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目的:比较开放、腹腔镜及机器人三种根治性膀胱切除术的手术疗效及围术期并发症。方法:回顾性分析2013年1月~2015年12月于本中心因膀胱恶性肿瘤行根治性膀胱切除术患者围术期的临床资料:共计325例,男282例,女43例,中位年龄66岁,其中开放根治性膀胱切除术(open radical cystectomy,ORC)226例(男194例,女32例),腹腔镜手术(laparoscopic radical cystectomy,LRC)61例(男54例,女7例),机器人手术(robot-assisted radical cystectomy,RARC)38例(男34例,女4例),收集三组患者年龄、性别组成、体质指数(BMI值)、ASA评分、既往手术史、肿瘤分期和分级、膀胱切除时间、出血量、术中输血率、术后住院天数、二次手术率、围术期并发症的发生率及死亡率等指标,比较各组手术疗效及围术期并发症差异。结果:325例手术均顺利完成,腔镜手术均未中转开放。三组患者的年龄及性别组成、BMI、ASA评分、既往手术史、肿瘤分期及分级之间的差异无统计学意义(P>0.05)。ORC、LRC及RARC的膀胱切除时间分别为(173.4±64.1)min、(224.7±82.5)min、(243.7±96.69)min,差异有统计学意义(P=0.032<0.05,F=14.85);术中出血量分别为(556.2±390.1)ml、(377.1±249.3)ml、(333.9±189.9)ml,差异有统计学意义(P<0.01,F=10.735);术中输血率分别为23.9%、13.8%、10%,差异有统计学意义(P=0.046<0.05,F=12.53);术后住院天数为(13.7±8.71)d、(10.08±4.92)d、(8.40±4.17)d,差异有统计学意义(P=0.042<0.05)。3例因术后粘连性肠梗阻(2例ORC,1例LRC)、2例因切口感染裂开(均为ORC)均行二次手术。围术期并发症发生率分别为25.2%、21.3%、18.4%,差异无统计学意义(P=0.568>0.05,F=1.132),ORC与微创手术(RARC及ORC)相比,ClavienⅡ级以上并发症发生率分别为8.0%、1.6%,差异有统计学意义(P=0.046<0.05)。围术期因感染性休克、失血性休克及心脏基础疾病死亡3例,均为ORC患者。结论:虽然膀胱切除时间较长,但与ORC相比,LRC及RARC的微创优势明显,并发症发生率,尤其是ClavienⅡ级以上并发症比重较低,整体手术疗效优于ORC。
Objective: To compare the curative effect and perioperative complications of three kinds of radical cystectomy: open, laparoscopic and robotic. Methods: A retrospective analysis was performed on the clinical data of 325 patients with 282 patients, including 43 males and 43 females, who underwent radical cystectomy for bladder cancer from January 2013 to December 2015. The median age 66 years old, of whom 226 cases (194 males and 32 females) had open radical cystectomy (ORC), 61 cases had laparoscopic radical cystectomy (LRC) (54 males and 7 females) 38 patients (34 males and 4 females) underwent robot-assisted radical cystectomy (RARC). The age, sex composition, body mass index (BMI), ASA score, history of previous surgery, Grade, cystectomy time, blood loss, intraoperative blood transfusion rate, postoperative hospital stay, secondary surgery rate, incidence of perioperative complications and mortality and other indicators were compared between the surgical treatment and perioperative complications . Results: All 325 cases were successfully completed and no endoscopic surgery was performed. There were no significant differences in age and gender composition, BMI, ASA score, previous surgery history, tumor staging and grading among the three groups (P> 0.05). The resection time of ORC, LRC and RARC were (173.4 ± 64.1) min, (224.7 ± 82.5) min and (243.7 ± 96.69) min, respectively, with significant difference (P = 0.032 <0.05, F = 14.85) The blood loss was (556.2 ± 390.1) ml, (377.1 ± 249.3) ml and (333.9 ± 189.9) ml respectively, with statistical significance (P <0.01, F = 10.735). The intraoperative blood transfusion rates were 23.9% The difference was statistically significant (P = 0.046 <0.05, F = 12.53). The number of hospital stay was (13.7 ± 8.71) d, (10.08 ± 4.92) d and (8.40 ± 4.17) d, respectively There was statistical significance (P = 0.042 <0.05). Three cases were complicated by postoperative adhesive intestinal obstruction (2 cases of ORC, 1 case of LRC) and 2 cases of incision infection (both ORC). The incidences of perioperative complications were 25.2%, 21.3% and 18.4% respectively, with no significant difference (P = 0.568> 0.05, F = 1.132). Compared with minimally invasive surgery (RARC and ORC), ClavienⅡ The above complication rates were 8.0% and 1.6% respectively, with significant difference (P = 0.046 <0.05). Perioperative septic shock, hemorrhagic shock and heart disease in 3 deaths, are ORC patients. CONCLUSION: Although the duration of cystectomy is longer, the minimally invasive advantages of LRC and RARC are obvious compared with those of ORC. The complication rate, especially the complication of Clavien grade II and above, is lower than that of ORC. The overall operative effect is better than that of ORC.