ВведениеВ настоящее время рак предстательной железы выходит на первое место среди всех онкологических заболеваний у мужчин во многих странах мира. За последние три десятилетия частота раковых заболе-ваний предстательной железы почти удвоилась. «Зо-лотым стандартом» лечения локализованной формы рака предстательной железы является открытая ра-дикальная простатэктомия. Однако в последнее время стали использовать роботическую радикаль-ную простатэктомию (РРП). Многочисленные ис-следования, анализирующие результаты использо-вания новой техники при выполнении радикальной простатэктомии, позволяют объективизировать преимущества роботической хирургии на основе принципов доказательной медицины. В течение не-скольких последних лет роботическая операция ста-ла серьезной альтернативой открытому вмешатель-ству для многих больных, подлежащих радикальной простатэктомии. В США, а также во многих странах Европы РРП пришла на смену открытой операции в качестве «золотого стандарта» лечения локализо-ванного рака простаты. Монополистом в роботиче-ской хирургии является компания «Intuitive Surgical» (США), создавшая роботическую хирургиче-скую систему da Vinci. Робот da Vinci является уни-кальным продуктом, в котором нашли отражение самые передовые научные и медицинские разработ-ки современности. По данным на начало 2012 г., в США функционировало 2500 роботических хирур-гических комплексов. Роботическая хирургия ис-пользуется во многих медицинских специальностях, таких как общая хирургия, гинекология, нейрохи-рургия, кардиохирургия, оториноларингология и др. Наибольшее распространение роботическая хи-рургия получила в урологии. В 2008 г. в США с по-мощью робота da Vinci было выполнено 72 тыс. ра-дикальных простатэктомий, что составило 80% все-го объема операций при заболеваниях железы, в 2011 г. эти показатели достигли соответственно 100 тыс. и 95% [26,29,34].В Российской Федерации на текущий момент установлен 21 хирургический эндоскопический комплекс da Vinci. Наибольшим опытом выполне-ния роботических вмешательств в России обладает коллектив клиники урологии МГМСУ. С начала действия роботической программы (ноябрь 2008 г.)
Background. Prostate cancer (PCa) is the 2nd most common oncological disease among men in the world. The first structured program of robot-assisted radical prostatectomy (RARP) was started in the year 2000. In the medical literature, a limited number of studies on long-term oncological treatment outcomes for patients with PCa after RARP is presented. In Russia, the Da Vinci robot was first installed in 2007. In the Urology Clinic of the A.I. Evdokimov Moscow State University of Medicine and Dentistry, the program of robot-assisted surgery was started in November of 2008.Aim. To perform first in Russia evaluation of 10-year oncological treatment outcomes for patients with localized PCa after RARP. To perform comparative analysis with the outcomes of radical retropubic prostatectomy (RRP).Materials and methods. Retrospective analysis of medical histories of 211 patients was performed. Among them, 62 patients did not satisfy the inclusion criteria. The remaining 149 patients were divided into 2 groups: 1st - RARP (n = 82), 2nd - RRP (n = 67). All RARP were performed by the same surgeon, RRP by 2 experienced surgeons.Results. Median follow-up was 110.35 ± 24.58 and 115.19 ± 15.37 months in the 1st and 2nd group, respectively; median follow-up was 120 months in both groups (p >0.05). Survival was calculated using the Kaplan-Meyer approach. Ten-year biochemical recurrence (BCR)-free survival was 79.3 and 82.1 %, clinical recurrence-free survival was 96.3 and 97.1 %, metastasis-free survival was 92.7 and 94.0 %, cancer-specific survival was 93.9 and 95.6 % and overall survival was 85.4 and 86.6 % in the 1st and 2nd group, respectively. Mean time to BCR was 17.00 ± 20.67 and 22.83 ± 26.51 months, respectively ( p >0.05). Calculation of BCR predictors was performed using correlation analysis based on contingency test and Cramer's V-test. In the 1st group, body mass index ≥30 kg/m2 (p = 0.01), prostate-specific antigen level >10 ng/mL (p = 0.04), high progression risk per the D'Amico classification (p = 0.01) were independent preoperative predictors of BCR. Gleason score 7 (4 + 3) (p = 0.04) and ≥8 (p <0.0001) per pathomorphological examination, pT3 stage, extraprostatic extension, invasion into the seminal vesicles and positive surgical margin (all p <0.0001) were independent postoperative predictors of BCR.Conclusion. RARP demonstrates long-term (10-year) oncological effectiveness comparable to oncological effectiveness of RRP in patients with localized PCa.
The aim of the study was to evaluate the role of urapidil hydrochloride for the management of abnormal cardiovascular response in patients undergoing robot-assisted radical prostatectomy (RARP).Material and methods. The total of 93 prostate cancer patients scheduled for elective RARP were included and randomized in two groups: urapidil (n=44) and standard anesthesia control group (n=49). Urapidil was used to control the elevated blood pressure intraoperatively. Central hemodynamic monitoring was performed at 5 steps of the surgery.Results. In the control group, the step 2 of the procedure was associated with elevated mean blood pressure (by 24.3%, P=0.045) and increased total peripheral vascular resistance (by 46.6%, P=0.011) compared with step 1, while in the urapidil group no significant changes in these parameters were found. In the urapidil group, the blood pressure was lower by 20.2% (P=0.047), afterload by 36.9% (P=0.02) vs the control group values, whereas the cardiac output was higher by 22.2% (P=0.043). Placing patient in the steep Trendelenburg position (step 3) resulted in a 22.4% increase in stroke volume (P=0.38) in the control group and a 19.2% increase in stroke volume (P=0.049) in the urapidil group compared with the previous step. Cardiac output in the urapidil group was higher by 34% (P=0.002) and blood pressure and vascular resistance were lower by 24.4% (P=0.031) and 45.7% (P=0.001), respectively, vs the control group. At steps 4 and 5, gradual stabilization of the hemodynamic parameters and peripheral vascular tone with significantly smaller differences between the groups were revealed.Conclusion. Urapidil was effective for maintaining central hemodynamic parameters in patients during robotic-assisted radical prostatectomy at step 2 of the procedure, avoiding blood pressure elevation at step 3 and significantly reducing the total peripheral vascular resistance compared with the control group.
Background. Prostate cancer is the 3rd most common diagnosis among malignant tumors. The first robot-assisted radical prostatectomy (RARP) was performed in 2001. Studies comparing RARP and radical retropubic prostatectomy (RRP) are limited. In Russia, the Da Vinci robot was first installed in 2007. At the Urology Clinic of the A.I. Evdokimov Moscow State University of Medicine and Dentistry the program of robot-assisted surgery started in November of 2008.Aim. To perform first in Russia evaluation of 10-year functional treatment outcomes for patients with localized prostate cancer after RARP. To perform comparative analysis with RRP outcomes.Materials and methods. Medical histories of 211 patients from the Urology Clinic of the A.I. Evdokimov Moscow State University of Medicine and Dentistry were analyzed. Among them, 62 patients did not satisfy the inclusion criteria. Therefore, the study included 149 patients who underwent surgical treatment for localized prostate cancer between January of 2009 and December of 2011. Depending on the technique of surgical intervention, patients were divided into 2 groups: 1st – RARP (n = 82), 2nd – RRP (n = 67). All RARP were performed by a single surgeon, RRP by 2 experienced surgeons (experience >1000 RRP).Results. Median follow-up was 120 months in both groups. Overall survival in the 1st and 2nd groups was 85.4 and 86.6 %, respectively (p >0.05). For accuracy of functional outcomes analysis, patients who died during follow-up were excluded from the study. Frequency of neurovascular bundle preservation in the 1st and 2nd groups was 60.9 % (50/82) and 40.2 % (27/67), respectively (p = 0.01). Erectile function was preserved in 60.0 and 44.4 % males of the 1st and 2nd groups, respectively (p = 0.01). Age below 60 years (р = 0.009) and disease stage рТ2 (p = 0.026) were predictors of erectile function preservation after RARP. Continence frequency was 92.7 and 82.1 % in the 1st and 2nd groups, respectively (p = 0.048).Conclusion. Ten-year comparative analysis shows that RARP allows to achieve significantly better parameters of urinary continence and erectile function preservation in men with localized prostate cancer than RRP.
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