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Title: [Robotic versus laparoscopic total mesorectal excision with partial preservation of Denonvilliers fascia: a comparative study of short-term efficacy and urinary and erectile function].
Author: Huang ZK, Chi P, Huang Y.
Journal: Zhonghua Wei Chang Wai Ke Za Zhi; 2021 Apr 25; 24(4):327-334. PubMed ID: 33878822.
Abstract:
Objective: Postoperative sexual and urinary dysfunctions are common in rectal cancer patients. This study was conducted to compare the short-term efficacy and the impact of surgery on urinary and erectile functions between laparoscopy and robotic-assisted total mesorectal excision (TME) with partial preservation of Denonvilliers fascia. Methods: A retrospective cohort study was carried out. Clinical data of 276 patients with low rectal cancer who underwent TME with partial preservation of Denonvilliers fascia in our department between January 2016 and March 2019, including 143 in robotic group and 133 in laparoscopic group, were analyzed. All the patients were positioned by rigid rectoscope, and the distance between the tumor and the anal verge was ≤7 cm. The urinary and erectile functions were followed up at postoperative 12-month and evaluated by IPSS score (0-7 points as mild symptoms, 8-19 points as moderate symptoms, 20-35 points as severe symptoms; the excellent rate was defined as the rate of mild symptoms) and IIEF-5 score (score ≥ 22 as no dysfunction, 12-21 as mild, 8-11 as moderate, and 5-7 as severe) respectively. Results: There were no significant differences in operation ways between the two groups (P>0.05). The operation time of the robotic group was longer than that of the laparoscopic group [(312.5±75.4) minutes vs. (273.9±65.6) minutes, t=4.514, P<0.001]. However, in patients with higher body mass index (BMI ≥25 kg/m(2)), there was no significant difference in operation time between the two groups [(309.3±78.5) minutes vs. (276.1±75.3) minutes, t=1.751, P=0.085]. The time to postoperative flatus [(1.3±0.4) days vs. (1.5±1.0) days, t=-2.037, P=0.046], defecation [1 (1-5) days vs. 1 (1-12) days, Z=-2.209, P=0.008] and liquid diet [(1.0±0.1) days vs. (1.2±0.1) days, t=3.195, P=0.002] in the robotic group were all shorter than those in the laparoscopic group. While postoperative length of hospital stay in the robotic group was longer than that in the laparoscopic group [(8.5±5.5) days vs. (7.2±3.3) days, t=2.419, P=0.016]. There were no significant differences between the two groups in intraoperative blood loss, conversion rate, morbidity of postoperative complications, positive rate of distal resection margin, positive rate of circumferential resection margin, and the number of resected lymph nodes (all P>0.05). At postoperative 12 months, none of the robotic group nor the laparoscopic group had severe urinary dysfunction, and the overall excellent rate of urinary function reached 97.6% (83/85) and 98.4% (61/62) respectively. The rate of normal and mild erectile dysfunction in the robotic group and the laparoscopic group were 92.2% (47/51) and 92.6% (38/41) respectively (P>0.05). There was no significant difference between the two groups was found regarding the urinary and erectile function (both P>0.05). Conclusions: Compared with laparoscopic, the robotic TME with partial preservation of Denonvilliers fascia has no significant differences in surgical safety and short-term efficacy. They have similar advantages in the protection of urinary and erectile function. Meanwhile the robotic surgery presents faster postoperative recovery of gastrointestinal function. 目的： 直肠癌患者术后性功能及泌尿功能障碍较为常见。本研究比较分析腹腔镜与机器人行低位直肠癌保留部分邓氏筋膜全直肠系膜切除术（TME）的近期疗效及手术对泌尿功能和勃起功能的影响情况。 方法： 采用回顾性队列研究的方法，分析2016年1月至2019年3月期间，于福建医科大学附属协和医院结直肠外科行保留部分邓氏筋膜TME的276例低位直肠癌患者的临床资料，其中腹腔镜手术组133例，机器人手术组143例。所有患者均经硬式直肠镜定位，肿瘤距离肛缘≤7 cm。收集患者的临床资料，并于术后12个月时通过随访，分别以国际前列腺症状评分（IPSS评分：0~7分为轻度症状，8~19分为中度症状，20~35分为重度症状；优良率定义为轻度症状比率）及国际勃起功能指数（IIEF-5评分：≥22分为无障碍，12~21分为轻度障碍，8~11分为中度障碍，5~7分为重度障碍）评价患者的泌尿功能及勃起功能。 结果： 两组患者手术方式差异无统计学意义（P>0.05）。机器人手术组手术时间较腹腔镜手术组长[（312.5±75.4）min比（273.9 ± 65.6）min，t=4.514，P<0.001]，但在体质指数≥25 kg/m(2)的患者中，两组手术时间差异无统计学意义[（309.3±78.5）min比（276.1±75.3）min，t=1.751，P=0.085]。机器人手术组术后首次排气时间[（1.3±0.4）d比（1.5±1.0）d，t=-2.037，P=0.046]、排粪时间[1（1~5）d比1（1~12）d，Z=-2.209，P=0.008]及恢复流质饮食时间[（1.0±0.1）d比（1.2±0.1）d，t=3.195，P=0.002]均早于腹腔镜手术组，差异均有统计学意义（均P<0.05）。但机器人手术组的术后住院时间较腹腔镜手术组更长[（8.5±5.5）d比（7.2±3.3）d，t=2.419，P=0.016]。两组患者在术中出血量、中转开腹率、术后并发症、远切缘阳性率、环周切缘阳性率、淋巴结检出数方面差异均无统计学意义（均P>0.05）。术后12个月随访时，机器人手术组和腹腔镜手术组患者均未出现严重的泌尿功能障碍，优良率分别达97.6%（83/85）及98.4%（61/62）；机器人手术组和腹腔镜手术组勃起功能正常及轻度障碍率分别为92.2%（47/51）和92.6%（38/41），两组泌尿和勃起功能的差异均无统计学意义（均P>0.05）。 结论： 机器人与腹腔镜手术对于低位直肠癌保留部分邓氏筋膜的TME，其手术安全性和术后近期疗效相当，在泌尿、勃起功能保护方面作用相当；但机器人手术后胃肠道功能恢复相比于传统腹腔镜TME手术更快。.

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