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目的:总结达芬奇机器人辅助根治性膀胱切除和原位回肠新膀胱术的安全性和临床效果。方法:2014年11月~2017年4月行机器人辅助膀胱手术53例,回顾分析患者围手术期及术后随访资料,包括肿瘤病理及功能恢复等。结果:1例因术中探查肠系膜下动脉旁转移淋巴结无法摘除,改行机器人辅助膀胱部分切除术,52例膀胱癌患者均行机器人辅助根治性膀胱切除术,其中2例(2/52)同期行腹腔镜单侧肾盂输尿管根治性切除术,46例(46/52)予原位回肠新膀胱术,无需输血病例,术后病理示手术切缘均为阴性,3例合并前列腺癌。所有病例确定无输尿管新膀胱吻合口漏后拔除双侧输尿管支架管(14~18d)并于1周后拔除正位膀胱导尿管,术后平均住院22d(12~33d)。术后随访15.8个月(2~30个月),拔除尿管后平均27d(1~71d)恢复白昼控尿,尿控满意,6例女性患者中3例尿控满意。随访期间输尿管新膀胱吻合口狭窄1例,慢性尿潴留2例,输尿管回肠输出道吻合口肿瘤复发1例,新膀胱尿道吻合口狭窄2例,尿道复发1例。结论:根据初期的围手术期及随访结果,机器人辅助根治性膀胱切除和原位回肠新膀胱术安全可行。在实施根治性脏器切除术的同时,机器人手术系统的操作优势能够较好保护盆底结构,利于术后控尿功能恢复。更多操作经验的积累和长期前瞻性对照研究有助于全面评估本技术的远期疗效。
Objective: To summarize the safety and clinical effects of da Vinci robot-assisted radical cystectomy and orthotopic ileal neo-bladder surgery. Methods: From November 2014 to April 2017, 53 cases of robot-assisted bladder surgery were performed. The data of perioperative and postoperative follow-up were retrospectively analyzed, including tumor pathology and functional recovery. Results: One case was robotic-assisted radical cystectomy in 52 cases of bladder cancer due to intraoperative exploration of inferior mesenteric artery lymph node metastasis and switch to robot-assisted partial cystectomy. Two of them (2/52) Laparoscopic unilateral ureteropelvic radical resection, 46 cases (46/52) to the ileal neo-bladder surgery, no blood transfusion cases, postoperative pathology showed surgical margins were negative, 3 cases with prostate cancer. All patients were confirmed without urethral anastomotic leakage after removal of bilateral ureteral stent tube (14 ~ 18d) and removal of anterior bladder catheter after 1 week, the average postoperative hospital stay 22d (12 ~ 33d). The patients were followed up for 15.8 months (range, 2 to 30 months). After removal of the catheter, the control of urine was restored on day 27d (1-7d) on average. Urinary control was satisfactory in 3 of 6 female patients. One case of ureteral neobladder anastomosis stenosis, two cases of chronic urinary retention, one case of ureteral ileal outlet anastomotic tumor recurrence, two cases of neovascular urethral anastomotic stenosis and one case of urethral recurrence during follow-up. Conclusion: According to the initial perioperative and follow-up results, robotic-assisted radical cystectomy and orthotopic ileal neo-bladder surgery are safe and feasible. In the implementation of radical resection of the organ at the same time, the operating advantages of robotic surgery system can better protect the pelvic floor structure, which will help postoperative urinary function recovery. The accumulation of more operational experience and long-term prospective controlled studies contribute to a comprehensive assessment of the long-term efficacy of this technique.