Cleveland Clinic Foundation, Cleveland, Ohio.
Cleveland Clinic Lerner School of Medicine, Cleveland, Ohio.
J Urol. 2020 Mar;203(3):512-521. doi: 10.1097/JU.0000000000000570. Epub 2019 Oct 3.
Bladder cancer management options include open radical cystectomy and robot-assisted radical cystectomy with intracorporeal or extracorporeal urinary diversion. The existing literature shows no difference in the major complication rate between open radical cystectomy and extracorporeal urinary diversion. However, the emerging popularity of intracorporeal urinary diversion has exposed the need to compare a completely intracorporeal method to alternative approaches. To our knowledge the robotic intracorporeal advantage regarding major complications has not yet been established in an evaluation of all 3 modalities. We compared outcomes and complications of open, intracorporeal and extracorporeal cystectomy techniques at a high volume institution.
We queried a prospectively maintained database for patients who underwent radical cystectomy from 2011 to 2018 for an oncologic indication. Perioperative and pathological outcomes, and 30 and 90-day major complications were assessed. Statistical analyses were done using the Pearson chi-square, Kruskal-Wallis and Kaplan-Meier tests, and multivariable regression.
A total of 948 patients met the study criteria, including 272, 301 and 375 treated with open radical cystectomy, intracorporeal urinary diversion and extracorporeal urinary diversion, respectively. Median followup was 26 months. Intracorporeal urinary diversion cases had lower estimated blood loss (p <0.001), shorter hospitalization (p <0.001) and a lower ileus rate (p=0.023) than extracorporeal urinary diversion and open radical cystectomy cases. Importantly, intracorporeal urinary diversion was associated with lower 30 and 90-day major complication rates vs extracorporeal urinary diversion and open radical cystectomy (90-day Clavien-Dindo III-V 16.9% vs 24.8% and 26.1%, respectively, p=0.015). There was no significant difference in the readmission rate according to the surgical approach. Multivariable predictors of increased 90-day major complications were patient age, the Charlson Comorbidity Index and operative time. On multivariable analysis intracorporeal urinary diversion was associated with reduced 90-day major complications (OR 0.58, p=0.037).
In a 3-way comparison intracorporeal urinary diversion demonstrated a lower major complication rate and perioperative benefits compared to extracorporeal urinary diversion and open radical cystectomy.
膀胱癌的治疗方法包括开放性根治性膀胱切除术和机器人辅助根治性膀胱切除术，伴或不伴体腔内或体腔外尿流改道。现有文献表明，开放性根治性膀胱切除术和体腔外尿流改道的主要并发症发生率无差异。然而，体腔内尿流改道的新兴普及使得需要将完全体腔内方法与替代方法进行比较。据我们所知，在对所有 3 种方法进行评估时，机器人辅助体腔内方法在主要并发症方面的优势尚未得到证实。我们在一家高容量机构比较了开放性、体腔内和体腔外膀胱切除术技术的结果和并发症。
我们对 2011 年至 2018 年间因肿瘤指征而行根治性膀胱切除术的患者前瞻性维护数据库进行了查询。评估围手术期和病理结果以及 30 天和 90 天的主要并发症。使用 Pearson χ 2 检验、Kruskal-Wallis 检验和 Kaplan-Meier 检验以及多变量回归进行统计分析。
共有 948 例患者符合研究标准，其中开放性根治性膀胱切除术 272 例，体腔内尿流改道 301 例，体腔外尿流改道 375 例。中位随访时间为 26 个月。与体腔外尿流改道和开放性根治性膀胱切除术相比，体腔内尿流改道的估计失血量更少（p＜0.001），住院时间更短（p＜0.001），肠梗阻发生率更低（p=0.023）。重要的是，与体腔外尿流改道和开放性根治性膀胱切除术相比，体腔内尿流改道与较低的 30 天和 90 天主要并发症发生率相关（90 天 Clavien-Dindo III-V 3 级及以上并发症发生率分别为 16.9%、24.8%和 26.1%，p=0.015）。根据手术方式，再入院率无显著差异。90 天主要并发症的多变量预测因素为患者年龄、Charlson 合并症指数和手术时间。多变量分析显示，体腔内尿流改道与 90 天主要并发症减少相关（OR 0.58，p=0.037）。
在 3 种方法的比较中，与体腔外尿流改道和开放性根治性膀胱切除术相比，体腔内尿流改道显示出较低的主要并发症发生率和围手术期获益。
