Department of Urology, Mayo Clinic Hospital, Phoenix, AZ.
Creighton University, Omaha, NE.
Urology. 2020 Jun;140:107-114. doi: 10.1016/j.urology.2019.12.058. Epub 2020 Feb 27.
To assess whether the beneficial perioperative effects of alvimopan differ with surgical approach for patients who undergo open radical cystectomy (ORC) vs robot-assisted radical cystectomy (RARC).
This retrospective study reviewed all patients who underwent cystectomy with urinary diversion at our institution between January 1, 2007, and January 1, 2018. Data were collected on demographic characteristics, comorbidities, surgical approach, alvimopan therapy, hospital length of stay (LOS), days until return of bowel function (ROBF), and complications. Outcomes and interactions were evaluated through regression analysis.
Among 573 patients, 236 (41.2%) underwent RARC, 337 (58.8%) underwent ORC, and 205 (35.8%) received alvimopan. Comparison of 4 cohorts (ORC with alvimopan, ORC without alvimopan, RARC with alvimopan, and RARC without alvimopan) showed that patients who underwent ORC without alvimopan had the highest rate of postoperative ileus (25.6%, P = .02), longest median hospital LOS (7 days, P < .001), and longest time until ROBF (4 days, P < .001). On multivariable analysis, the interaction between surgical approach and alvimopan use was significant for the outcome of ROBF (estimate, 1.109; 95% confidence interval, 0.418-1.800; P = .002). In the RARC cohort, multivariable analysis showed no benefit of alvimopan with respect to ileus (P = .27), LOS (P = .09), or ROBF (P = .36). Regarding joint effects of robotic approach and alvimopan, RARC had no effect on gastrointestinal tract outcomes.
We observed a diminished beneficial effect of alvimopan among patients undergoing RARC and a statistically significant benefit of alvimopan among patients undergoing ORC. The implications of these findings may permit more selective medication use for patients who would benefit the most from this drug.
评估 alvimopan 的围手术期有益效果是否因接受开放式根治性膀胱切除术（ORC）与机器人辅助根治性膀胱切除术（RARC）的患者而有所不同。
本回顾性研究分析了 2007 年 1 月 1 日至 2018 年 1 月 1 日期间在我院行膀胱切除术+尿流改道术的所有患者的数据。收集人口统计学特征、合并症、手术方式、alvimopan 治疗、住院时间（LOS）、肠道功能恢复时间（ROBF）以及并发症等数据。通过回归分析评估结局和交互作用。
在 573 例患者中，236 例（41.2%）接受 RARC，337 例（58.8%）接受 ORC，205 例（35.8%）接受 alvimopan。对 4 个队列（ORC+alvimopan、ORC-alvimopan、RARC+alvimopan 和 RARC-alvimopan）的比较表明，未使用 alvimopan 的 ORC 患者术后肠梗阻发生率最高（25.6%，P=0.02），中位 LOS 最长（7 天，P<0.001），ROBF 时间最长（4 天，P<0.001）。多变量分析显示，手术方式与 alvimopan 使用的交互作用对 ROBF 结局有显著影响（估计值，1.109；95%置信区间，0.418-1.800；P=0.002）。在 RARC 队列中，多变量分析显示 alvimopan 对肠梗阻（P=0.27）、LOS（P=0.09）或 ROBF（P=0.36）均无获益。关于机器人辅助手术和 alvimopan 的联合作用，RARC 对胃肠道结局没有影响。
我们观察到，接受 RARC 的患者中 alvimopan 的有益效果减弱，而接受 ORC 的患者中 alvimopan 的有益效果显著。这些发现的意义可能使最受益于这种药物的患者更有选择性地使用药物。
