Miller Catherine, Campain Nicholas J, Dbeis Rachel, Daugherty Mark, Batchelor Nicholas, Waine Elizabeth, McGrath John S
Urology Department, Torbay Hospital, Torquay.
Exeter Surgical Health Services Research Unit, Royal Devon and Exeter NHS Foundation Trust, Exeter, Devon, UK.
BJU Int. 2017 Aug;120(2):265-272. doi: 10.1111/bju.13702. Epub 2016 Dec 21.
To describe the implementation phase of a robot-assisted radical cystectomy (RARC) programme including side-effect profiles and impact on length of stay (LOS).
In all, 114 consecutive patients (82% male) underwent RARC and urinary diversion between April 2013 and December 2015 [ileal conduit (97 patients) and orthotopic neobladder (17)]. Surgery was performed by two surgeons within a designated regional cancer centre. No exclusion criteria were applied. All patients were managed on the Exeter Enhanced Recovery Pathway (ERP) in a unit where embedded enhanced recovery practice was already established. Data were collected prospectively on the national cystectomy registry - the British Association of Urological Surgeons (BAUS) Complex Operations Dataset.
RARC was technically feasible in all but one case. The mean operating time was 3-5 h with an overall transfusion rate of 8.8%. There were higher-grade complications (Clavien-Dindo grade III-IV) in 18.4% of patients, with a 30-day mortality rate of 0.9%. The median (range) LOS after RARC was 7 (3-68) days, with a re-admission rate of 18.4%.
The present series shows that RARC can be safely implemented in a unit experienced in robot-assisted surgery (RAS). Case-selection in this setting is not deemed necessary. There are benefits in terms of lower transfusion rates and reduced LOS. The side-effect profile appears to differ from that of open RC, and despite the fact that complication rate is equivalent; 'technical' complications are over-represented in the RAS group. As such, they should improve with experience, recognition, and modification of surgical technique. ERPs can be safely applied to all patients undergoing RARC to maximise the benefits of minimally invasive surgery.
描述机器人辅助根治性膀胱切除术（RARC）项目的实施阶段，包括副作用情况以及对住院时间（LOS）的影响。
2013年4月至2015年12月期间，共有114例连续患者（82%为男性）接受了RARC及尿流改道手术[回肠膀胱术（97例患者）和原位新膀胱术（17例）]。手术由两名外科医生在指定的区域癌症中心进行。未应用排除标准。所有患者均在已建立嵌入式强化康复实践的科室按照埃克塞特强化康复路径（ERP）进行管理。数据前瞻性收集于国家膀胱切除术登记处——英国泌尿外科医师协会（BAUS）复杂手术数据集。
除1例病例外，RARC在技术上均可行。平均手术时间为3 - 5小时，总体输血率为8.8%。18.4%的患者出现高级别并发症（Clavien-Dindo III - IV级），30天死亡率为0.9%。RARC术后中位（范围）住院时间为7（3 - 68）天，再入院率为18.4%。
本系列研究表明，RARC可在有机器人辅助手术（RAS）经验的科室安全实施。在此情况下无需进行病例选择。在降低输血率和缩短住院时间方面存在益处。副作用情况似乎与开放性根治性膀胱切除术不同，尽管并发症发生率相当；但“技术”并发症在RAS组中占比过高。因此，随着经验的积累、识别以及手术技术的改进，这些情况应会改善。ERP可安全应用于所有接受RARC的患者，以最大限度地发挥微创手术的益处。
