Eden Christopher G, Neill Mischel G, Louie-Johnsun Mark W
Department of Urology, The Royal Surrey County Hospital, Guildford, UK.
BJU Int. 2009 May;103(9):1224-30. doi: 10.1111/j.1464-410X.2008.08169.x. Epub 2008 Nov 20.
To report the initial experience of one surgeon, with contemporary experience of both open radical prostatectomy (ORP) and reconstructive laparoscopy, in laparoscopic radical prostatectomy (LRP) in 1000 patients, and to investigate the rate of change of various outcome variables for this procedure with time.
Between March 2000 and December 2007, 1000 consecutive patients with clinical stage T < or = 3aN0M0 prostate cancer underwent LRP, either supervised (17%) or performed (83%), by one surgeon. The median prostate-specific antigen (PSA) level was 7.0 (1-50) ng/mL and median Gleason sum 6 (4-10); the clinical stage was T1 in 46.9%, T2 in 49.8% and T3 in 3.3%.
The median (range) operative duration was 177 (78-600) min. There was one conversion (patient 8) to open surgery. The median blood loss was 200 (10-1300) mL and four patients were transfused (0.4%). The median postoperative hospital stay was 3.0 (3-28) nights. The median catheterization time was 10.0 (0.8-120) days. There were 48 complications (4.8%) requiring surgical intervention in 33 (3.3%) patients, 58% of these as a day-case admission. The positive margin rates according to d'Amico risk groups were: low, 9.1%; intermediate, 20.3%; and high, 36.8%. The overall positive margin rate was 13.3%. The PSA level was < or =0.1 mg/L at 3 months in 99.1% of patients. At a mean follow-up of 27.7 (3-72) months, 96.1% of patients were free of biochemical recurrence. In patients with a follow-up of > or =24 months potency rates peaked in the series at 86% for all men and 94% for men aged < or =65 years, and continence rates at 98% before declining thereafter in men with a shorter follow-up.
The learning curve for operating time and blood loss was overcome within the first 100-150 cases, but complication and continence rates took 150-200 cases to reach a plateau. The longest learning curve was for potency, which did not stabilize until 700 cases. These learning curves are likely to be considerably shorter when surgeons are taught in departments with a high throughput of cases but both surgeons and patients should be aware of them. In view of these findings, the authors recommend that LRP should not be self-taught and should be learned within an immersion teaching programme. Even then, a large surgical volume is likely to be needed to maintain clinical outcomes at the highest level.
报告一名同时具备开放性根治性前列腺切除术（ORP）和重建性腹腔镜手术经验的外科医生开展1000例腹腔镜根治性前列腺切除术（LRP）的初步经验，并探讨该手术各种结果变量随时间的变化率。
2000年3月至2007年12月期间，1000例临床分期为T≤3aN0M0的前列腺癌患者连续接受了LRP手术，由一名外科医生实施，其中17%为带教手术，83%为独立手术。前列腺特异性抗原（PSA）水平中位数为7.0（1 - 50）ng/mL，Gleason评分中位数为6（4 - 10）；临床分期T1占46.9%，T2占49.8%，T3占3.3%。
手术时间中位数（范围）为177（78 - 600）分钟。有1例（第8例患者）转为开放手术。失血中位数为200（10 - 1300）mL，4例患者接受输血（0.4%）。术后住院时间中位数为3.0（3 - 28）晚。导尿时间中位数为10.0（0.8 - 120）天。有48例并发症（4.8%），33例（3.3%）患者需要手术干预，其中58%为日间手术入院。根据达米科风险分组的切缘阳性率分别为：低风险组9.1%；中风险组20.3%；高风险组36.8%。总体切缘阳性率为13.3%。99.1%的患者在3个月时PSA水平≤0.1 mg/L。平均随访27.7（3 - 72）个月时，96.1%的患者无生化复发。在随访≥24个月的患者中，所有男性的勃起功能恢复率在该系列中达到峰值，为86%，年龄≤65岁男性为94%，尿失禁率在98%，之后在随访时间较短的男性中有所下降。
手术时间和失血量的学习曲线在前100 - 150例病例中被克服，但并发症和尿失禁率在完成150 - 200例病例后才达到平台期。最长学习曲线是关于勃起功能的曲线，直到700例病例时才趋于稳定。当外科医生在病例量高的科室接受培训时，这些学习曲线可能会显著缩短，但外科医生和患者都应了解这些情况。鉴于这些发现，作者建议LRP不应自学，而应在沉浸式教学计划中学习。即便如此，可能仍需要大量的手术量才能将临床结果维持在最高水平。
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