手术经验对机器人辅助根治性膀胱切除术联合体腔内尿流改道术的围手术期和肿瘤学结局的影响：来自机器人手术经验丰富的转诊中心的证据。

The Effect of Surgical Experience on Perioperative and Oncological Outcomes After Robot-assisted Radical Cystectomy with Intracorporeal Urinary Diversion: Evidence from a Referral Centre with Extensive Experience in Robotic Surgery.

机构信息

ORSI, Academy, Melle, Belgium; Department of Urology, Onze Lieve Vrouw Hospital, Aalst, Belgium.

ORSI, Academy, Melle, Belgium; Department of Urology, Onze Lieve Vrouw Hospital, Aalst, Belgium; Unit of Urology, Division of Experimental Oncology, Urological Research Institute, IRCCS San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Milan, Italy.

出版信息

Eur Urol Focus. 2021 Mar;7(2):352-358. doi: 10.1016/j.euf.2020.01.016. Epub 2020 Feb 13.

DOI:10.1016/j.euf.2020.01.016

PMID:32061537

Abstract

BACKGROUND

Evidence on the learning curve for robot-assisted radical cystectomy (RARC) with intracorporeal urinary diversion (ICUD) is limited.

OBJECTIVE

To assess the effect of surgical experience (SE) on perioperative and intermediate-term oncological outcomes in a large contemporary cohort of RARC patients after accounting for the impact of intersurgeon variability.

DESIGN, SETTING, AND PARTICIPANTS: The study cohort included 164 patients treated with RARC and ICUD by two surgeons between 2004 and 2017 at a single European referral centre.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

For each patient, SE was defined as the total number of RARCs performed by each surgeon before the patient's operation. The relationship between SE and operative time (OT), lymph node yield (LNY), positive surgical margins (PSMs), Clavien-Dindo grade ≥2 30-d postoperative complication (CD≥2), and oncological outcomes (18-mo recurrence rate) was evaluated in multivariable linear and logistic regression models, clustering at a single-surgeon level.

RESULTS AND LIMITATIONS

After adjusting for case mix, SE was associated with shorter OT (p= 0.003), lower probability of postoperative CD≥2 rates (p= 0.01), and lower 18-mo recurrence rates (p= 0.002). Conversely, SE did not predict lower PSM rates (p= 0.3) and higher LNY (p= 0.4). The relationship between SE and OT was nonlinear, with a plateau observed after 50 cases. Conversely, the relationship between SE and CD≥2 and 18-mo recurrence was linear without reaching a plateau after 88 procedures.

CONCLUSIONS

SE affects perioperative and oncological outcomes after RARC with ICUD in a linear fashion, and its beneficial effect does not reach a plateau. Conversely, after 50 cases, no further improvement was observed for OT.

PATIENT SUMMARY

Robot-assisted radical cystectomy with intracorporeal urinary diversion is a complex surgical procedure with a relatively long learning curve.

摘要

背景

机器人辅助根治性膀胱切除术（RARC）联合体内尿路转流（ICUD）的学习曲线相关证据有限。

目的

在考虑到术者间变异性影响的情况下，评估外科经验（SE）对 RARC 患者围手术期和中期肿瘤学结果的影响，该研究纳入了在单一欧洲转诊中心由两位外科医生于 2004 年至 2017 年间治疗的 164 例接受 RARC 和 ICUD 的患者。

测量和统计分析

对于每位患者，SE 定义为每位外科医生在患者手术前完成的 RARC 总数。在单外科医生水平聚类的多变量线性和逻辑回归模型中，评估 SE 与手术时间（OT）、淋巴结收获量（LNY）、阳性切缘（PSMs）、Clavien-Dindo 分级≥2 的术后 30 天并发症（CD≥2）和肿瘤学结果（18 个月复发率）之间的关系。

结果和局限性

在调整病例组合后，SE 与较短的 OT 相关（p=0.003）、术后 CD≥2 发生率较低（p=0.01）和 18 个月复发率较低（p=0.002）相关。相反，SE 与 PSM 发生率较低（p=0.3）和 LNY 较高（p=0.4）无关。SE 与 OT 之间的关系是非线性的，在 50 例后观察到一个平台。相反，SE 与 CD≥2 和 18 个月复发之间的关系是线性的，在 88 例手术后没有达到平台。