Anderson C B, Elkin E B, Atoria C L, Eastham J A, Scardino P T, Touijer K
The Urology Service, Department of Surgery, Sidney Kimmel Center for Prostate and Urological Malignancies and Memorial Sloan-Kettering Cancer Center, New York, NY, USA.
Department of Epidemiology and Biostatistics Memorial Sloan-Kettering Cancer Center, New York, NY, USA.
Prostate Cancer Prostatic Dis. 2015 Mar;18(1):75-80. doi: 10.1038/pcan.2014.49. Epub 2014 Dec 16.
The diffusion of minimally invasive radical prostatectomy (MIRP) in the United States may have led to adverse patient outcomes due to rapid surgeon adoption and collective inexperience. We hypothesized that throughout the early period of minimally invasive surgery, MIRP patients had inferior outcomes as compared with those who had open radical prostatectomy (ORP).
We used the Surveillance, Epidemiology and End RESULTS-Medicare dataset and identified men who had ORP and MIRP for prostate cancer from 2003-2009. Study endpoints were receipt of subsequent cancer treatment, and evidence of postoperative voiding dysfunction, erectile dysfunction (ED) and bladder outlet obstruction. We used proportional hazards regression to estimate the impact of surgical approach on each endpoint, and included an interaction term to test for modification of the effect of surgical approach by year of surgery.
ORP (n=5362) and MIRP (n=1852) patients differed in their clinical and demographic characteristics. Controlling for patient characteristics and surgeon volume, there was no difference in subsequent cancer treatments (hazard ratio (HR) 0.89, 95% confidence interval (CI) 0.76-1.05), although MIRP was associated with a higher risk of voiding dysfunction (HR 1.31, 95% CI 1.20-1.43) and ED (HR 1.43, 95% CI 1.31-1.56), but a lower risk of bladder outlet obstruction (HR 0.86, 95% CI 0.75-0.97). There was no interaction between approach and year for any outcome. When stratifying the analysis by year, MIRP consistently had higher rates of ED and voiding dysfunction with no substantial improvement over time.
MIRP patients had adverse urinary and sexual outcomes throughout the diffusion of minimally invasive surgery. This may have been a result of the rapid adoption of robotic surgery with inadequate surgeon preparedness.
在美国，由于外科医生迅速采用微创根治性前列腺切除术（MIRP）且普遍缺乏经验，可能导致患者出现不良预后。我们推测，在微创手术的早期阶段，与接受开放性根治性前列腺切除术（ORP）的患者相比，接受MIRP的患者预后较差。
我们使用了监测、流行病学和最终结果 - 医疗保险数据集，识别出2003年至2009年因前列腺癌接受ORP和MIRP的男性患者。研究终点为是否接受后续癌症治疗，以及术后排尿功能障碍、勃起功能障碍（ED）和膀胱出口梗阻的证据。我们使用比例风险回归来估计手术方式对每个终点的影响，并纳入一个交互项以检验手术方式的效果是否因手术年份而异。
ORP（n = 5362）和MIRP（n = 1852）患者在临床和人口统计学特征方面存在差异。在控制患者特征和外科医生手术量后，后续癌症治疗方面无差异（风险比（HR）0.89，95%置信区间（CI）0.76 - 1.05），尽管MIRP与排尿功能障碍风险较高（HR 1.31，95% CI 1.20 - 1.43）和ED风险较高（HR 1.43，95% CI 1.31 - 1.56）相关，但膀胱出口梗阻风险较低（HR 0.86，95% CI 0.75 - 0.97）。任何结局在手术方式和年份之间均无交互作用。按年份分层分析时，MIRP的ED和排尿功能障碍发生率始终较高，且随时间无显著改善。
在微创手术普及过程中，接受MIRP的患者出现了不良的泌尿和性功能预后。这可能是由于机器人手术迅速采用但外科医生准备不足所致。
