手術用ロボット(da Vinci, Intuitive surgical社)を使用した根治的前立腺全摘除術 : 本邦初24例の経験

Abstract

手術用ロボットを使用した腹腔鏡下根治的前立腺全摘除術(RALP)24例の手術成績について検討した。その結果, 1例を除く23例でRALPを完遂しえた。平均console timeは223.0分, 平均setup timeは47.0分, 平均術中尿込み出血量は313.0mlであった。全例で術後早期合併症は認めず, 術後経過は良好であった。術後疼痛は鎮痛剤の使用回数で評価したが, 21例は2POD以降鎮痛剤を使用しなかった。術後平均カテーテル留置日数は平均10.5日, 平均在院日数は16.6日であった。病理結果での断端陽性率はpT2で7.6%(1/13), pT3で56%(5/9), 全体で30%(7/23)であった。術後3, 6, 12ヵ月での尿禁制回復率はそれぞれ65, 78, 100%であった。片側神経温存症例6例中1例, 両側神経温存例3例中2例は術後の性交可能であった。

In Japan, as of September 2007, prostatectomy is conducted with open surgical procedures in more than 90% of the cases. Following the first reported robotic prostatectomy by Binder, et al. in 2000, a robotic-assisted laparoscopic radical prostatectomy (RALP) using the daVinci Surgical System (Intuitive Surgical, Inc., Sunnyvale, California, USA) has been extensively used as a standard procedure with gratifying results in the United States. In the Asian region, in contrast, RALP is still in an introductory phase. Recently, we introduced RALP in Japan. A total of 24 patients received robotic surgery within a year since August 2006. RALP was completed in all patients without conversion to open surgery, except for the first patient in whom a restriction to a 2-hour operation had been imposed by the Ethical Committee. The mean operative time using the daVinci device and the mean estimated blood loss were 232.0 (range; 136-405) minutes and 313.0 (range; 10-1, 000) ml, respectively. The training program we recently developed proved remarkably effective in reducing the learning curve of robotic surgery in Japan, where there is no person with expertise in this operating procedure. In particular, the intraoperative guidance given by the expert was useful after relevant problematic points were delineated by operators who received comprehensive video-based image training and actually performed robot surgery in several cases. With direct intraoperative guidance by the mentor during cases 13 and 14, both the operation time and estimated blood loss was markedly reduced.