通盤規劃如何避免及處理達文西機器手臂輔助腹腔鏡根除性攝護腺
切除術的併發症-單一外科醫師執行 1000 例之經驗
歐宴泉1、楊晨洸1、張光喜2、王約翰 3、熊小澐4
台中榮總泌尿外科1、中國醫藥大學生統小組2、台中榮總病理部3、台中榮總放射部4
Prevention and management of complications during robotic assisted laparoscopic radical prostatectomy from comprehensive planning : experience of a single surgeon of 1000 cases
Yen-Chuan Ou1,2,6, Chun-Kuang Yang1,6, Kuangh-Si Chang2,6, John Wang3,6, Siu-Wan Hung4,6, Min-Che Tung5,6 , Ashutosh K Tewari7 , Vipul R Patel 8
1Division of Urology, Department of Surgery, 2Department of Research, 3Department of Pathology, and 4Department of Radiation, Taichung Veterans General Hospital, Taichung, Taiwan;
5Division of Urology, Department of Surgery, Tungs’ Taichung MetroHarbor Hospital, Taichung, Taiwan; 6School of Medicine, National Yang-Ming University, Taipei, Taiwan;
7Department of Urology, Icahn School of Medicine at Mount Sinai, New York, NY; 8Global Robotics Institute, Florida Hospital, Orlando, Florida, USA.
Purpose:
To report how to prevent and manage complications of robotic assisted laparoscopic radical prostatectomy (RALP) performed by a single surgeon in Taiwan from 1000 cases experience.
Patients and Methods:
Complication (Clavien system) rates were prospectively assessed in 1000 consecutive patients undergoing RALP ( Group I: cases 1-200, IIa: 201-400, IIb: 401-600, IIIa: 601-800 and IIIb:801-1000). Preoperative evaluation focus on gouty history, drugs influence clotting time and cardiopulmonary problems. Magnetic resonance imaging were routinely done. Operative difficulty was assessed including neo-adjuvant hormonal therapy (NHT), obese patients (BMI>30), prostate volume>70 g, large median lobe with intravesical protrusion >1 cm, previous transurethral resection of the prostate (TURP), previous pelvic surgery, received extended pelvic lymph nodes dissection (EPLND), salvage robotic radical prostatectomy (SRP). Clinical pathway was described below: Patients were allowed to have water and then resumed regular diet on POD 1-2. The drainage tube was removed and intravenous fluid discontinued on POD 1-3.
Results
The trend of more older age, higher ASA score, body mass index (BMI) and more advanced clinical stage from Group I to Group IIIb, it is significantly statistical differences. The trend of cases of NHT, obese patients (BMI>30), previous pelvic surgery, received EPLND and SRP were significantly increased from Group I to Group IIIb. Conversely, a trendy significantly less blood loss occurred (Group I 179 ml, IIa 117 ml, IIb 90 ml, IIIa 99ml, IIIb: 97 ml, p<0.001). Blood transfusion (BT) incidence was gradually reduced from 3.5% to 0.5% in Groups I and IIIb, respectively (p=0.022). The total complication was 6.4% (64/1000) (surgical/medical : 5% / 1.4%). Statitically significant decrease tendency of complication rate was 12%, 6%, 6%,4% and 4% in Groups I, IIa, IIb,IIIa and IIIb respectively (p=0.003). The most common complication (11/1000=1.1%) was blood transfusion and bowel problem.
Conclusions
Learning curve for every 200 cases of RALP showed significantly less complication even the operative difficulty was increased. The keys to prevent complication was preoperation evaluation meticulously, MRI planning and a dedicated robotic team to do RALP intraoperatively. Early diagnosis and management of complication is paramount in patients have any deviation from the normal postoperative course and clinical care pathway.
Keywords
Complication; Laparoscopy; Prostate cancer; Radical prostatectomy; Robotics