USC Institute of Urology, University of Southern California, Los Angeles, California, and Karolinska Institute, Stockholm, Sweden.
USC Institute of Urology, University of Southern California, Los Angeles, California, and Karolinska Institute, Stockholm, Sweden.
J Urol. 2014 Dec;192(6):1734-40. doi: 10.1016/j.juro.2014.06.087. Epub 2014 Jul 9.
We present a 2-institution experience with completely intracorporeal robotic orthotopic ileal neobladder after radical cystectomy in 132 patients.
Established open surgical techniques were duplicated robotically with all neobladders suture constructed intracorporeally in a globular configuration. Nerve sparing was performed in 56% of males. Lymphadenectomy was extended (up to aortic bifurcation in 51, 44%) and superextended (up to the inferior mesenteric artery in 20, 17%). Ureteroileal anastomoses were Wallace-type (86, 65%) or Bricker-type (46, 35%). The learning curve at each institution was assessed using chronological subgroups and by trends across the entire cohort. Data were prospectively collected and retrospectively queried.
Mean operating time was 7.6 hours (range 4.4 to 13), blood loss was 430 cc (range 50 to 2,200) and hospital stay was 11 days (median 8, range 3 to 78). Clavien grade I, II, III, IV and V complications within 30 days were 7%, 25%, 13%, 2% and 0%, respectively, and between 30 and 90 days were 5%, 9%, 11%, 1% and 2%, respectively. Mean nodal yield was 29 (range 7 to 164) and the node positivity rate was 17%. Operative time, blood loss, hospital stay and prevalence of late complications improved with experience. During a mean followup of 2.1 years (range 0.1 to 9.8) cancer recurred in 20 patients (15%). Five-year overall, cancer specific and recurrence-free survival was 72%, 72% and 71%, respectively.
We developed a refined technique of robotic intracorporeal orthotopic neobladder diversion, duplicating open principles. Operative efficiency and outcomes improved with experience. Going forward, we propose a prospective randomized comparison between open and robotic intracorporeal neobladder surgery.
我们报告了在 132 例患者中，通过完全经体内机器人辅助技术进行根治性膀胱切除术后，构建 2 个机构的机器人辅助原位直肠管状膀胱经验。
使用所有新膀胱均在体内缝合构建的球形结构，复制建立的开放式手术技术。56%的男性进行了神经保留。淋巴结切除术进行了扩展（51 例达到主动脉分叉，占 44%）和超扩展（20 例达到肠系膜下动脉，占 17%）。输尿管-回肠吻合术采用 Wallace 式（86 例，65%）或 Bricker 式（46 例，35%）。使用时间顺序分组和整个队列的趋势，在每个机构评估学习曲线。前瞻性收集数据并回顾性查询。
平均手术时间为 7.6 小时（范围 4.4 至 13），失血量为 430cc（范围 50 至 2200），住院时间为 11 天（中位数 8，范围 3 至 78）。术后 30 天内，Clavien 分级 I、II、III、IV 和 V 并发症分别为 7%、25%、13%、2%和 0%，术后 30 至 90 天分别为 5%、9%、11%、1%和 2%。平均淋巴结产量为 29（范围 7 至 164），淋巴结阳性率为 17%。随着经验的增加，手术时间、失血量、住院时间和晚期并发症的发生率均有所改善。在平均 2.1 年（范围 0.1 至 9.8）的随访中，20 例患者（15%）癌症复发。5 年总生存率、癌症特异性生存率和无复发生存率分别为 72%、72%和 71%。
我们开发了一种改良的机器人辅助体内原位直肠管状膀胱分流术技术，复制了开放式原则。手术效率和结果随着经验的增加而改善。今后，我们建议在开放式和机器人辅助体内新膀胱手术之间进行前瞻性随机比较。
