Karolinska University Hospital, Stockholm, Sweden.
Eur Urol. 2013 Oct;64(4):654-63. doi: 10.1016/j.eururo.2013.05.020. Epub 2013 May 27.
Although open radical cystectomy (ORC) remains the gold standard of care for muscle-invasive bladder cancer, robot-assisted radical cystectomy (RARC) continues to gain wider acceptance. In this article, we focus on the steps of RARC, describing our approach, which has been developed over the past 10 yr. Totally intracorporeal RARC aims to offer the benefits of a complete minimally invasive approach while replicating the oncologic outcomes of open surgery.
We report our outcomes of a totally intracorporeal RARC procedure, describing step by step our technique and highlighting the variations on this standard template of nerve-sparing and female organ-preserving approaches in men and women.
DESIGN, SETTING, AND PARTICIPANTS: Between December 2003 and October 2012, a total of 113 patients (94 male and 19 female) underwent totally intracorporeal RARC.
We performed RARC, extended pelvic lymph node dissection, and a totally intracorporeal urinary diversion (UD) in all patients. In the accompanying video, we focus on the standard template for RARC, also describing nerve-sparing and female organ-preserving approaches.
Complications and oncologic outcomes are reported, including overall survival (OS) and cancer-specific survival (CSS) using Kaplan-Meier analysis.
RARC with intracorporeal UD was performed in 113 patients. Mean age was 64 yr (range: 37-84). Forty-three patients underwent intracorporeal ileal conduit, and 70 had intracorporeal neobladder. On surgical pathology, 48% of patients had ≤ pT1 disease, 27% had pT2 disease, 13% had pT3 disease, and 12% had pT4 disease. The mean number of lymph nodes removed was 21 (range: 0-57). Twenty percent of patients had lymph node-positive disease. Positive surgical margins occurred in six cases (5.3%). Median follow-up was 25 mo (range: 3-107). We recorded a total of 70 early complications (0-30 d) in 54 patients (47.8%), with 37 patients (32.7%) having Clavien grade ≥ 3. Thirty-six late complications (>30 d) were recorded in 30 patients (26.5%), with 20 patients (17.7%) having Clavien grade ≥ 3. One patient (0.9%) died within 90 days of operation from pulmonary embolism. Using Kaplan-Meier analysis, CSS was 81% at 3 yr and 67% at 5 yr.
Our structured approach to RARC has enabled us to develop this complex service while maintaining patient outcomes and complication rates comparable with ORC series. Our results demonstrate acceptable oncologic outcomes and encouraging long-term CSS rates.
虽然开放性根治性膀胱切除术（ORC）仍然是肌层浸润性膀胱癌的金标准治疗方法，但机器人辅助根治性膀胱切除术（RARC）仍在继续得到更广泛的认可。本文重点介绍 RARC 的步骤，描述我们过去 10 年来开发的方法。完全腔内 RARC 旨在提供完全微创方法的益处，同时复制开放手术的肿瘤学结果。
我们报告了完全腔内 RARC 手术的结果，逐步描述了我们的技术，并强调了在男性和女性中神经保留和女性器官保留方法的标准模板上的变化。
设计、地点和参与者：2003 年 12 月至 2012 年 10 月期间，共有 113 名患者（94 名男性和 19 名女性）接受了完全腔内 RARC。
我们对所有患者进行了 RARC、扩大的盆腔淋巴结清扫术和完全腔内尿流改道术（UD）。在随附的视频中，我们重点介绍了 RARC 的标准模板，还描述了神经保留和女性器官保留方法。
113 例患者行 RARC 联合腔内 UD。平均年龄为 64 岁（范围：37-84 岁）。43 例患者行腔内回肠导管，70 例行腔内新膀胱。手术病理上，48%的患者疾病≤pT1，27%的患者疾病为 pT2，13%的患者疾病为 pT3，12%的患者疾病为 pT4。平均淋巴结切除数为 21 个（范围：0-57 个）。20%的患者有淋巴结阳性疾病。6 例（5.3%）发生切缘阳性。中位随访时间为 25 个月（范围：3-107 个月）。我们记录了 54 名患者（47.8%）共 70 例早期并发症（0-30 天），其中 37 名患者（32.7%）发生 Clavien 分级≥3 级。30 名患者（26.5%）记录了 36 例晚期并发症（>30 天），其中 20 名患者（17.7%）发生 Clavien 分级≥3 级。1 例患者（0.9%）术后 90 天因肺栓塞死亡。Kaplan-Meier 分析显示，3 年时 CSS 为 81%，5 年时为 67%。
我们对 RARC 的结构化方法使我们能够在保持患者结局和并发症发生率与 ORC 系列相当的情况下发展这一复杂的服务。我们的结果表明，肿瘤学结果可接受，长期 CSS 率令人鼓舞。
