RESUMEN
Objective To discuss outcome and safety after implementation of enhanced recovery after surgery(ERAS) protocols to patients who underwent robotic assisted radical cystectomy (RARC) with intracorporeal orthotopic "U" shaped ileal neobladder creation using STAPLER technique.Methods Between October 2014 and April 2019,71 patients(59 males and 12 females)with MIBC (Muscle Invasive Bladder Cancer) who underwent RARC with intracorporeal urinary diversion using orthotopic "U" shaped ileal neobladder in Zhejiang Provincial People's Hospital (People's Hospital of Hangzhou Medical College) were studied retrospectively.They had an average age of (65.2 ± 5.6)y and BMI of (22.18 ± 3.75) kg/m2.The median age-adjusted charlson comorbidity index (aCCI) was 4,median ASA score was 2.All patients underwent these inspections pre-RARC:chest Xray,vascular ultrasound (jugular vein included),abdominal ultrasound,CT urography,cystoscopy with biopsy or TURBT(trans-urethral resection of a bladder tumour).All patients were pathological diagnosed with MIBC,with no evidence of systemic metastasis and no history of radiotherapy,systemic chemotherapy and open abdominal surgery before RARC.All 71 patients received RARC with intracorporeal orthotopic "U" shaped ileal neobladder creation using STAPLER technique.Between October 2014 and September 2016,37 cases (29 males and 8 females) were managed without ERAS protocols perioperatively.They had an average age of (65.3 ±5.7)y and BMI of (23.66 ± 3.47)kg/m2.The median aCCI was 4,median ASA score was 2.Between October 2016 and April 2019,another group of 34 cases (30 males and 4 females) were managed with ERAS protocols including nutritional assessment,thrombosis prevention,pain assessment and management,perioperative diet management etc.They had an average age of (64.5 ± 4.3) y and BMI of (21.87 ± 4.85) kg/m2.The median aCCI was 4,median ASA score was 2.There were no statistical significance between the two groups with regard to general information.Surgical and follow-up data were collected for all patients.Results Surgeries were successful in all 71 cases with postoperative follow up for 3-51 months.In ERAS group,there were 22 cases in pT2 and 12 cases pT3 according to classification of malignant tumours:with 2 cases of incidental prostate cancer (IPCa).In non-ERAS group,pT2 in 25 cases and pT3 in 12 cases:with 1 case of IPCa.Statistical significance were observed between groups with regard to the first anal exhaust time [(20.5 ± 18.7) h vs.(29.9 ± 17.4)h,P =0.032],the first defecation time [(72.6 ±27.1)h vs.(88.7 ±35.8)h,P =0.004],length of hospital stay after surgey [(14.1 ± 3.3) d vs.(16.2 ± 4.8) d,P =0.037],numeric rating scales (NRS) Pain Score 8.0,24.0,48.0 h after surgery [(3.2 ±0.5)vs.(3.6 ±0.8),P =0.015;(1.9 ±0.3) vs.(2.2 ± 0.6),P =0.011;(1.3 ± 0.4) vs.(1.6 ± 0.7),P =0.032],respectively.There were no significance between groups with regard to operating time [(290 ± 65) min vs.(282 ± 46) min,P =O.549],intraoperative blood loss [(190.5 ± 235.6) ml vs.(221.1 ± 250.3) ml,P =0.438],transfusion rate [5.9％ (2/34) vs.8.1％ (3/37),P =0.922],readmission within 30 days after surgery [2.9％ (1/34) vs.5.4％ (2/37),P =0.940],early severe complications(within 30 days) [2.9％ (1/34) vs.2.7％ (1/37),P =0.940],late severe complications (after 30 days) [5.9％ (2/34) vs.8.1％ (3/37),P =0.922].Conclusions The implementation of ERAS protocols to patients who underwent RARC with intracorporeal orthotopic "U" shaped ileal neobladder using STAPLER technique is safe and effective.It can reduce postoperative pain and hospital stay,shorten bowel recovery time,improve early functional recovery without increasing major complications.This adoption should be encouraged.
RESUMEN
Objective To investigate the surgical skills of pure robotic-assisted radical cystectomy with orthotopic U-shape ileal neobladder.Methods From October 2014 to September 2016,37 patients with locally advanced bladder cancer(cT2-3 N0-2 Mo)were diagnosed,including 29 males and 8 females,Their age ranged from 52 to 71 years old.According to preoperative cystoscopy,pathological diagnosis and bladder enhanced CT and other examination,25 patients were staged as cT2,12 cases were staged as cT3.25 cases of them were primary tumors,who underwent pure robotic-assisted radical cystectomy and Endo-GIA assisted orthotopic U-shape ileal neobladder reconstruction.First,bilateral lymph nodes were dissected.And the ureter was explored and dissected to the outer wall of the bladder.Then,we ligated the superior artery of bladder and expose the seminal vesicle,vas deferent duct.The DV fascia was opened to expose the posterior wall of prostate.Incise was performed along the both sides of the bladder and prostate fascia to maintain the vascular nerve bundle until the tip of prostate.The urethra was cut off and then the bladder was remove.We used Endo-GIA to cut 30-35 cm ileum and construct U-shaped bladder.The anastomosis between ureter and neo-bladder and the anastomosis between urethra and neo-bladder were performed.Perioperative and followup data were collected.Results The surgeries were successful in all 37 cases.The operation time ranged from 245 to 335 min,mean (285 ± 37) min.The mean intraoperative blood loss was (187 ± 56) ml (ranging 90-300 ml).The average postoperative hospital stay was (17 ± 2)days (ranging 15-20 days).Postoperative intestinal function recovery time ranged from 1.3 to 2.2 days,mean (1.7 ± 0.4) days.Surgical margins were all negative.Lymph node positive rate was 21.6％ (8/37).After 1 nonth,22 cases achieved complete continence.After 3 months,35 cases get fully self-control urination,8 cases have noctual incontinence.Postoperative follow-up ranged from 6 to 24 months,no recurrence or distant metastasis was found in this study.After 6 months,cystoscopy showed no obvious formation of bladder stones.Neo-bladder capacity ranged from 270 to 350 ml.The urodynamic examination showed bladder pressure was maintained between 19 and 25cm H2O.Conclusions Pure robotic-assisted radical cystectomy can achieve better bladder resection,better remaining of urethral and neurovascular bundles and good control of urinary continence after operation.Endo-GIA assisted orthotopic U-shaped ileal bladder need shorter intestinal tract and cause less influence to the intestinal function.The neo-bladder shape is more regular,simple doing,earn shorter operation duration,less bleeding,quick recovery,which is a safe and effective surgical approach.