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中华妇幼临床医学杂志(电子版)

中华妇幼临床医学杂志(电子版) ›› 2018, Vol. 14 ›› Issue (03) : 296 -304. doi: 10.3877/cma.j.issn.1673-5250.2018.03.008

所属专题： 机器人手术； 文献；

论著

达芬奇机器人手术系统与腹腔镜手术在子宫内膜癌全面分期手术中安全性和有效性的Meta分析
王卫杰1, 高玲玲1, 徐建波1, 郭勤浩1, 高俊1, 张艳馨1, 罗嘉莉1, 顾扬1, 马志松1, 尹香花1,†()   
  1. 1. 225001　扬州，江苏省苏北人民医院妇产科
  • 收稿日期:2018-01-07 修回日期:2018-05-09 出版日期:2018-06-01
  • 通信作者: 尹香花

Safety and efficacy of Da Vinci surgical system versus laparoscopy for surgical staging of endometrial cancer: a Meta-analysis

Weijie Wang1, Lingling Gao1, Jianbo Xu1, Qinhao Guo1, Jun Gao1, Yanxin Zhang1, Jiali Luo1, Yang Gu1, Zhisong Ma1, Xianghua Yin1,†()   

  1. 1. Department of Obstetrics and Gynecology, Northern Jiangsu People′s Hospital, Yangzhou 225001, Jiangsu Province, China
  • Received:2018-01-07 Revised:2018-05-09 Published:2018-06-01
  • Corresponding author: Xianghua Yin
  • About author:
    Corresponding author: Yin Xianghua, Email:
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引用本文：

王卫杰, 高玲玲, 徐建波, 郭勤浩, 高俊, 张艳馨, 罗嘉莉, 顾扬, 马志松, 尹香花. 达芬奇机器人手术系统与腹腔镜手术在子宫内膜癌全面分期手术中安全性和有效性的Meta分析[J/OL]. 中华妇幼临床医学杂志(电子版), 2018, 14(03): 296-304.

Weijie Wang, Lingling Gao, Jianbo Xu, Qinhao Guo, Jun Gao, Yanxin Zhang, Jiali Luo, Yang Gu, Zhisong Ma, Xianghua Yin. Safety and efficacy of Da Vinci surgical system versus laparoscopy for surgical staging of endometrial cancer: a Meta-analysis[J/OL]. Chinese Journal of Obstetrics & Gynecology and Pediatrics(Electronic Edition), 2018, 14(03): 296-304.

目的

系统评价达芬奇机器人手术系统(DVSS)与腹腔镜手术在子宫内膜癌全面分期手术中的安全性与有效性。

方法

采用Cochrane系统评价法，应用计算机检索Cochrane library、PubMed、Embase、Web of Science(WOS)等英文数据库和中国知网(CNKI)、万方数据库、《中文科技期刊数据库》(CSTJ)等中文数据库；手工检索《国际肿瘤学杂志》《实用妇产科杂志》《中华妇产科杂志》《中国实用妇科与产科杂志》《现代妇产科进展》等中文期刊，检索年限为2007年1月1日至2017年8月31日，纳入DVSS与腹腔镜手术在子宫内膜癌全面分期手术的非随机对照试验(NRCT)。采用《纽卡斯尔-渥太华量表》(NOS)文献质量评价表，由2位经过该项目培训合格的研究者独立筛选文献、提取资料，并评价纳入研究的偏倚风险后，采用RevMan 5.3软件对DVSS和腹腔镜手术在子宫内膜癌全面分期手术中的安全性与有效性进行相关Meta分析。其中，安全性指标包括患者术中出血量、住院时间、中转开腹率、输血率、术中及术后并发症发生率，有效性指标包括手术时间、盆腔淋巴结切除数、腹主动脉旁淋巴结切除数。

结果

通过文献检查，并追踪检索已获取全文的相关参考文献，共计8篇符合本研究纳入标准，纳入患者为1 118例。在子宫内膜癌全面分期手术中，DVSS组患者为499例，腹腔镜手术组为619例。这8篇文献均为队列研究，其中前瞻性队列研究为3篇，回顾性队列研究为5篇。NOS量表评价文献质量均为高质量文献。本研究Meta分析结果显示，在子宫内膜癌全面分期手术中，①针对安全性方面的Meta分析结果显示，DVSS较腹腔镜手术具有患者术中出血量显著减少(SMD＝－88.95，95%CI：－102.42～－75.47，P<0.001)，住院时间显著缩短(SMD＝－0.40，95%CI：－0.75～－0.06，P＝0.02)，中转开腹率显著降低(RR＝0.37，95%CI：0.17～0.81，P＝0.01)，术中及术后并发症发生率显著降低(RR＝0.67，95%CI：0.51～0.87，P＝0.003)等优势，但2组患者的输血率比较，差异无统计学意义(RR＝0.76，95%CI：0.39～1.50，P＝0.43)。②针对有效性方面的Meta分析结果显示，2组患者的手术时间(SMD＝3.21, 95%CI：－21.51～27.93, P＝0.80)，盆腔淋巴结切除数(SMD＝－0.23, 95%CI：－3.06～2.60, P＝0.87)，及腹主动脉旁淋巴结切除数(SMD＝0.77, 95%CI：－1.69～3.23, P＝0.54)比较，差异均无统计学意义(P>0.05)。

结论

在子宫内膜癌全面分期手术中，与腹腔镜手术相比，DVSS具有术中导致的患者出血量少、中转开腹率低、术中及术后并发症发生率低、住院时间短等优势。但是，DVSS因其费用昂贵而使临床应用受到一定限制。

关键词: 子宫内膜肿瘤, 机器人手术, 腹腔镜, 队列研究, Meta分析, 妇女
Objective

To evaluate the safety and efficacy between Da Vinci surgical system (DVSS) and laparoscopy for surgical staging of endometrial cancer.

Methods

All the non-randomized controlled trials (NRCT) about robotic surgery and laparoscopy for surgical staging of endometrial cancer were electronically collected by searching English databases, including Cochrane library, PubMed, Embase, Web of Science (WOS), and Chinese databases, including China National Knowledge Infrastructure (CNKI), Wanfang Database, China Science and Technology Journal Database (CSTJ). Meanwhile, Journal of International Oncology, Journal of Practical Obstetrics and Gynecology, Chinese Journal of Obstetrics and Gynecology, Chinese Journal of Practical Gynecology and Obstetrics, Progress in Obstetrics and Gynecology were manually searched to collect NRCT about the same topic. Retrieval time ranged from January 1, 2007 to August 31, 2017. Two reviewers independently screened literature, extracted data and assessed the risk of bias of included studies, then, Meta-analysis was performed by using RevMan 5.3 software.Heterogeneity inspection was done for each study, and different effect model, included the random effect model and fixed effect model was chose according to the results of the heterogeneity inspection. Meta-analysis was conducted to evaluate the efficacy and safety between robotic surgery and laparoscopy for surgical staging of endometrial cancer. The safety indexes included intraoperative blood loss, hospital stay, conversion to open surgery, blood transfusion rate, intraoperative and postoperative complications. The efficacy indexes included operation duration, the number of pelvic lymph node dissection and para-aortic lymph node dissection.

Results

A total of eight English NRCTs involving 1 118 patients were included.Among them, 499 patients received robotic surgery and 619 patients received laparoscopic surgery.All the 8 articles were cohort study, 3 were prospective cohort study, while 5 were retrospective cohort study. After the quality assessment, all studies were high quality. Meta-analysis showed the following results. ① In term of the safty, compared with laparoscopy surgery, robotic surgery had less intraoperative blood loss (SMD=-88.95, 95%CI: -102.42--75.47, P<0.001), shorter hospital stay (SMD=-0.40, 95%CI: -0.75--0.06, P=0.02), lower rate of conversion to open surgery (RR=0.37, 95%CI: 0.17-0.81, P=0.01), and lower rate of intraoperative or postoperative complications (RR=0.67, 95%CI: 0.51-0.87, P=0.003). But there was no statistically significant difference in term of blood transfusion rate (RR=0.76, 95%CI: 0.39-1.50, P=0.43). ②In terms of efficacy, there were no statistically significant differences in aspects of operative duration (SMD=3.21, 95%CI: -21.51-27.93, P=0.80), the number of pelvic lymph node dissection (SMD=-0.23, 95%CI: -3.06-2.60, P=0.87) and the number of para-aortic lymph node dissection (SMD=0.77, 95%CI: -1.69-3.23, P=0.54).

Conclusions

Compared the robotic surgery with laparoscopic surgery in surgical staging of endometrial cancer, robotic surgery has less intraoperative blood loss, lower rate of conversion to open surgery, lower rate of intraoperative or postoperative complications and shorter hospital stay. But the cost of robotic surgery is still expensive which restricts clinical application.

Key words: Endometrial neoplasms, Robotics, Laparoscopes, Cohort studies, Meta-analysis, Women
图1 文献检索流程及结果
表1 纳入研究的基本情况
纳入文献(第一作者，文献发表年) 国家及地区 研究类型 研究时间(年) 患者例数(例) 平均年龄(岁) 平均BMI(kg/m2)
DVSS组 腹腔镜组 DVSS组 腹腔镜组 DVSS组 腹腔镜组
Boggess，2008[6] 美国 PC，S 2005—2007 103 81 62 62 34.7 29.0
Lim，2010[7] 美国 PC，S 2008—2009 56 56 62 61 30.4 28.2
Jung，2010[8] 韩国 PC，M 2006—2009 28 25 53 50 23.4 25.2
Bell，2008[9] 美国 RC，S 2000—2007 40 30 63 68 33.0 31.9
Coronado，2012[10] 西班牙 RC，S 2003—2011 71 84 67 66 28.7 27.2
Cardenas-Goicoechea，2010[11] 美国 RC，S 2003—2009 102 173 62 60 32.3 32.7
Holtz，2010[12] 美国 RC，S 2005—2006 13 20 64 63 35.3 27.8
Chiou，2014[13] 中国台湾 RC，S 2005—2013 86 150 54 51 26.0 25.6
表2 纳入研究的方法学质量评价得分(分)
纳入文献(第一作者，文献发表年) 研究人群 干预措施 研究结果 总分
Boggess，2008[6] 3 2 2 7
Lim，2010[7] 2 2 2 6
Jung，2010[8] 4 2 2 8
Bell，2008[9] 3 2 2 7
Coronado，2012[10] 3 2 2 7
Cardenas-Goicoechea，2010[11] 4 2 2 8
Holtz，2010[12] 3 2 2 7
Chiou，2014[13] 2 2 2 6
图2 机器人手术组和腹腔镜手术组子宫内膜癌患者手术时间比较的随机效应模型的Meta分析结果
图3 机器人手术组和腹腔镜手术组子宫内膜癌患者术中出血量比较的固定效应模型的Meta分析结果
图4 机器人手术组和腹腔镜手术组子宫内膜癌患者住院时间比较的随机效应模型的Meta分析结果
图5 机器人手术组和腹腔镜手术组子宫内膜癌患者盆腔淋巴结比较的随机效应模型的Meta分析结果
图6 机器人手术组和腹腔镜手术组子宫内膜癌患者腹主动脉旁淋巴结比较的随机效应模型的Meta分析结果
图7 机器人手术组和腹腔镜手术组子宫内膜癌患者输血率比较的固定效应模型的Meta分析结果
图8 机器人手术组和腹腔镜手术组子宫内膜癌患者中转开腹比较的固定效应模型的Meta分析结果
图9 机器人手术组和腹腔镜手术组子宫内膜癌患者并发症发生率比较的固定效应模型的Meta分析结果
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