Robotic-assisted laparoscopy in gynecological surgery.

BACKGROUND: Laparoscopic surgery has revolutionized the concept of minimally invasive surgery for the last 3 decades. Robotic-assisted surgery is one of the latest innovations in the field of minimally invasive surgery. Already, many procedures have been performed in urology, cardiac surgery, and general surgery. In this article, we attempt to report our preliminary experience with robotic-assisted laparoscopy in a variety of gynecological surgeries. We sought to evaluate the role of robotic-assisted laparoscopy in gynecological surgeries. METHODS: The study was a case series of 15 patients who underwent various gynecologic surgeries for combined laparoscopic and robotic-assisted laparoscopic surgery. The da Vinci robot was used in each case at a tertiary referral center for laparoscopic gynecologic surgery. An umbilicus, suprapubic, and 2 lateral ports were inserted. These surgeries were performed both using laparoscopic and robotic-assisted laparoscopic techniques. The assembly and disassembly time to switch from laparoscopy to robotic-assisted surgery was measured. Subjective advantages and disadvantages of using robotic-assisted laparoscopy in gynecological surgeries were evaluated. RESULTS: Fifteen patients underwent a variety of gynecologic surgeries, such as myomectomies, treatment of endometriosis, total and supracervical hysterectomy, ovarian cystectomy, sacral colpopexy, and Moskowitz procedure. The assembly time to switch from laparoscopy to robotic-assisted surgery was 18.9 minutes (range, 14 to 27), and the disassembly time was 2.1 minutes (range, 1 to 3). Robotic-assisted laparoscopy acts as a bridge between laparoscopy and laparotomy but has the disadvantage of being costly and bulky. CONCLUSION: Robotic-assisted laparoscopic surgeries have advantages in providing a 3-dimensional visualization of the operative field, decreasing fatigue and tension tremor of the surgeon, and added wrist motion for improved dexterity and greater surgical precision. The disadvantages include enormous cost and added operating time for assembly and disassembly and the bulkiness of the equipment.     

Robotic-assisted laparoscopic radical cystoprostatectomy

OBJECTIVES: Recent small case series have been reported for robotic-assisted laparoscopic radical cystoprostatectomy. The present literature includes 34 patients who have undergone robotic-assisted cystectomy procedures. We report our initial experience with robotic-assisted laparoscopic radical cystoprostatectomy, describing stepwise the surgical procedure and evaluating perioperative and pathologic outcomes of this novel procedure. METHODS: Twenty men underwent robotic-assisted laparoscopic radical cystoprostatectomy and extracorporeal urinary diversion for clinically localized bladder cancer. The stepwise operative procedure is described in detail. Outcome measures evaluated included operative variables, hospital recovery, pathologic outcomes, and complication rate. Comparisons were made to these gender-matched 24 men who underwent an open procedure during this same period. RESULTS: Mean age was 62.3 yr (range: 54-76 yr). Ten patients underwent ileal conduit diversion and 10 patients underwent an orthotopic neobladder. In all cases the urinary diversion was performed extracorporeally. Mean operating room time of all patients was 6.1h (most recent 10 cases, 5.2h). Mean surgical blood loss was 313 ml. On surgical pathology, 14 patients were < or =pT2, 4 patients pT3, and 2 patients N+. In no case was there inadvertent entry into the bladder or positive surgical margins. Mean number of lymph nodes removed was 19 (range: 6-29). Mean time to flatus was 2.1 d and bowel movement 2.8 d. Sixteen patients were discharged on postoperative day (POD) 4, three patients on POD 5, and one on POD 8. There were six postoperative complications (30%) in five patients. CONCLUSIONS: Our initial experience with robotic-assisted laparoscopic radical cystoprostatectomy appears to be favorable with acceptable operative, pathologic, and short-term clinical outcomes. As our experience increases, we should expect to continue to refine our surgical technique and reduce operating room times. Larger experiences are required to adequately evaluate and validate this procedure as an appropriate surgical and oncologic option for the bladder cancer patient.     

妇科恶性肿瘤化疗患者癌因性疲乏的影响因素及路径分析

目的 探索影响妇科恶性肿瘤化疗患者癌因性疲乏的因素,并分析心理社会因素对其的作用路径。方法 采用便利抽样法,运用一般资料调查表、心理复原力量表、社会支持评定量表和多维疲劳量表对185例妇科恶性肿瘤化疗患者进行问卷调查。利用SPSS22.0软件及PROCESS3.3插件对数据进行统计分析。结果 患者的癌因性疲乏总分为（35.44±14.40）分,中、重度疲乏者分别占57.84%和11.35%。多元线性回归分析结果显示,心理复原力、每日步数、疼痛、支持利用度和有无商业保险是妇科恶性肿瘤化疗患者癌因性疲乏的独立影响因素（均P＜0.05）。中介效应检验显示,支持利用度的中介效应为-0.055,中介效应占总效应的15.03%。结论 妇科恶性肿瘤化疗患者癌因性疲乏发生率高,医护人员应对可控的影响因素（如疼痛、运动）制订针对性干预措施帮助患者缓解疲乏。且由于支持利用度在心理复原力对癌因性疲乏的影响中起部分中介作用,可通过提高患者支持利用度作为癌因性疲乏防治的突破口。     

机器人胃癌根治术

Troca采用“W型”5孔法布局。探查完毕后,辅助臂提起横结肠系膜,助手于对侧牵拉横结肠,超声刀沿横结肠切断大网膜,分离横结肠系膜前叶,清扫N0.4淋巴结。接着剥离胰腺前背膜,游离部分脾静脉,根部切断胃网膜左动、静脉及两支胃短血管。解剖胃结肠静脉干及胃网膜右血管,根部切断胃网膜右动、静脉,清扫N0.6淋巴结。沿肝脏侧切开肝胃韧带,幽门上方清扫N0.5淋巴结。辅助臂提起胃,清扫N0.8,9淋巴结,根部结扎并切断胃左动脉、静脉,清扫N0.7淋巴结。向上切除肝胃韧带并游离至贲门部,清扫N0.1,3淋巴结,左侧切断脾胃韧带。幽门下2cm处用切割闭合器横断十二指肠。     

Limb-preserving radical surgery for malignant bone tumors

There is no proven evidence that ablative surgery is superior to radical local surgery of bone tumors in the process of survival. When locally radical bone tumor resection is anatomically possible, such a procedure is advantageous. Skip lesions are extremely rare and can be detected at present by refined methods of diagnosis; thus, they do not interfere with the principle of local bone tumor surgery. Replacement of the skeletal defect obtained can be managed by specialized surgical methods. Massive autologous and/or homologous bone grafting is often a useful technique. For replacement of large defects, custom-made endoprostheses serve a useful purpose regarding limb function. Resection of the total shoulder girdle can be performed without sacrificing normal hand function. A corresponding resection of the hip area, including the acetabular ring, can save a lower extremity having a good or acceptable function. Differentiated bone tumor surgery also calls for differentiated rehabilitative measures.     

Robotic-assisted laparoscopic radical prostatectomy after aborted retropubic radical prostatectomy

Robotic-assisted laparoscopic prostatectomy (RALP) has surged in popularity since US Food and Drug Administration approval in 2000. Advantages include improved visualization and increased instrument dexterity within the pelvis. Obesity and narrow pelves have been associated with increased difficulty during open retropubic radical prostatectomy (RRP), but the robotic platform theoretically allows one to perform a radical prostatectomy despite these challenges. We present an example of a RALP performed following an aborted RRP. A 49-year-old male with intermediate risk prostate cancer and body mass index of 38 kg/m² presented for RALP after RRP was aborted by an experienced open surgeon following incision of the endopelvic fascia due to poor visualization, a prominent pubic tubercle, and a narrow pelvis. The enhanced visualization and precision of the robotic platform allowed adequate exposure of the prostate and allowed us to proceed with an uncomplicated prostatectomy, which was not possible to perform easily via an open approach. The bladder was densely adherent to the pubis and the anterior prostatic contour and apex were difficult to develop due to a dense fibrotic reaction from the previous endopelvic fascia incision. However, we were able to successfully complete RALP with subtle technical modifications. Estimated blood loss was 160 mL and operating time was 145 min. The patient’s pathology was significant for a positive peri-prostatic lymph node and he has been referred to radiation oncology for adjuvant radiotherapy and androgen deprivation therapy. At 3 months follow-up he had a prostate-specific antigen level of 0.06 ng/mL, partial erections, and mild urinary incontinence requiring one pad per day. Superior intracorporeal laparoscopic visualization and improved instrument dexterity afforded by the robotic surgical platform may make RALP the preferred approach in obese men or men with difficult pelvic anatomy who are deemed poor RRP candidates.     

Robotic-assisted radical cystectomy is associated with lower perioperative mortality in octogenarians

ObjectivesTo compare perioperative outcomes between robotic and open radical cystectomy in octogenarians using real-world dataSubjects and methodsUsing the Premier Healthcare Database, we found 13,127 patients who underwent robotic-assisted radical cystectomy (RARC) between 2008 and 2017, of which 15.1% were ≥80 years old. Perioperative mortality was the primary outcome of interest. Secondary outcomes include complications, hospital length of stay, readmission rates, and disposition after discharge. Multivariable regression analysis was used to adjust for patient and hospital characteristics.ResultsIn octogenarians, mortality at the index admission was 2.2% in those who underwent RARC, compared to 4.6% in those who underwent open surgery (P = 0.027). On multivariable analysis, robotic surgery was associated with lower in-hospital mortality in octogenarians (OR 0.46, 95% CI 0.22–0.99, P = 0.047) even after controlling for patient, and hospital characteristics.ConclusionRARC is safe and feasible in octogenarians. Elderly patients may derive more benefit from minimally invasive radical cystectomy compared to a younger cohort.     

术后化疗对妇科恶性肿瘤患者骨密度及骨代谢的影响

目的 观察术后化疗对切除卵巢后的妇科恶性肿瘤患者骨密度及骨代谢的影响,并探讨其可能的影响机理。方法 两组观察对象,肿瘤组20例,术后行PC方案化疗,连续6个疗程,每次间隔4周;对照组与肿瘤组年龄匹配,因良性病变切除卵巢,两组在研究期间均无激素应用。术前及术后6个月采用双能X线骨密度仪对腰椎(L2-L4)及髋部进行骨密度的测定,同时测定血清雌二醇(E2),卵泡刺激素(FSH),黄体生成素(LH),骨钙素(BGP),尿钙/肌酐(ca/Cre),对检测结果进行分析。结果 化疗组腰椎骨密度在治疗后下降22.9％±8.4％,髋骨的骨密度下降12.6％±6.39％,对照组腰椎骨密度下降8.86％±2.87％,髋骨骨密度下降6.12％±2.38％,两组比较差异有显著性P<0.01;E2水平在治疗后下降明显,FSH、LH均在治疗后明显升高,组间无差异;反映骨代谢的指标BGP、Ca/Cre均升高,组间差异无显著性。结论 术后化疗可加重妇科恶性肿瘤患者切除卵巢后的骨质丢失,提示化疗药物(PC)对骨质代谢存在直接的不良影响。     

DTIC therapy in patients with malignant intra-abdominal neuroendocrine tumors

Malignant intra-abdominal neuroendocrine tumors are rare; consequently, a standard chemotherapeutic protocol for patients with unresectable disease has not been established. This prompted a review of our experience with dimethyltriazeno imidazole carboxamide (dacarbazine) (DTIC) treatment for these tumors. From 1976 to 1986, 14 patients were treated with DTIC for metastatic neuroendocrine tumors. There were seven men and seven women whose ages ranged from 19 to 76 years. Diagnoses included eight nonfunctioning islet-cell carcinomas, three retroperitoneal neuroendocrine tumors, two glucagonomas, and one ileal carcinoid. Before DTIC chemotherapy, four patients were treated with streptozotocin and 5-FU, and one was treated with cytoxan and methotrexate without response. Two patients who were initially treated with DTIC with no response were subsequently treated with streptozotocin and 5-FU without benefit. Standard treatment with DTIC consisted of monthly cycles of 250 mg/m2/day administered intravenously for 5 days. Seven patients had an objective response to DTIC with both improvement in quality of life and a decrease of more than 50% in tumor size on computerized tomography (CT) or liver scanning. Response duration ranged from 1 to 10 years. One patient with a glucagonoma was treated for two years and had no evidence of disease at laparotomy 7 years later. Four patients with nonfunctioning islet cell carcinoma had a positive response to DTIC, but three of these patients had tumor recurrence 3 to 6 years after treatment. Two patients with retroperitoneal neuroendocrine tumors had a positive response to DTIC treatment. One patient with a glucagonoma and one with a nonfunctioning islet-cell tumor had equivocal responses with transient clinical improvement but no objective changes in tumor size. Five patients did not respond; two were given DTIC therapy as a last resort and died 1 and 12 days later. Of the other three patients, two died 6 months and one 2 years after treatment. DTIC chemotherapy was effective in 50% of patients with intra-abdominal neuroendocrine tumors. Although DTIC therapy was associated with nausea, no major gastrointestinal, hematologic, or renal complications were noted. This favorable experience with DTIC chemotherapy for nonresectable intra-abdominal neuroendocrine tumors indicates that further clinical evaluation and use are warranted.     

X线引导下置入肠梗阻导管治疗妇科恶性肿瘤所致恶性肠梗阻

目的 观察X线引导下置入肠梗阻导管治疗妇科恶性肿瘤所致恶性肠梗阻（MBO）效果。方法 回顾性分析60例妇科恶性肿瘤术后小肠MBO患者资料,其中30例接受X线引导下肠梗阻导管置入（A组）、30例接受传统鼻胃管置入（B组）,之后均接受持续胃肠减压。对比2组MBO症状缓解情况、排气排便时间及治疗后饮食恢复情况,记录24 h平均引流量、导管留置时间及有无治疗相关并发症,以及治疗后1年内生存情况。结果 对60例均成功置管。A组置管后排气排便、经口进食均早于,导管留置时间短于而24 h平均引流量大于B组（P均＜0.05）,组间肠梗阻症状缓解率差异无统计学意义（P=0.472）。治疗中A组8例出现鼻部轻微出血、4例口咽部不适,B组5例鼻部出血、5例口咽部不适,均未经特殊处理后自行缓解;组间治疗相关并发症差异无统计学意义（P=0.361）。治疗后1年,2组均有28例完成随访、失访2例,A组生存率［25.00%（7/28）］与B组［17.86%（5/28）］差异无统计学意义（P=0.745）。结论 X线引导下置入肠梗阻导管治疗妇科恶性肿瘤所致MBO安全、有效。     

Robotic-assisted laparoscopic radical cystectomy with extracorporeal urinary diversion: initial experience

BACKGROUND: The use of robotic technology for laparoscopic prostatectomy is now well established. The same cannot yet be said of robotic-assisted laparoscopic radical cystectomy (RARC), which is performed in just a few centres worldwide. OBJECTIVE: We present our technique and experience of this procedure using the da Vinci surgical system. DESIGN, SETTING, AND PARTICIPANTS: From 2004 to 2007, 23 patients underwent RARC and urinary diversion at our institution. SURGICAL PROCEDURE: We report the development of our technique for RARC, which involves posterior dissection, lateral pedicle control, anterior dissection, and lymphadenectomy prior to either ileal conduit urinary diversion or Studer pouch reconstruction performed extracorporeally. MEASUREMENTS: Demographic and perioperative data were recorded prospectively. Oncologic and functional outcomes were assessed at 3- to 6-mo intervals. RESULTS AND LIMITATIONS: To date, 23 patients have undergone this procedure at our institution. Of those, 19 had ileal loop urinary diversion and 4 were suitable for Studer pouch reconstruction. Mean total operative time plus or minus (+/-) standard deviation (SD) was 397+/-83.8min. Mean blood loss +/-SD was 278+/-229ml with one patient requiring a blood transfusion. Surgical margins were clear in all patients with a median +/-SD of 16+/-8.9 lymph nodes retrieved. The complication rate was 26%. At a mean follow-up +/-SD of 17+/-13 (range 4-40) mo, one patient had died of metastatic disease and one other is alive with metastases. The remaining 21 patients are alive without recurrence. CONCLUSIONS: RARC remains a procedure in evolution in the small number of centres carrying out this type of surgery. Our initial experience confirms that it is feasible with acceptable morbidity and good short-term oncologic results.     

Secondary surgery in patients with malignant germ cell tumors.

A total of 102 men treated for germ cell tumor with chemotherapy containing cisplatin was referred for a secondary operation with signs of tumor in the retroperitoneum or chest. Of the patients 85 underwent laparotomy, 14 underwent thoracotomy and 3 had both operations. Residual tumors were completely resected in 66 patients and incompletely resected in 30, while no tumor was found in 6. The resected specimen was malignant in 18 patients, of whom 11 had complete removal of all malignant tissue. All patients with malignancy in the resected specimen received further chemotherapy. Long-term disease-free status was obtained in 75% of those patients who had a complete resection, compared with 14% in the group with incomplete resection. There was no evidence of malignant disease at operation in 78 patients but 5 of them later died of the disease. Malignant tissue was present in the residual tumor in only 1 of 15 patients whose primary tumor was seminoma alone. Resection was attempted in 14 patients despite abnormal tumor markers preoperatively. Only 5 of these patients achieved a disease-free status and 2 of them died later of malignant disease. Over-all 79 of the 102 patients are without evidence of disease (medium postoperative observation 23 1/2 months). We conclude that a secondary operation constitutes an important part of the treatment of patients with germ cell cancer.     

Robotic-assisted laparoscopic radical prostatectomy: the Frankfurt technique

The robotic technique, which was first introduced in laparoscopic heart surgery, has revolutionized laparoscopic surgery over the last 5 years. In May 2000, our department accomplished the first robot assisted laparoscopic radical prostatectomy. Since that time we have performed more than 118 such procedures and several other laparoscopic operations using the robotic technique. We here summarize our experience in robot assisted laparoscopic radical prostatectomy as it has been developed over the past 3 years. Between May 2000 and May 2003, 118 patients with clinically localized prostate cancer were operated using the telerobotic da Vinci Surgical System. Operations were performed with a senior surgeon at the console, assisted by an assistant and a nurse at the operating table. Bilateral pelvic lymph node dissection was undertaken as a first step in all patients. In the initial 60 cases, we investigated different laparoscopic approaches. We used transperitoneal as well as extraperitoneal approaches. For dissection of the prostate we used ascending, descending as well as combined techniques. The combined ascending and descending technique via the transperitoneal route was chosen in 30 patients, and via the extraperitoneal route in seven patients. A modification of the descending Montsouris technique was performed in 81 patients. The robot assisted laparoscopic radical prostatectomy with the da Vinci system has been well standardized. After performing more than 100 radical prostatectomies with this system, we conclude that in our hands the Mountsouris technique with only minor adoptions is the most appropriate technique for performing robot assisted radical prostatectomy.