Contemporary techniques and outcomes of robotic assisted radical cystectomy with intracorporeal urinary diversion

The open approach to radical cystectomy continues to be accompanied by significant morbidity despite enhanced recovery protocols (ERP). Robotic assisted radical cystectomy (RARC) with intracorporeal urinary diversion (ICUD) has become an increasingly popular technique for removal of aggressive bladder cancer and subsequent urinary diversion. Randomized clinical trials comparing the robotic and open techniques address the uncertainty surrounding oncological efficacy of the RARC and show that RARC is at least comparable to open radical cystectomy (ORC) in terms of oncologic adequacy and survival. Although RARC with ICUD is a technically challenging procedure, surgeons have noted ergonomic advantages while patients experience less blood loss and quicker time to recovery and to adjuvant chemotherapy (AC), if necessary. Even with these benefits, there is a paucity of data describing outcomes of ICUD. For those surgeons who have switched to ICUD, priority remains standardization of a protocol for the reconstructive component and for a safe transition from extracorporeal urinary diversion (ECUD) to ICUD. Additionally, there is a need for evidence of reduced financial toxicity for the patient, as well as more comprehensive cost-effectiveness analyses. The literature from this review represents 10 years of accumulating data on techniques and outcomes of RARC with ICUD.     

Totally intracorporeal robot‐assisted radical cystectomy: optimizing total outcomes

We performed a systematic literature review to assess the current status of a totally intracorporeal robot‐assisted radical cystectomy (RARC) approach. The current ‘gold standard’ for radical cystectomy remains open radical cystectomy. RARC has lagged behind robot‐assisted prostatectomy in terms of adoption and perceived patient benefit, but there are indications that this is now changing. There have been several recently published large series of RARC, both with extracorporeal and with intracorporeal urinary diversions. The present review focuses on the totally intracorporeal approach. Radical cystectomy is complex surgery with several important outcome measures, including oncological and functional outcomes, complication rates, patient recovery and cost implications. We aim to answer the question of whether there are advantages to a totally intracorporeal robotic approach or whether we are simply making an already complex procedure more challenging with an associated increase in complication rates. We review the current status of both oncological and functional outcomes of totally intracorporeal RARC compared with standard RARC with extraperitoneal urinary diversion and with open radical cystectomy, and assess the associated short‐ and long‐term complication rates. We also review aspects in training and research that have affected the uptake of RARC. Additionally we evaluate how current technology is contributing to the future development of this surgical technique.     

腹腔镜和开放手术膀胱癌根治术疗效比较的Meta分析简

目的 利用Meta分析的方法,评价腹腔镜膀胱癌根治术（LRC）与开放性膀胱癌根治术（ORC）两种手术方式治疗浸润性膀胱癌的疗效。 方法 选取发表于中国核心期刊及PubMed上的1990-2012年的文献,对比LRC与ORC两种术式治疗浸润性膀胱癌的临床对照试验,并应用Meta分析评价手术所需时间、手术过程中出血量、手术过程中输血情况、术后胃肠道恢复情况、术后患者住院时间、术后并发症、切缘阳性率、膀胱容量、膀胱内压、残余尿等相关指标。结果 本篇Meta分析6篇临床同期对照试验。共纳入了597例患者,其中行LRC 336例患者,行ORC 261例患者。LRC手术所需时间（WMD 34.87 min,95%CI 25.94～43.79 min,P＜0.000 01）长于开放手术,而LRC手术过程中出血量（WMD -506.61 mL,95%CI-571.13～-442.09 mL,P＜0.000 01）、术中输血几率（OR 0.20,95% CI 0.11～0.38,P＜0.000 01）均小于ORC,术后胃肠道恢复时间（WMD -2.12 d,95% CI-2.20～ -2.03 d,P＜0.000 01）、术后患者住院时间（WMD -4.99 d,95% CI-5.79～-4.19 d,P＜0.000 01）、术后并发症发生率（OR 0.30,95% CI 0.18～0.48,P＜0.000 01）均少于ORC。LRC术后手术切缘阳性率、新膀胱的膀胱容量、膀胱内压、残余尿与ORC组均无统计学差异。 结论 对于浸润性膀胱癌,LRC的手术时间长于ORC,但在减少术中出血量、缩短术后肠道功能恢复时间及术后住院时间、降低并发症发生率方面更优越。而腹腔镜与ORC的手术切缘阳性率及新膀胱功能相似。     

Perioperative outcomes and complications of intracorporeal vs extracorporeal urinary diversion after robot-assisted radical cystectomy for bladder cancer: a real-life,multi-institutional french study

Purpose

To compare perioperative outcomes and complications of extracorporeal (ECUD) vs intracorporeal urinary diversion (ICUD) in patients after undergoing robot-assisted radical cystectomy (RARC) at five referral centers in France.

Methods

We retrospectively reviewed our multi-institutional, prospectively-collected database to select patients undergoing RARC between 2010 and 2016 with at least 3 months of follow-up. At each center, the surgery was performed by one surgeon with extensive experience in robotic surgery and radical cystectomy but no prior experience in RARC.

Results

Overall, 108 patients were included. ECUD and ICUD were performed in 34 (31.5%) and 74 (68.5%) patients, respectively. Patient characteristics were comparable among the two groups, except for a higher proportion of patients with high surgical risk (ASA score?≥?3) in the ECUD group. Ileal conduit and ileal neobladder were performed in 63/108 (58%) and 45/108 (42%) cases, respectively. Ileal conduit was performed more often with an extracorporeal approach while ileal neobladder with an intracorporeal approach. Overall, operative time, length of hospital stay, positive margin rate, and number of lymph nodes removed did not significantly differ among the two cohorts. Estimated blood loss and transfusion rates were significantly higher in the ECUD group. Rate of early (38.2 vs 47.3%, p?=?0.4) and late (29.4 vs 18.9%, p?=?0.2) surgical complications did not significantly differ between the ECUD and ICUD groups. Results were comparable in the subgroup analysis in the ileal conduit subpopulation.

Conclusion

In our real-life, multi-institutional study, RARC with ICUD achieved perioperative outcomes and complication rates comparable to those of RARC with ECUD.

     

加速康复外科理念在机器人辅助全腔内STAPLER法根治性膀胱切除术中的初步应用

目的探讨应用加速康复外科(ERAS)理念行机器人辅助全腔内STAPLER法根治性膀胱切除术的初步应用效果和安全性。方法回顾性分析浙江省人民医院2014年10月至2019年4月收治的71例膀胱浸润性尿路上皮癌患者的病例资料,男59例,女12例。年龄(65.2±5.6)岁。体质指数(22.18±3.75)kg/m^2。中位年龄矫正Charlson合并症指数(aCCI)为4。中位美国麻醉医师协会(ASA)评分2分。所有患者术前完善肺部X线片、血管超声(颈内静脉等)、腹部超声、尿路增强CT,以及膀胱镜活检或诊断性膀胱电切等检查,确诊为浸润性膀胱尿路上皮癌,无全身脏器转移证据。术前均无外放疗和静脉化疗史,腹部无传统开放手术史。71例均行完全机器人辅助STAPLER法根治性膀胱切除术+标准盆腔淋巴结清扫术+原位回肠U形新膀胱。以ERAS理念的引入时间为分组依据,其中2016年10月至2019年4月34例围手术期采用ERAS处理方案(ERAS组),重点增加营养风险筛查评估及处理、血栓风险评估及防治、疼痛评估及处理、围手术期饮食管理等ERAS策略。男30例,女4例。年龄(64.5±4.3)岁。体质指数(21.87±4.85)kg/m2。中位aCCI为4。中位ASA评分2分。选择2014年10月至2016年9月37例围手术期采用传统处理方案的患者为对照组。男29例,女8例。年龄(65.3±5.7)岁。体质指数(23.66±3.47)kg/m2。中位aCCI为4。中位ASA评分为2分。两组患者的一般资料比较差异均无统计学意义(P>0.05)。记录两组围手术期资料及术后随访情况。结果两组手术均顺利完成,术后均随访3~51个月。ERAS组根治术后病理分期为pT2期22例,pT3期12例;合并前列腺偶发癌2例。对照组根治术后病理分期为pT2期25例,pT3期12例;合并前列腺偶发癌1例。ERAS组和对照组术后首次排气时间[(20.5±18.7)h与(29.9±17.4)h,P=0.032]、首次排便时间[(72.6±27.1)h与(88.7±35.8)h,P=0.004]、术后住院时间[(14.1±3.3)d与(16.2±4.8)d,P=0.037],以及术后8.0、24.0、48.0 h疼痛数字评分(NRS)[(3.2±0.5)分与(3.6±0.8)分,P=0.015;(1.9±0.3)分与(2.2±0.6)分,P=0.011;(1.3±0.4)分与(1.6±0.7)分,P=0.032]差异均有统计学意义。ERAS组和对照组的手术时间[(290±65)min与(282±46)min,P=0.549]、术中失血量[(190.5±235.6)ml与(221.1±250.3)ml,P=0.438]、围手术期输血率[5.9%(2/34)与8.1%(3/37),P=0.922]、术后30 d再入院率[2.9%(1/34)与5.4%(2/37),P=0.940]、术后0.5 h疼痛NRS评分[(2.5±0.6)分与(2.7±0.7)分,P=0.241]、术后早期(≤30 d)严重并发症发生率[2.9%(1/34)与2.7%(1/37),P=0.940]、术后晚期(>30 d)严重并发症发生率[5.9%(2/34)与8.1%(3/37),P=0.922]等差异均无统计学意义(P>0.05)。结论应用ERAS理念行机器人辅助全腔内STAPLER法根治性膀胱切除术安全、有效,降低了术后疼痛反应,肠道功能恢复更快,不增加术后主要并发症,缩短了术后住院时间,可促进患者早日康复。     

Robotic assisted radical cystectomy versus open radical cystectomy: a review of what we do and don’t know

Radical cystectomy (RC) is the gold standard treatment for muscle-invasive and high-risk, noninvasive bladder cancer. Since 2003, robot-assisted radical cystectomy (RARC) has been gaining popularity. Metanalyses show that the primary advantage of RARC is less blood loss and the primary advantage of open radical cystectomy (ORC) is shorter operative times. There do not appear to be significant differences in complications, cancer-related outcomes or survival between the two approaches. Cost analyses comparing RARC and ORC are complicated by the often-ill-defined distinction between the cost to the hospital versus the cost to payors. However, it is likely that for both hospitals and payors, RARC is cost effective at high-volume centers. It is feasible that in the future, increased experience with RARC will lead to improved outcomes and justify the use of RARC over ORC.     

Comparison of surgical stress response to laparoscopic and open radical cystectomy

Objectives  

To prospectively compare stress response to laparoscopic and open radical cystectomy by the measurement of humoral mediators and the incidence of systemic inflammatory response syndrome (SIRS).     

经腹腔途径与经腹膜外单孔途径RARP的临床疗效对比

目的:比较经腹腔途径机器人辅助腹腔镜根治性前列腺切除术(RARP)与经腹膜外单孔途径RARP的临床疗效。方法:回顾性分析四川省人民医院2019年7月至2020年6月采用RARP治疗的142例前列腺癌患者的病例资料,其中经腹腔途径(A组)82例,经腹膜外单孔途径(B组)60例。A组年龄70.0(65.6~78.0)岁;既...