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Objective:To explore the feasibility and safety of robotic-assisted living donor left lateral segmentectomy (LDLLS) in a large pediatric liver transplant program.Methods:Retrospective analysis was performed for clinical data of 45 LDLLS donors and recipients from June 2021 to September 2022.Traditional open donor liver resection (n=30) and robotic-assisted segmentectomy (n=15) were performed.Two groups were compared with regards to operative duration, intraoperative hemorrhage, postoperative healing and postoperative complications.SPSS 21.0 was utilized for statistical analysis.Independent sample T, paired sample T, Wilcoxon rank sum and Chi-square tests were performed for examining the inter-group differences.Results:Operative duration of robot-assisted surgery group was substantially longer than that of traditional open surgery group ( P<0.001). Intraoperative blood loss was less in robot-assisted surgery group was less than that in traditional open surgery group[(106.0±39.8) vs.(251.0±144.8) ml, P=0.001]. Postoperative hospital stay of robot-assisted surgery group was shorter than that of traditional open surgery group[6.0(6.0, 6.0) vs.7.0(6.0, 9.0), P<0.05]. Two cases of postoperative biliary leakage were observed in donor of traditional open surgery group.Among 2 cases of abdominal infection, one was due to biliary leakage from liver section and secondary surgery was then performed.One case of incisional infection and another case of thrombosis occurred in donor of traditional open surgery group.In robot-assisted surgery group, only one donor had amylase elevation.In traditional open surgery group, there were one case of local thrombosis in middle hepatic vein and one case of bile duct stricture.No long-term complications occurred in robot-assisted surgery group during a follow-up period of over 6 months.Finally recipient data analysis indicated that no significant inter-group differences existed in operative duration, intraoperative blood loss, postoperative hospital stay or postoperative abdominal infection ( P=0.634, P=0.180, P=0.86 and P=0.153). Conclusions:Robotic-assisted LDLLS proves to be be a safe and reliable option for living donor segmentectomy.It is superior to conventional LDLLS in terms of shorter hospital stay, less intraoperative blood loss and fewer postoperative complications.
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Objective:To determine the impact of body mass index (BMI) on perioperative and oncological outcomes after robot-assisted radical cystectomy (RARC) with intracorporeal urinary diversion.Methods:Clinical data of bladder cancer patients undergoing robot-assisted radical cystectomy with intracorporeal urinary diversion in Zhejiang Provincial People's Hospital from January 2017 to January 2020 were retrospectively analyzed. Patients were divided into three groups according to BMI, including 61 cases in normal group (<25.0 kg/m2), 52 cases in overweight group (25.0-29.9 kg/m2) and 33 cases in obese group (≥30.0 kg/m2). In the normal group, the median age was 73.6(59, 79), including 45 male(73.8%), with 51 cases(83.6%) of ASA score 0-2, 10 cases (16.4%)of 3 or higher, and 10 cases (16.4%) undergoing neoadjuvant chemotherapy. Past medical history included smoking in 34 cases (55.7%), hypertension in 19 cases (31.1%), diabetes in 10 cases (16.4%), heart disease in 12 cases (19.7%), and abdominal surgery in 6 cases (9.8%). In the overweight group, the median age was 69.7(60, 78), including 38 male (73.1%), with 25 cases (48.1%)of ASA score 0-2, 27 cases (51.9%) of 3 or higher, and 9 cases (17.3%) undergoing received neoadjuvant chemotherapy. Past medical history included smoking in 30 cases (57.7%), hypertension in 20 cases (38.5%), diabetes in 10 cases (19.2%), heart disease in 9 cases (17.3%), and abdominal surgery in 5 cases (9.6%). In the obses group, the median age was 69.9(61, 78), including 21 male(63.7%), with 20 cases (60.6%)of ASA score 0-2, 13 cases(39.4%) of 3 or higher, 9 cases (27.3%) undergoing neoadjuvant chemotherapy. Past medical history included smoking in 18 cases (54.5%), hypertension in 17 cases (51.5%), diabetes in 19 cases (57.6%), heart disease in 7 cases (21.2%), and abdominal surgery in 4 cases (12.1%). After statistical comparison among the three groups, it was found that the proportion of patients with hypertension and diabetes in the obesity group and overweight group was higher than that in the normal group (all P<0.05), but there was no significant difference in other factors (all P>0.05). During the surgical process, robot-assisted radical cystectomy and bilateral pelvic lymph node dissection were performed firstly. The scope of lymph node dissection was divided into standard range and expanded range, and the diversion was divided into orthotopic neobladder and ileal bladder. During the orthotopic neobladder process, 40-50 cm ileum at the distance of 15 cm away from ileocecum was obtained by stapler, and then the U-shaped neobladder was made, and the new bladder was anastomosed with urethra and bilateral ureter. For ileal bladder, the ileum was cut off 15cm away from the ileocecum with stapler to obtain the 15 cm ileum to prepare the ileal conduit and restore the continuity of the ileum. The bilateral ureteral spacing 3cm was implanted on the ileal conduit. In the normal group, standard range lymphatic dissection was performed in 20 cases (32.8%), enlarged dissection in 41 cases (67.2%), orthotopic neobladder in 22 cases(36.1%), and ileal conduit in 39 cases (63.9%). In the overweight group, standard range lymphatic dissection was performed in 12 cases (23.1%), enlarged dissection in 40 cases (76.9%), orthotopic neobladder in 26 cases (49.1%), and ileal conduit in 26 cases (50.9%). In the obesity group, the standard range of lymphatic dissection was performed in 7 cases (21.2%), enlarged dissection in 26 cases (78.7%), orthotopic neobladder in 7 cases (21.2%), and ileal conduit in 26 cases (78.8%). There was no significant difference among the three groups (all P>0.05). Compared the operation time, intraoperative blood loss, postoperative exhaust time, postoperative time of taking solid food, postoperative hospital stay, postoperative complications (according to the Clavien-Dindo grading system, postoperative complications are reported inⅠ-Ⅱ grade as mild complications and above Ⅲ grade as serious complications) and pathology results in three groups. Results:All cases successfully underwent robotically without conversion or major intraoperative complications. The operation time in overweight and obsess group were longer than that of normal group with RARC or orthotopic neobladder [310(250, 350) min, 370(310, 420) min, 250(230, 310) min, ( P<0.05)], but there was no significant difference in RARC and ileal conduit[270(220, 300) min, 280(230, 300) min, 240(220, 290)min, P>0.05]. The estimated blood loss in overweight and obsess group was more than that in normal group [230(150, 450)ml, 310(250, 600)ml, 190(100, 350)ml, P<0.05], but there was no difference in blood transfusion rate [4(7.7%), 2(6.1%), 5(8.2%), P>0.05]. The exhaust time [2(1, 3) days, 2(1, 4)days, 2(1, 4)days], postoperative solid food intake time [4(3, 5)days, 4(3, 6)days, 4(3, 6)days] and the hospital stay[10(5, 16)days, 10(6, 17)days, 12(6, 20)days] were not different in three groups(all P>0.05). The mild complication rates in 90 days were significant higher in overweight and obsess groups[28 (53.8%), 16(48.5%), 20(32.8%), P<0.05], but the total and severe complication rates were not significantly different. The incidences of urinary system complications and incision complications in obese and overweight patients were significantly higher than those in normal group ( P<0.05). There was no significant difference in the incidence of gastrointestinal complications and ureteral anastomosis-related complications (stricture or urinary leakage)( P>0.05). There was no significant difference in the number of dissected lymph node, positive lymph node, positive rate of incisional margin and postoperative pathological stage among three different BMI groups(all P>0.05). Conclusion:Robot-assisted radical cystectomy combined with intracorporeal urinary diversion is a safe and effective method for the treatment of overweight, obese and even morbidly obese patients with bladder cancer. The recovery of intestinal function and the oncological results are not affected by body mass index. However, laparoscopic radical cystectomy for overweight and obese patients, especially for orthotopic neobladder, has the risk of long operation time, large amount of intraoperative bleeding and increased risk of minor postoperative complications.
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【Objective】 To compare the outcomes of robot-assisted laparoscopic transperitoneal and retroperitoneal operation for huge (>6 cm) adrenal tumors. 【Methods】 The clinical data of 45 patients with huge adrenal tumors who underwent robotic surgery during Jan.2017 and Dec.2021 were retrospectively analyzed, including 28 cases via the transperitoneal approach and 17 cases via the retroperitoneal approach. 【Results】 No patients were converted to open operations. There were no significant differences in postoperative drainage time (2.24±0.44 vs. 2.36±0.49) d, operation time (130.88±5.96 vs. 136.61±8.39) min, blood loss (189.41±13.91 vs. 192.5±12.36) mL and postoperative hospital stay (7.06±0.56 vs. 7.46±0.69) d between the retroperitoneal and transperitoneal approaches. Retroperitoneal approach was better than transperitoneal approach in early postoperative feeding [(38.82±6.75 vs. 74.14±6.57) h, P<0.01] . 【Conclusion】 Robotic surgery is safe and effective in the treatment of large adrenal tumors. The choice of surgical approach should be based on patients’ condition, tumor volume and location.
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Objective:To explore the safety and efficacy of renal arterial hypothermia perfusion in robot-assisted laparoscopic partial nephrectomy.Methods:The data of 11 patients with complex renal tumors admitted to our hospital from March 2020 to December 2021 were retrospectively analyzed. There were 7 males and 4 females. The patients’age was (64.64±13.56) years old.The median R. E.N.A.L. score was 8 (7, 9) points. Preoperative glomerular filtration rate (GFR) was (64.40±25.52) ml/min. All patients had a renal artery cold solution perfusion robot-assisted laparoscopic partial nephrectomy. 4℃ sodium lactate Ringer's solution was injected into the affected kidney by the catheter, which could provide the kidney a hypothermic state during the operation and protected the renal function during the long period of warm ischemia. The intraoperative data and postoperative complications were recorded. The data of postoperative renal function, routine urine test, urinary CT, preoperative and postoperative glomerular filtration rate (GFR) were analyzed.Results:The renal artery blocking time was (34.09±2.84) min during the surgery. The patients’ body temperature was (36.10±0.44) ℃. The surgical duration was (126.73±47.08) min. The intraoperative bleeding was (81.82±53.07) ml. There were no complications, such as urinary leakage, low body temperature, fever, etc. There was no significant difference between the 3-months postoperative GFR (59.06±25.67) ml/min and preoperative GFR ( P=0.636). Conclusions:For patients with complex renal tumors, renal arterial cold solution perfusion in robot-assisted laparoscopic partial nephrectomy can help obtain longer operative duration during hot ischemia, preserve renal function, and it provide a safe and feasible surgical method for patients.
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Objective:To explore and compare the perioperative result and complications of robot-assisted radical cystectomy with intracorporeal and extracorporeal urinary diversion.Methods:Clinical data of bladder cancer patients undergoing robot-assisted radical cystectomy with ileal conduit in Zhejiang Provincial People's Hospital from January 2015 to March 2020 were retrospectively analyzed. Eighty-two patients underwent extracorporeal urinary diversion (ECUD group), and 122 underwent intracorporeal urinary diversion (ICUD group). In the ECUD group, the median age was 70(61, 76)years old, including 67 male (81.7%), the median BMI was 26.1(24.3, 28.5), 67 cases(81.7%) was ASA score 0-2, 15 cases (18.3%)was 3 or higher, 15 cases (18.3%) were high risk non-muscular invasive bladder cancer. 67 cases (81.7%) were muscular invasive bladder cancer. 16 cases (19.5%) received neoadjuvant chemotherapy. Past medical history included smoking in 35 cases (43.2%), hypertension in 31 cases (37.5%), diabetes in 17 cases (21.3%), heart disease in 13 cases (15.7%), and abdominal surgery in 15 cases (17.8%). In the ICUD group, the median age was 68 (62, 75), 95 male (77.9%), the median BMI was 25.6 (23.4, 27.8)kg/m 2, 105 cases(86.1%) was ASA score 0-2, 17 cases (13.9%)was 3 or higher, 29 cases (24.9%) were high risk non-muscular invasive bladder cancer, and 93 cases (75.1%) were muscular invasive bladder cancer. There were 22 cases (18.0%) undergoing neoadjuvant chemotherapy. Past medical history included smoking in 58 cases (47.3%), hypertension in 44 cases (32.6%), diabetes in 33 cases (22.8%), heart disease in 28 cases (26.7%), and abdominal surgery in 17 cases (14.2%). No significance was detected in characteristics between the two groups. For ileal bladder making and ureteral implantation method in ICUD group, 15 cm ileum was taken using stapler at the 15 cm from ileocecum to make ileal conduit and restore the continuity of the ileum. The proximal end of the ileal conduit was closed. The bilateral ureteral were implanted 3 cm apart on the ileal bladder. F6 single J tube was placed into both of the ureters to drain urine. For ECUD group, the subumbilical 5 cm incision was taken to enter the abdominal cavity. The ileocecum was found and the terminal ileum was taken out of the body. A segment of 15 cm in length ileocecum 15 cm away from the cecum was cut off with a linear cutting stapler and the blood vessels of arterial arch were ligated, then a small opening at the same ileum position was cut. The continuity of the ileocecum was restored. The ileal conduit was irrigated, and the bilateral ureters were placed into a single J tube and anastomosed to the ileal conduit 3 cm apart. The operation time, intraoperative blood loss, postoperative exhaust time, postoperative feeding time, postoperative hospital stay, postoperative incision pain score, postoperative readmission rate, peri-operative mortality, postoperative complications and pathology results were compared between the two groups. Results:All cases were successfully performed robotically without conversion or major intraoperative complications. There was no significant difference in operation time between ICUD group and ECUD group [260(230, 310) min and 235(220, 290) min, P=0.078]. The estimated blood loss in ECUD group was more than that in ICUD group [300(200, 400) ml and 150(100, 300), P=0.037], but there was no difference in blood transfusion rate between the two groups [7(8.6%) and 9(7.4%), P=0.196]. The exhaust time [4(2-6) days and 2(1, 3) days] and postoperative solid food feeding time [7(4, 9) days and 4(3, 5) days] in the ECUD group were longer than those in the ICUD group (all P<0 05). The exhaust time[4(2-6)day and 2(1, 3)day] and solid food feeding time[7(4, 9)day and 4(3, 5)day] in ECUD group were longer than those in ICUD group. There was no significant difference in postoperative hospital stay between ECUD group and ICUD group[8(5, 11)day and 6(5, 9)day, P=0.212]. Clavien-Dindo Ⅰ-Ⅱ grade was defined mild complication, Ⅲ grade or above was defined serious complication, early complication was defined within 30 days after operation, and late complication was defined 30-90 days after operation. The overall early postoperative complication rate were 19.6%(24) and 34.2%(28)(ICUD vs.ECUD), the mild complications rate were 13.9%(17) and 25.6%(21)(ICUD vs.ECUD), and the late severe complication rate were 4.1%(5)and 10.1%(8)(ICUD vs.ECUD). ICUD group were significantly lower than those of ECUD group (all P<0.05). There was no difference in the early severe complication rate [5.7%(7) and 8.5%(7)], the total late complication rate [15.6%(19) and 16.1%(13)], and the late mild complication rate [11.5% (14) and 6.0% (5)] (all P>0.05). There was no significant difference between ICUD group and ECUD group, in term of the number of lymph nodes dissected [21(14, 25) and 19(15, 24)], the positive rate of lymph nodes [10.7%(13) and 10.0%(8)], the positive rate of surgical margin [3.3%(4) and 4.8%(4)] and postoperative pathological stage T 1-T is [25(20.3%) and 14(17.1%)], and T 2-T 3 [97(79.7%) and 68(82.9%)]. The number of patients with postoperative incision pain (pain score >5) was 43 (35.6%) in ICUD and 46 (56.5%) in ECUD( P< 0.05). The 30-day and 90-day readmission rates were 1.6% (2/82) and 4.9% (6/82) in ICUD group, and 1.2% (1/122) and 9.8% (8/122) in ECUD group, respectively. There was no peri-operative mortality in both groups. Conclusions:Robot-assisted radical cystectomy with ileal conduit is a safe and repeatable method for the treatment of muscular invasive or high-risk non-muscular invasive bladder cancer. Complete intracorporeal bladder reconstruction is feasible and has the advantages of less intraoperative bleeding, faster postoperative intestinal function recovery and less complications.
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Objective To explore the influencing factors of operative time, blood loss and nerve-sparing of robotassisted laparoscopic radical prostatectomy (RALP). Methods A total of 184 patients with local or locally advanced prostate cancer were enrolled, and they underwent RALP by the single surgeon in Department of Urology of Changhai Hospital of Navy Medical University (Second Military Medical University) from January 1, 2016 to October 1, 2017. The effects of age, prostate volume, postoperative pathological Gleason score, pelvic lymph node dissection and biopsy approach on the operative time, blood loss and nerve-sparing of RALP were analyzed. The influencing factors of operative time and blood loss were analyzed by multivariate linear regression analysis. Linear correlation analysis was used to identify the correlation between operative time and prostate volume. LSD-t test was used to detect the difference of operative time among the patients with different lymph node dissections. The influencing factors of nerve-sparing during RALP were analyzed by multivariate logistic regression analysis. The difference of age was analyzed by one-way ANOVA and the differences of postoperative pathological Gleason score, lymph node dissection and biopsy approach were analyzed by Kruskal-Wallis H test between the patients with unreserved, reserved unilateral and reserved bilateral nerves. Results Multivariate linear regression analysis showed that prostate volume and lymph node dissection were independent influencing factors of RALP operative time (both P0.01). There was a significantly positive linear correlation between prostate volume and operative time (r＝0.201, P＝ 0.006). The patients with extended lymph node dissection had significantly longer operative time than those with obturator lymph node dissection, and the latter had significantly longer operative time than those without lymph node dissection (both P0.01). Age, prostate volume, postoperative pathological Gleason score, pelvic lymph node dissection, and biopsy approach had no significant effect on intraoperative blood loss (all P0.05). Multivariate logistic regression analysis showed that age, postoperative pathological Gleason score, lymph node dissection and biopsy approach were independent influencing factors of nerve-sparing during RALP (OR＝0.949, 95% CI 0.906-0.995, P＝0.027; OR＝0.742, 95% CI 0.551-0.999, P＝ 0.049; OR＝0.540, 95% CI 0.322-0.903, P＝0.019; OR＝0.457, 95% CI 0.230-0.905, P＝0.025). The cases with unreserved, reserved unilateral and reserved bilateral nerves were 108, 20 and 56, respectively; and the age, postoperative pathological Gleason score, lymph node dissection and biopsy approach were significantly different among the three groups (all P0.05). Conclusion The patients with prostate cancers, who have larger prostate volume or undergo lymph node dissection during RALP, may have longer operative time. Older age, higher postoperative pathological Gleason score, undergoing lymph node dissection or transrectal biopsy are not conductive to nerve-sparing during RALP.