[腹膜外内镜下根治性前列腺切除术：学习曲线有多陡？5年经验中个人技术发展的费用]

[Extraperitoneal endoscopic radical prostatectomy: How steep is the learning curve? Overheads on the personal evolution technique in 5-years experience].

作者信息

Starling E S, Reis L O, Vaz Juliano R, Korkes F, Wanderlei Dos Santos M, Lima Pompeo A C, Tobias-Machado M

机构信息

Departamento de Urología, São Paulo, Brasil.

出版信息

Actas Urol Esp. 2010 Jul;34(7):598-602.

PMID:20540876

Abstract

OBJECTIVE

Prospectively investigate endoscopic extra peritoneal radical prostatectomy (EERP) learning curve impact on outcomes.

MATERIALS AND METHODS

In a 5 year period (2004-2008) 270 patients underwent 5-6 ports laparoscopic radical prostatectomy at a referral center in Brazil. The initial 70 cases learning curve protocol included low body mass index patients with low volume, low grade prostate cancer. After that there were no criteria to exclude laparoscopic surgery. The patients were analyzed in two groups: Group 1, first 70 patients (30 transperitoneal and 40 extra peritoneal)-learning curve and Group 2, last 200 patients - EERP only. Surgical and outcome parameters were compared through Student's t test and Fisher's Exact Test.

RESULTS

The mean age was 65 years (+/-8.2) and comparing Groups 1 and 2, mean operative time was 300 (+/-190) versus 180 (+/-100) minutes, blood loss 330 (+/-210) versus 210 (+/-180) mL, hospital stay 3 (2 to 5) versus 2 (1 to 3) days, positive surgical margins 15% versus 10%, erection sufficient to penetration in previous potent patients 73.3% versus 75%, respectively with no difference between groups. Overall, 78% of patients referred no previous impotence with groups' equivalence. Severe urinary incontinence, transfusion and complications rates were higher in group 1 (p<0.05): 10% versus 2%, 12% versus 2.25% and 30% versus 12.5%, respectively. Peritoneum perforation occurred in 40% and conversion to open surgery was not required. Nerve sparing procedure was applied in 85%. In 3.5-years mean follow-up 90% of patients were free of PSA recurrence with no difference between groups.

CONCLUSION

Severe urinary incontinence, transfusion and complications rates are related to learning curve which is continuous, although a significant improvement is pragmatic after 70 cases. An intensive mentored training program should be considered to minimize the learning outlays.

摘要

目的

前瞻性研究内镜下腹膜外根治性前列腺切除术（EERP）学习曲线对手术结果的影响。

材料与方法

在5年期间（2004 - 2008年），270例患者在巴西一家转诊中心接受了5 - 6孔腹腔镜根治性前列腺切除术。最初的70例病例学习曲线方案纳入了低体重指数、低瘤体体积、低分级前列腺癌患者。此后，不再有排除腹腔镜手术的标准。患者被分为两组：第1组，前70例患者（30例经腹腔和40例腹膜外）——学习曲线组；第2组，后200例患者——仅接受EERP组。通过学生t检验和Fisher精确检验比较手术及结果参数。

结果

平均年龄为65岁（±8.2），比较第1组和第2组，平均手术时间分别为300（±190）分钟和180（±100）分钟，失血量分别为330（±210）毫升和210（±180）毫升，住院时间分别为3（2至5）天和2（1至3）天，手术切缘阳性率分别为15%和10%，既往有勃起功能的患者中勃起功能足以进行性交的比例分别为73.3%和75%，两组之间无差异。总体而言，78%的患者既往无阳痿，两组相当。第1组严重尿失禁、输血和并发症发生率更高（p<0.05）：分别为10%对2%、12%对2.25%和30%对12.5%。40%发生了腹膜穿孔，但无需转为开放手术。85%的患者采用了保留神经手术。在3.5年的平均随访中，90%的患者无PSA复发，两组之间无差异。