標準化達文西機器手臂輔助腹腔鏡根除性攝護腺切除術-從第一例到一千兩百例
歐宴泉1,2 楊晨洸1熊小澐3
1臺中榮總外科部泌尿外科、2醫學研究部、3臺中榮總放射線部
Standardized procedure of robotic assisted laparoscopic radical prostatectomy from case 1 to case 1200
Yen-Chuan Ou1,2, Chun-Kuang Yang1 Siu-Wan Hung3
1Division of Urology, Department of Surgery, 2Department of Research, and 3Department of Radiation, Taichung Veterans General Hospital, Taichung, Taiwan
Purpose: To standardize the procedure of robotic assisted laparoscopic radical prostatectomy (RALP) after evolution, learning and modification from 1200 cases experience. Outcomes of RALP was present.
Patients and Methods: From Dec. 2005 to Apr. 2016, 1200 cases received RALP performed by a single surgeon.
Preoperative: 1.5-Tesla multiparametric endorectal coil magnetic resonance imaging (MRI) was done before 2011, and a 3.0-Tesla magnet with a slice thickness <3.0 mm was used for MRI after 2011. The procedure of RALP was evolutive and modified from learning. Posterior approach from Cul-de Sac, first step was vas and seminal vesicle dissection at case 106. Four robotic arms and six trocars were set at case 180. After dropping of urinary bladder (UB) and bilateral pelvic lymph node dissection were performed. Bladder neck identified and transected is crucial step. The key tricks of the trade was from preoperative MRI, digital rectal examination (DRE) and intraoperative demarcation between UB and prostate by pinch method, perivesical fat, foley catheter waggle and UB distention. Mostly, deep dorsal vascular complex was sutured and ligated to obviate bleeder influencing operative field. Apical dissection may be anterior or retro-apical transected urethra.
Neurovascular bundle (NVB) preservation was assessed according to D’Amico risk classification, biopsy tumor percentage, and MRI. The urethrovesical anastomosis was modified by Van Velthoven ‘s method. Suspension stitches was done about case 30-100 and posterior pelvic reconstruction from 101-1000. No more posterior pelvic reconstruction was done after case 1001, except difficulty case for urethrovesical anastomosis. Normal saline 200 ml for UB challenge was routinely done during intraoperation. Complication (Clavien system) rates were prospectively assessed in 1200 consecutive patients undergoing RALP.
Results: The mean age was 65.90±7.66 yrs and ASA I/II/III was 10%/80%/10%. Mean PSA: 18.17±28.24 ng/ml and Gleason score: 6.88±1.02. Clinical stage T1/T2/T3–4/N1or M1 was 30%/54%/9%/1%and suspicious prostate cancer included 6% of patients. Obese patients (BMI >30), included 6% and 10.5% of prostate volume >70 cm3,10.5% of previous transurethral resection of prostate (TURP), 1.1% of salvage-RALP. Decrease tendency of complication rate was 4% after case 600. The trifecta rate was 83% and pentafecta rate was 63%. The 3-year, 5-year, and 7-year biochemical recurrence (BCR)-free survival rates were 79.2%, 75.3%, and 70.2%, respectively.
Conclusions: Preoperation evaluation meticulously, MRI planning and a dedicated robotic team to do RALP intraoperatively. The procedure was standardization step by step. Complication was minimized. Excellent pentafecta rate in patients with NVB preservation. High risk patients was acceptable oncologic outcome.