Guliev B G, Komyakov B K, Bolokotov R R, Al-Attar T Kh
Department of urology of North-Western State Medical University named after I.I. Mechnikov, Saint Petersburg, Russia.
Center of Urology with robot-assisted surgery of City Mariinsky hospital, Saint Petersburg, Russia.
Urologiia. 2020 Nov(5):54-60.
Robot-assisted radical cystectomy (RARC) with intracorporeal neobladder formation is a complex surgical procedure.
To describe the main stages of RARC and to analyze its short-term results.
RARC with ileocystoplasty was performed in 16 patients, most of whom were men (n=14). In 15 patients, the indication for surgery was bladder cancer (BCa), while one patient has radiation-induced sigmoid fistula with a formation of small, contracted bladder. During radical cystectomy (RC), the lower ureters were dissected, followed by posterior dissection of the bladder with mobilization from both sides to the pelvic fascia, clipping and transection of the vesical pedicles, and suturing of the dorsal venous complex with urethral dissection. After pelvic lymph node dissection, 40 cm of the ileum was resected, after that two distal segments of 15 cm were U-shaped, and a 1.5 cm incision was made in the lower part of the bowel, followed by a formation of the urethral anastomosis. Then bowel segments were detubularized, and continuous suture on the posterior and anterior walls of the neobladder was done. Ureters were implanted in the proximal tubular part of the resected colon according to the Nesbit technique.
The mean operation time was 380 minutes. The blood loss ranged from 80 to 200 ml; however, blood transfusion was not performed. Complications during 30-days after RARC were observed in 7 (43.7%) patients, including 4 (25%) of class I-II according to Clavien - Dindo, and 3 (18.7%) of class III-IV. In patients with leakage at the uretero- intestinal anastomosis (n=2) and urethro-neobladder anastomosis (n=1), percutaneous drainage was performed, which allowed to resolve these complications. There were no cases of bowel obstruction. One patient with gastrointestinal bleeding required blood transfusion. The 90-day late complications occurred in 6 (37.5%) patients, including 2 cases of upper urinary tract infection. One patient died of acute myocardial infarction.
RARC is a contemporary minimally invasive method for muscle-invasive BCa. Stepwise approach to RARC with intracorporeal neobladder formation may reduce the operation time and the rate of complications.
机器人辅助根治性膀胱切除术（RARC）并进行体内新膀胱成形术是一种复杂的外科手术。
描述RARC的主要阶段并分析其短期结果。
对16例患者实施了RARC并进行回肠膀胱成形术，其中大多数为男性（n = 14）。15例患者的手术指征为膀胱癌（BCa），1例患者为放射性乙状结肠瘘伴小而挛缩膀胱的形成。在根治性膀胱切除术（RC）过程中，游离下段输尿管，然后从两侧向盆筋膜游离膀胱后壁，夹闭并切断膀胱蒂，缝合背侧静脉复合体并游离尿道。盆腔淋巴结清扫术后，切除40 cm回肠，之后将两段15 cm的远端肠段做成U形，在肠管下部做一个1.5 cm的切口，接着进行尿道吻合。然后将肠段去管化，在新膀胱的前后壁进行连续缝合。根据Nesbit技术将输尿管植入切除结肠的近端管状部分。
平均手术时间为380分钟。失血量在80至200 ml之间；然而，未进行输血。RARC术后30天内，7例（43.7%）患者出现并发症，其中根据Clavien - Dindo分级为I - II级的有4例（25%），III - IV级的有3例（18.7%）。输尿管 - 肠吻合口漏（n = 2）和尿道 - 新膀胱吻合口漏（n = 1）的患者进行了经皮引流，从而解决了这些并发症。无肠梗阻病例。1例胃肠道出血患者需要输血。术后90天晚期并发症发生在6例（37.5%）患者中，包括2例上尿路感染。1例患者死于急性心肌梗死。
RARC是一种用于肌层浸润性BCa的现代微创方法。采用逐步进行体内新膀胱成形的RARC方法可能会减少手术时间和并发症发生率。
