2019年10月42例接受完全LRC+MIC患者的临床资料。男34例,女8例;年龄(63.4±9.1)岁。其中术者1行34例手术,术者2行8例。将术者1的34例按时间顺序分为3组,第1~12例为A组,第13~23例为B组,第24~34例为C组;术者2实施的8例为D组。4组中有腹部手术史者分别为0、1、4、3例,差异有统计学意义(P<0.05);4组年龄、体质指数、美国麻醉医师协会评分等差异均无统计学意义(P>0.05)。改良术式的重要步骤包括光源透射下离断肠系膜、输出袢固定的条件下行输尿管-输出袢反流性对端吻合、缝合后腹膜缺口。比较各组患者手术时间、构建回肠通道时间、出血量、并发症发生比例、淋巴结清扫数量、切缘阳性比例等重要手术指标。结果各组手术均顺利完成,均无中转开放手术。A~C组手术时间分别为330.0(320.0,360.0)、300.0(250.0,308.0)、270.0(216.0,324.0)min,差异有统计学意义(P=0.010);3组构建回肠通道时间分别为136.5(131.3,147.5)、92.0(79.0,119.0)、79.0(72.0,115.0)min,差异有统计学意义(P<0.001)。手术时间和构建回肠通道时间组间两两比较,A、B组,A、C组差异均有统计学意义(P<0.05),B、C组差异无统计学意义(P>0.05)。3组出血量200.0(125.0,300.0)、100.0(100.0,150.0)、200.0(100.0,400.0)ml]、并发症发生比例4/12、4/11、3/11]、淋巴结清扫数量(19.0±10.7)、(16.0±9.8)、(23.3±8.5)枚]、切缘阳性比例(1/12、1/11、2/11)的比较,差异均无统计学意义(P>0.05)。D组手术时间420.0(350.0,450.0)min,与A组比较差异有统计学意义(P<0.05)。D组出血量200.0(112.5,350.0)ml,并发症发生比例2/8,淋巴结清扫数量(13.8±7.1)个,切缘阳性比例1/8,与A组比较差异均无统计学意义(P>0.05)。结论完全LRC+MIC学习效果明显,随着手术例数的增加,手术时间及构建回肠通道时间显著下降;该术式具有较好的可重复性和安全性。

The learning effect of modified ileal conduit intracorporeally accomplished following laparoscopic radical cystectomy

Objective To analyze the learning effect of laparoscopic radical cystectomy(LRC)+modified ileal conduit(MIC).Methods From 2014 to 2019,42 patients underwent MIC and their clinical data was retrospectively analyzed.34 operations were performed by surgeon 1 and 8 operations by surgeon 2.We divided the 34 patients of surgeon 1 into three groups according to their surgical sequence(group A,1st to 12th;group B,13th to 23th;group C,24 th to 34 th),the 8 cases of surgeon 2 was regarded as group D.The history of abdomen surgery in the 4 groups were 0,1,4,3 cases,respectively(P<0.05).There was no significant difference of the other baseline characteristics,such as age,BMI,American Society of Anesthesiologists.Then we compared several variables between the 4 groups like operation time,time of ileal conduit construction,blood loss,complication rate,lymph node yield,surgical margin,etc.The key steps of the MIC included isolating terminal ileum when the mesentery was transilluminated,performing end-to-end reflux ureterointestinal anastomosis after the efferent loop was fixed,closing the rent of the retroperitoneum.Results All operations were performed intracorporeally with no transition to open surgery.The operative time for group A,B,C were 330.0(320.0,360.0)min,300.0(250.0,308.0)min,270.0(216.0,324.0)min,respectively(P=0.010).The time of ileal conduit construction of the 3 groups were 136.5(131.3,147.5)min,92.0(79.0,119.0)min,79.0(72.0,115.0)min,respectively(P<0.001).In addition,the difference of the two variables above between A and B,A and C groups separately reached statistical significance(P<0.05),while the difference between B and C groups did not(P>0.05).Other variables,such as blood loss,complication rate,lymph node yield,surgical margin,between the 3 groups reached no statistical significance(P>0.05).The operative time of group D was 420.0(350.0,450.0)min,and it reached statistical significance(P<0.05)when compared with group A.There were no significant differences in other variables,such as blood loss,complication rate,lymph node yield,surgical margin,among the 2 groups(P>0.05).Conclusions The learning effect of LRC+MIC was obvious.When surgeon volume increased,the operative time decreased significantly.Variables like estimated blood loss and complication rate of the 2 surgeons did not reached significant difference,which indicated reproductivity and safety of this procedure.