单一术者机器人辅助腹腔镜前列腺癌根治术术中指标影响因素分析

目的 探究行机器人辅助腹腔镜前列腺癌根治术（RALP）手术时间、术中出血量以及神经保留的影响因素。方法 收集2016年1月1日至2017年10月1日184例于海军军医大学（第二军医大学）长海医院泌尿外科由单一术者完成RALP的局部或局部进展性前列腺癌患者的手术资料及临床信息，分析患者年龄、前列腺体积、术后病理Gleason评分、盆腔淋巴结切除范围、穿刺方式等对手术时间、术中出血量和神经保留的影响。对手术时间和术中出血量的影响因素进行多因素线性回归分析，手术时间与前列腺体积的相关性采用线性相关分析，不同盆腔淋巴结切除范围的患者RALP手术时间的比较采用LSD-t检验。对RALP术中神经保留影响因素的分析采用多因素logistic回归分析。RALP术中未保留、保留单侧与保留双侧神经患者年龄的差异采用单因素方差分析，术后病理Gleason评分、盆腔淋巴结切除范围和穿刺方式的差异采用Kruskal-Wallis H检验。结果 多因素线性回归分析结果显示前列腺体积和盆腔淋巴结切除范围是RALP手术时间的独立影响因素（P均<0.01）；前列腺体积与手术时间呈正相关（r=0.201，P=0.006）；盆腔淋巴结扩大切除患者的RALP手术时间长于闭孔切除者，且盆腔淋巴结闭孔切除者的手术时间长于未切除者（P均<0.01）；患者年龄、前列腺体积、术后病理Gleason评分、盆腔淋巴结切除范围、穿刺方式等对RALP术中出血量无明显影响（P>0.05）。多因素logistic回归分析结果显示，年龄、术后病理Gleason评分、盆腔淋巴结切除范围和穿刺方式是RALP术中神经保留的独立影响因素（OR=0.949，95% CI：0.906~0.995，P=0.027；OR=0.742，95% CI：0.551~0.999，P=0.049；OR=0.540，95% CI：0.322~0.903，P=0.019；OR=0.457，95% CI：0.230~0.905，P=0.025）。RALP术中未保留、保留单侧和保留双侧神经的前列腺癌患者分别为108、20、56例，3组患者的年龄、术后病理Gleason评分、盆腔淋巴结切除范围和穿刺方式的差异均有统计学意义（P均<0.05）。结论 前列腺体积大以及进行盆腔淋巴结切除的前列腺癌患者手术时间较长，年龄大、术后病理Gleason评分高、进行盆腔淋巴结切除以及经直肠穿刺不利于RALP术中神经保留。

Retrospective analysis on influencing factors of intraoperative indexes of robot-assisted laparoscopic radical prostatectomy

Objective To explore the influencing factors of operative time, blood loss and nerve-sparing of robot-assisted laparoscopic radical prostatectomy (RALP). Methods A total of 184 patients with local or locally advanced prostate cancer were enrolled, and they underwent RALP by the single surgeon in Department of Urology of Changhai Hospital of Navy Medical University (Second Military Medical University) from January 1, 2016 to October 1, 2017. The effects of age, prostate volume, postoperative pathological Gleason score, pelvic lymph node dissection and biopsy approach on the operative time, blood loss and nerve-sparing of RALP were analyzed. The influencing factors of operative time and blood loss were analyzed by multivariate linear regression analysis. Linear correlation analysis was used to identify the correlation between operative time and prostate volume. LSD-t test was used to detect the difference of operative time among the patients with different lymph node dissections. The influencing factors of nerve-sparing during RALP were analyzed by multivariate logistic regression analysis. The difference of age was analyzed by one-way ANOVA and the differences of postoperative pathological Gleason score, lymph node dissection and biopsy approach were analyzed by Kruskal-Wallis H test between the patients with unreserved, reserved unilateral and reserved bilateral nerves. Results Multivariate linear regression analysis showed that prostate volume and lymph node dissection were independent influencing factors of RALP operative time (both P<0.01). There was a significantly positive linear correlation between prostate volume and operative time (r=0.201, P=0.006). The patients with extended lymph node dissection had significantly longer operative time than those with obturator lymph node dissection, and the latter had significantly longer operative time than those without lymph node dissection (both P<0.01). Age, prostate volume, postoperative pathological Gleason score, pelvic lymph node dissection, and biopsy approach had no significant effect on intraoperative blood loss (all P>0.05). Multivariate logistic regression analysis showed that age, postoperative pathological Gleason score, lymph node dissection and biopsy approach were independent influencing factors of nerve-sparing during RALP (OR=0.949, 95% CI 0.906-0.995, P=0.027; OR=0.742, 95% CI 0.551-0.999, P=0.049; OR=0.540, 95% CI 0.322-0.903, P=0.019; OR=0.457, 95% CI 0.230-0.905, P=0.025). The cases with unreserved, reserved unilateral and reserved bilateral nerves were 108, 20 and 56, respectively; and the age, postoperative pathological Gleason score, lymph node dissection and biopsy approach were significantly different among the three groups (all P<0.05). Conclusion The patients with prostate cancers, who have larger prostate volume or undergo lymph node dissection during RALP, may have longer operative time. Older age, higher postoperative pathological Gleason score, undergoing lymph node dissection or transrectal biopsy are not conductive to nerve-sparing during RALP.