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。

Implementation of enhanced recovery after surgery protocols to robotic assisted radical cystectomy with intracorporeal urinary diversion using orthotopic U-shape ileal neobladder

Objective To discuss outcome and safety after implementation of enhanced recovery after surgery(ERAS)protocols to patients who underwent robotic assisted radical cystectomy(RARC)with intracorporeal orthotopic"U"shaped ileal neobladder creation using STAPLER technique.Methods Between October 2014 and April 2019,71 patients(59 males and 12 females)with MIBC(Muscle Invasive Bladder Cancer)who underwent RARC with intracorporeal urinary diversion using orthotopic"U"shaped ileal neobladder in Zhejiang Provincial People's Hospital(People's Hospital of Hangzhou Medical College)were studied retrospectively.They had an average age of(65.2±5.6)y and BMI of(22.18±3.75)kg/m^2.The median age-adjusted charlson comorbidity index(aCCI)was 4,median ASA score was 2.All patients underwent these inspections pre-RARC:chest Xray,vascular ultrasound(jugular vein included),abdominal ultrasound,CT urography,cystoscopy with biopsy or TURBT(trans-urethral resection of a bladder tumour).All patients were pathological diagnosed with MIBC,with no evidence of systemic metastasis and no history of radiotherapy,systemic chemotherapy and open abdominal surgery before RARC.All 71 patients received RARC with intracorporeal orthotopic"U"shaped ileal neobladder creation using STAPLER technique.Between October 2014 and September 2016,37 cases(29 males and 8 females)were managed without ERAS protocols perioperatively.They had an average age of(65.3±5.7)y and BMI of(23.66±3.47)kg/m2.The median aCCI was 4,median ASA score was 2.Between October 2016 and April 2019,another group of 34 cases(30 males and 4 females)were managed with ERAS protocols including nutritional assessment,thrombosis prevention,pain assessment and management,perioperative diet management etc.They had an average age of(64.5±4.3)y and BMI of(21.87±4.85)kg/m2.The median aCCI was 4,median ASA score was 2.There were no statistical significance between the two groups with regard to general information.Surgical and follow-up data were collected for all patients.Results Surgeries were successful in all 71 cases with postoperative follow up for 3-51 months.In ERAS group,there were 22 cases in pT2 and 12 cases pT3 according to classification of malignant tumours:with 2 cases of incidental prostate cancer(IPCa).In non-ERAS group,pT2 in 25 cases and pT3 in 12 cases:with 1 case of IPCa.Statistical significance were observed between groups with regard to the first anal exhaust time[(20.5±18.7)h vs.(29.9±17.4)h,P=0.032],the first defecation time[(72.6±27.1)h vs.(88.7±35.8)h,P=0.004],length of hospital stay after surgey[(14.1±3.3)d vs.(16.2±4.8)d,P=0.037],numeric rating scales(NRS)Pain Score 8.0,24.0,48.0 h after surgery[(3.2±0.5)vs.(3.6±0.8),P=0.015;(1.9±0.3)vs.(2.2±0.6),P=0.011;(1.3±0.4)vs.(1.6±0.7),P=0.032],respectively.There were no significance between groups with regard to operating time[(290±65)min vs.(282±46)min,P=0.549],intraoperative blood loss[(190.5±235.6)ml vs.(221.1±250.3)ml,P=0.438],transfusion rate[5.9%(2/34)vs.8.1%(3/37),P=0.922],readmission within 30 days after surgery[2.9%(1/34)vs.5.4%(2/37),P=0.940],early severe complications(within 30 days)[2.9%(1/34)vs.2.7%(1/37),P=0.940],late severe complications(after 30 days)[5.9%(2/34)vs.8.1%(3/37),P=0.922].Conclusions The implementation of ERAS protocols to patients who underwent RARC with intracorporeal orthotopic"U"shaped ileal neobladder using STAPLER technique is safe and effective.It can reduce postoperative pain and hospital stay,shorten bowel recovery time,improve early functional recovery without increasing major complications.This adoption should be encouraged.