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。     

腹腔镜全膀胱切除术临床分析(附10例报告)

目的:探讨腹腔镜下根治性全膀胱切除术的手术方法和临床体会。方法:我院于2008年7月～2010年12月对10例经病理证实为浸润性膀胱移行细胞癌患者行腹腔镜下根治性全膀胱切除术。其中男9例,女1例,年龄64～80岁,平均69岁。其中5例行原位回肠代膀胱术,5例行输尿管皮肤造口术,观察手术用时、术中出血量、术后肠道功能恢复时间、并发症及手术疗效。结果:手术用时170～290min,平均210min;术中出血150～950ml,平均250ml;术后肠道功能恢复约72h;术后未发生肠瘘及吻合口狭窄及尿瘘等严重并发症,无围手术期死亡,术后3个月IVU未见肾积水。结论:经腹腹腔镜全膀胱切除术安全可行,能明显减少手术创伤,术中出血少,术后恢复快、并发症少,随着器械的改进及技术熟练,该术式将成为全膀胱切除手术的一种很有前景的方法。     

Mid-term oncological control after laparoscopic radical cystectomy in men: a single-centre experience

Study Type – Therapy (case series) Level of Evidence 4

OBJECTIVE

? To assess the mid‐term (3 years of follow‐up) oncological control of laparoscopic radical cystectomy (LRC) for high‐grade muscle‐invasive bladder cancer in a well studied male population.

PATIENTS AND METHODS

? We assessed 40 men with bladder cancer (mean [range] age 66.5 [50–75] years) who underwent LRC and extended pelvic lymphadenectomy at our institution between April 2004 and September 2008. ? Of the 40 patients, 13 (32.5%) had a complete laparoscopic procedure (ileal conduit: seven patients; neobladder: five patients; bilateral ureterostomy: one patient) and 27 (67.5%) had an LRC procedure only (ileal conduit: 15 patients; neobladder: 12 patients).

RESULTS

? No major complications were observed intraoperatively. ? The mean operating time was 407 min and the mean blood loss was 720 mL. Four patients (10%) required conversion to open surgery. The mean (range) hospital stay was 10.2 (7–25) days. One patient died of myocardial infarction in the postoperative period. ? Pathological analysis showed organ‐confined tumours (stage pT0/pT1/pT2/pT3a) in 22 patients (55%) and extravesical disease (pT3/pT4) in 18 (45%). Of the 40 patients, six (15%) had lymph node involvement. The mean (range) number of nodes removed was 19.9 (5–40). ? At a mean (range) follow‐up period of 36 (0–72) months, 26 patients were alive with no evidence of disease (disease‐free survival rate 67%).

CONCLUSION

? Laparoscopic radical cystectomy is a safe, feasible, and effective alternative to open radical cystectomy (ORC). The 3‐year oncological efficacy was comparable with that of ORC.     

Surveillance guidelines based on recurrence patterns after radical cystectomy for bladder cancer: the Canadian Bladder Cancer Network experience

Study Type – Prognosis (cohort) Level of Evidence 2a What's known on the subject? and What does the study add? Radical cystectomy with pelvic lymph node dissection is recognized as the standard of care for carcinoma invading bladder muscle and for refractory non‐muscle‐invasive bladder cancer. Owing to high recurrence and progression rates, a two‐pronged strict surveillance regimen, consisting of both functional and oncological follow‐up, has been advocated. It is also well recognized that more aggressive tumours with extravesical disease and node‐positive disease recur more frequently and have worse outcomes. This study adds to the scant body of literature available regarding surveillance strategies after radical cystectomy for bladder cancer. In the absence of any solid evidence supporting the role of strict surveillance regimens, this extensive examination of recurrence patterns in a large multi‐institutional project lends further support to the continued use of risk‐stratified follow‐up and emphasizes the need for earlier strict surveillance in patients with extravesical and node‐positive disease.

OBJECTIVES

• ? To review our data on recurrence patterns after radical cystectomy (RC) for bladder cancer (BC).
• ? To establish appropriate surveillance protocols.

PATIENTS AND METHODS

• ? We collected and pooled data from a database of 2287 patients who had undergone RC for BC between 1998 and 2008 in eight different Canadian academic centres.
• ? Of the 2287 patients, 1890 had complete recurrence information and form the basis of the present study.

RESULTS

• ? A total of 825 patients (43.6%) developed recurrence.
• ? According to location, 48.6% of recurrent tumours were distant, 25.2% pelvic, 14.5% retroperitoneal and 11.8% to multiple regions such as pelvic and retroperitoneal or pelvic and distant.
• ? The median (range) time to recurrence for the entire population was 10.1 (1–192) months with 90 and 97% of all recurrences within 2 and 5 years of RC, respectively.
• ? According to stage, pTxN+ tumours were more likely to recur than ≥pT3N0 tumours and ≤pT2N0 tumours (5‐yr RFS 25% vs. 44% vs. 66% respectively, P < 0.001). Similarly, pTxN+ tumours had a shorter median time to recurrence (9 months, range 1–72 months) than ≥pT3N0 tumours (10 months, range 1–70 months) or ≤pT2N0 tumours (14 months, range 1–192 months, P < 0.001).

CONCLUSIONS

• ? Differences in recurrence patterns after RC suggest the need for varied follow‐up protocols for each group.
• ? We propose a stage‐based protocol for surveillance of patients with BC treated with RC that captures most recurrences while limiting over‐investigation.

     

Minimal incisions for laparoscopic radical cystectomy with extracorporeal-assisted urinary diversion

ObjectiveLaparoscopic radical cystectomy (LRC) had been used for >10 years. However, longer wound incisions for extracorporeal-assisted urinary diversion decrease the benefits of a laparoscopic approach. In this study, we describe our experience of modified LRC with extracorporeal-assisted urinary diversion using minimal wound incisions.Materials and methodsFrom January 2011 to January 2013, 22 consecutive patients underwent radical cystectomy by a single surgeon. Seven patients underwent open radical cystectomy (ORC), and 15 patients underwent LRC with four-port incisions.ResultsThe LRC group had a significantly lower estimated blood loss (p = 0.005), lower blood transfusion rate (p = 0.004), and lower ileus rate (p = 0.031) than the ORC group. No significant differences were noted in operative time, time to flatus, pain score, overall complication rate, pathological stage, positive surgical margin rate, or lymph node yield (27.6 for LRC and 29.1 for ORC). The 1-year disease free survival rate was 86.7% in the LRC group and 71.4% in the ORC group, and the 1-year overall survival rates were both 100%.ConclusionOur experience shows that LRC with extracorporeal-assisted urinary diversion using minimal incisions is a safe and feasible surgical technique with less blood loss. Further reports with a longer follow-up period and large number of cases are necessary to validate our findings.     

完全腹腔镜下根治性膀胱切除回肠膀胱术的疗效观察

目的:探讨完全腹腔镜下根治性膀胱切除回肠膀胱术的可行性,并总结手术技巧。方法:回顾性分析3例膀胱肿瘤患者行完全腹腔镜下根治性膀胱切除回肠膀胱术的临床资料。结果:3例手术均获成功,手术时间分别为480、450和420min,出血量分别为400、750和330ml,肠道功能恢复时间分别为56、62和78h,引流管于术后8~15天拔除。术后住院时间分别为17、13和15d,术后4周拔除单J管。术中、术后均无并发症,无尿瘘、肠瘘或肠梗阻等发生。随访3~6个月,肾功能正常,无肾积水,未见肿瘤复发、转移等。结论:完全腹腔镜下根治性膀胱切除回肠膀胱术安全可行,但手术难度大,需熟练掌握腹腔镜操作技术后方可开展。     

Contemporary outcomes of 2287 patients with bladder cancer who were treated with radical cystectomy: a Canadian multicentre experience

Study Type – Therapy (case series) Level of Evidence 4

OBJECTIVE

To evaluate data obtained from a large, multi‐institutional, contemporary series of patients who underwent radical cystectomy (RC) in a universal healthcare system aiming to assess outcome and identify novel prognostic variables.

MATERIALS AND METHODS

Data were collected and pooled from 2287 patients treated with RC between 1998 and 2008 by urological oncologists from eight Canadian academic centres. Collected variables included various clinicopathological parameters, recurrence and death. Survival and prognostic variables were analyzed using the Kaplan‐Meier method and Cox regression analysis.

RESULTS

The median age of patients was 68 years with a mean (median) follow‐up time of 35 (29) months. The 30, 60 and 90‐day postoperative mortality rates were 1.3%, 2.6% and 3.2%, respectively. The 5‐year overall, recurrence‐free and cancer‐specific survival was 57%, 48% and 67%, respectively, with a local recurrence rate of 6%. Pathological stage distribution was n= 498 (23%); pT2N0, n= 365 (17%); pT3N0, n= 463 (21%); pT4N0, n= 170 (8%); and pTxN+, n= 507 (23%). Only 3.1% of patients received neoadjuvant chemotherapy and 19.4% received adjuvant chemotherapy. On multivariate analysis, lower pathological stage, negative surgical margins, receipt of adjuvant chemotherapy, performance of pelvic lymphadenectomy and an absence of smoking were associated with prolonged disease‐specific and overall survival.

CONCLUSIONS

RC performed at academic centres provides excellent local control of disease and an acceptable clinical outcome with low perioperative mortality in patients who are treated within a universal healthcare system. Smoking, pelvic lymphadenectomy and receipt of adjuvant chemotherapy are independent prognostic factors for survival. Neoadjuvant chemotherapy continues to be under‐utilized in Canada.     

腹腔镜膀胱根治性切除原位回肠新膀胱的随访疗效观察

目的随访探讨腹腔镜膀胱根治性切除原位回肠新膀胱术的疗效。方法 61例行腹腔镜膀胱根治性切除原位回肠新膀胱术的膀胱癌患者,随访1~24个月,每月定期门诊复查、电话等方式详细记录术后自主排尿情况等资料。结果所有患者均未见肿瘤复发。42例患者于拔除尿管后28~35d自控通畅排尿,每次尿量约180~410mL,每次间隔60~180min;13例患者出院后仍有不同程度日间尿失禁现象,6例有夜间尿失禁现象;3例术前性功能正常男性患者出现勃起功能障碍;彩超及静脉肾盂造影检查发现4例单侧肾积水,2例双肾积水。结论腹腔镜膀胱根治性切除原位回肠新膀胱术肿瘤控制好,患者术后可具有较好的控尿功能和较低的尿失禁发生率,部分有效保存性功能,能够有效确保患者的生活质量。     

Early recovery protocol in patients undergoing laparoscopic radical cystectomy

IntroductionThe Enhanced Recovery After Surgery program (ERAS), has become the basis of perioperative management after colorectal surgery, vascular, thoracic, and more recently the radical cystectomy. The aim of this study is to show our initial experience using an ERAS protocol.Materials and methodsA total of 47 laparoscopic radical cystectomies (LRC) were compared in this study. For retrospective data analysis, the patients were divided into two groups: Group A included patients who underwent LRC before the ERAS protocol was implemented; and Group B included patients who underwent LRC after the ERAS protocol was implemented.ResultsHospital stay was significantly shorter (p = 0,04) in Group B with a median of 11.73 days versus 17.53 days in Group A. The paralytic ileus is the most common complication in both groups, and only two complications seem to be lower between groups; central vein catheter infection in Group A was 14.2% versus 5.2% in Group B and paralytic ileus in Group A was 35.7% versus 21.0% in Group B. There was no statistical difference between groups in the appearance of minor or major complications.ConclusionThe combination of minimally invasive surgery and an ERAS protocol is a feasible multidisciplinary challenge and is useful in the recovery of patients undergoing LRC.     

Mini-laparotomy approach to radical cystectomy

Study Type – Therapy (case series) Level of Evidence 4 What’s known on the subject? and What does the study add? In the recent decade minimally invasive endoscopically approaches have been suggested as a way to reduce morbidity following radical cystectomy. The present study suggests that the same advantages found, when comparing endoscopical cystectomy to classical open cystectomy, can be achieved by reducing the wound length of the open approach.

OBJECTIVE

• ? To investigate the feasibility of performing radical cystectomy (RC) through a mini‐laparotomy and to evaluate the effect of a smaller incision on wound problems, immediate postoperative pain, bowel function and length of hospital stay (LOS).

PATIENTS AND METHODS

• ? Two consecutive cohorts of patients, one with 75 patients undergoing open RC (ORC) with lymph node dissection up to the aortic bifurcation through a conventional long midline incision and one with 75 patients undergoing RC through a mini‐laparotomy (MinilapRC) of intentionally <8–10 cm.
• ? Patient characteristics, operative duration, estimated blood loss (EBL), incidence and severity of wound problems, return of bowel function, amount of analgesics needed and LOS were analysed according to the intention‐to‐treat principle.

RESULTS

• ? The demographic characteristics of the two groups were similar.
• ? An incision of ≤10 cm was made in 65% of the patients in the MinilapRC group with a median (range) length of incision of 9 (6.5–19) cm. In the final third of patients operated on in the MinilapRC group, 76% had an incision of ≤8 cm.
• ? The operative duration and EBL were not significantly different between the groups.
• ? Wound problems were significantly fewer, bowel function was restored more quickly and the need of postoperative analgesics was less in the MinilapRC group.
• ? In the MinilapRC group LOS was reduced by a median of 3 days.

CONCLUSION

• ? MinilapRC is feasible in most patients without increasing operative duration. The reduced incision length reduces postoperative morbidity.

     

Laparoscopic radical cystectomy and continent orthotopic ileal neobladder performed completely intracorporeally: the initial experience

PURPOSE: We introduce the operative technique of laparoscopic radical cystectomy and orthotopic ileal neobladder with a Studer limb performed completely intracorporeally. MATERIALS AND METHODS: The procedure was performed in 1 man and 1 woman. Using a 6 port transperitoneal approach, radical cystectomy in the female patient and radical cystoprostatectomy in the male patient were completed laparoscopically with the urethral sphincter preserved. Bilateral pelvic lymphadenectomy was done. A 65 cm. segment of ileum 15 cm. from the ileocecal junction was isolated, and ileo-ileal continuity was restored using Endo-GIA staplers (U.S. Surgical, Norwalk, Connecticut). The distal 45 cm. of the isolated ileal segment were detubularized, maintaining the proximal 10 cm. segment intact as an isoperistaltic Studer limb. A globular shaped ileal neobladder was constructed and anastomosed to the urethra. Bilateral stented ureteroileal anastomoses were individually performed to the Studer limb. All suturing was done exclusively using free-hand laparoscopic techniques and the entire procedure was completed intracorporeally. An additional case is described of Indiana pouch continent diversion in which the pouch was constructed extracorporeally. RESULTS: Total operative time for laparoscopic radical cystectomy and orthotopic neobladder was 8.5 and 10.5 hours, respectively, with a blood loss ranging from 200 to 400 cc. Hospital stay was 5 to 12 days and surgical margins of the bladder specimen were negative in each case. Both patients with orthotopic neobladder had complete daytime continence. Postoperative renal function was normal and excretory urography revealed unobstructed upper tracts. During followup ranging from 5 to 19 months 1 patient died of metastatic disease, while the other 2 are doing well without local or systematic progression. CONCLUSIONS: Laproscopic radical cystectomy and orthotopic ileal neobladder performed completely intracorporeally are feasible.     

腹腔镜下全膀胱切除术的临床应用

目的 探讨腹腔镜下全膀胱切除术的手术方法和临床效果。方法 28例男性患者，58—73岁，26例病理证实为浸润性膀胱移行细胞癌Ⅱ一Ⅲ级，2例鳞状细胞癌；TNM分期：T2N0M0 16例，T3aN0M0 10例，T3bN0M0 2例。行腹腔镜下全膀胱切除，15例原位回肠代膀胱术，10例Sigma直肠膀胱术，3例输尿管造口术，观察手术时间、术中出血量、术后肠道功能恢复、术后并发症及手术效果。结果 手术时间7—10h，术中失血600—1500mL，术后约72h肠道功能恢复，术后2周拔输尿管导管，术后3周拔尿管后腹压排尿正常，术后3月IVu未见肾积水，未出现腹腔并发症。结论 本组共28例行经腹全膀胱切除术，均取得满意效果，无腹腔并发症；15例原位回肠代膀胱术，应注意保护盆腔神经丛和尿道外括约肌，尤其应防止尿道外括约肌受损，避免发生术后尿失禁和排尿功能障碍。该术式具有微创，出血少，恢复快等特点，随着技术的进步，该术式将成为治疗浸润性膀胱癌的较好方法之一。     

Hand-assisted versus pure laparoscopic radical cystectomy: A clinical outcome comparison

Objectives:   To compare hand-assisted laparoscopic radical cystectomy (HALRC) with the standard laparoscopic radical cystectomy (LRC) in an attempt to delineate their role in bladder cancer treatment.
Methods:   We retrospectively analyzed 51 patients who underwent HALRC (HALRC group, 31 cases) or LRC (LRC group, 20 cases). Urinary diversion was performed extracorporeally through the hand port or the incision for specimen retrieval, respectively, in the two groups. Baseline patient characteristics, intraoperative parameters, and postoperative outcomes were evaluated.
Results:   There was no statistically significant difference in age, sex, body mass index, previous abdominal surgeries, or tumor stage between the two groups. Although the LRC group yielded a significantly smaller incision for urinary diversion than the HALRC group (7.3 cm vs 6.2 cm, P  < 0.05), mean operative time, mean estimated blood loss, blood transfusion rate, time to oral intake and complications were similar in the two groups. Hernia formation was observed with increased frequency in the HALRC group. No patients in the HALRC group and only one patient (5%) in the LRC group presented a positive margin.
Conclusions:   The HALRC group yielded the same outcomes as the LRC group, except with a larger incision. The hand-assisted approach might be preferred for obese patients or those having multiple previous abdominal surgeries.     

改良腹腔镜根治性膀胱切除术加Studer原位回肠新膀胱重建初步研究

目的:总结11例腹腔镜根治性膀胱切除、标准淋巴结清扫加Studer原位回肠新膀胱重建的经验,评价此术式肿瘤学结果与功能性结果。方法:2008年7月～2011年5月,选择11例肌层浸润性膀胱肿瘤患者实施腹腔镜根治性膀胱切除加下腹壁小切口行Studer原位回肠新膀胱重建术,对手术时间、淋巴结数量、围手术期并发症、出血量、输血量、生存率、上尿路形态与功能、控尿情况进行分析。结果:平均手术时间为6.17(5.5～7.5)h,平均出血量为300(0～800)ml,仅1例输血400ml,平均清扫淋巴结数15(5～30)个,无围手术期死亡,围手术期并发症发生率为18.19%(2/11)。上尿路检查,提示18.19%(2/11)术后拔出双J管后出现双侧肾盂及输尿管的轻度暂时性扩张,其中1例血肌酐上升。随访15(1～67)个月,1例鳞癌死于广泛转移,91%(10/11)无复发生存。患者日间完全控尿率达到90%(9/10);夜间完全控尿率70%(7/10),小于1块尿垫20%(2/10)。结论:选择适当病例行改良的腹腔镜根治性膀胱切除、标准淋巴结清扫加下腹壁小切口行Studer原位回肠新膀胱重建术取得了满意肿瘤学与功能性结果;Studer原位回肠新膀胱顺向蠕动输入袢能够保护上尿路形态与功能。