| Objective:To investigate the prevention and treatment of intraoperative and postoperative complications of robot-assisted hybrid transvaginal natural orifice transluminal endoscopic surgery nephrectomy and the effect of this operation on renal function,cosmetic effect,quality of life,sexual function and reproductive function,and comprehensively evaluate the clinical application value of this operation.Subjects and Methods:Clinical data of 40 patients undergoing nephrectomy in the department of urology,The First Affiliated Hospital of Gannan Medical University from january2018 to December 2021 were collected.Including 16 patients who underwent RA-HTV-NOTES-N(study group)and 24 patients who underwent hybrid transvaginal natural orifice transluminal endoscopic surgery nephrectomy(HTV-NOTES-N,control group).Collect hospitalization data and early follow-up data of patients,inform patients to return to the hospital for regular examination of renal function and urinary system by telephone,SMS,wechat,email,etc.,and chest and abdominal CT,cystoscope,magnetic resonance and bone scan when necessary.Follow-up registration form,female sexual function index(FSFI),fertility function questionnaire,patient scar assessment questionnaire(PSAQ),and 36-item short form health survey(SF-36),and the data obtained were statistically analyzed.Result:In this study,a total of 46 patients received complete clinical data,and 6patients in the control group were not followed up due to change of contact information or error of contact information.Finally,40 patients received complete follow-up,with an access rate of 87.0%.16 patients were included in the study group and 24 in the control group.Preoperative general data:The age of 16patients in the study group was 56.1±6.7 years,and body mass index(BMI)was21.9±3.8kg/m~2.The age of 24 patients in the control group was 54.0±11.4 years and BMI was 22.5±4.2kg/m~2at the time of surgery.The average preoperative estimated glomerular filtration rate(e GFR)of the study group and the control group was 74.1±30.1 ml/min·1.73m~2and 65.5±21.9ml/min·1.73m~2,respectively.Reasons for nephrectomy include renal dysfunction and tumor.The study group included 15 cases of nephrectomy and 1 case of radical nephrectomy.The control group included 19 cases of nephrectomy and 5 cases of radical nephrectomy.Non-functional kidney:in the study group,8 cases were located on the left side and 7 cases were located on the right side;In the control group,9 cases were located on the left and 10 cases on the right.Renal tumor:1 case was located on the right side of the study group with a maximum tumor diameter of 5.4cm;In the control group,there were 2 cases on the left and 3 cases on the right,and the maximum tumor diameter was 5.8±2.0cm.The mean operation time was124.9±21.8min,161.5±24.8min,the mean blood loss was 105.0ml(64.0,157.5)、175.0 ml(104.5,255.5),24h postoperative pain visual analogue scale VAS scores were 2.3±0.6 and 2.5±0.7,the average duration of abdominal drainage tube indplacement was 3.9±2.0d and 3.7±1.2d,the average duration of gastrointestinal function recovery was 24.1±10.4h and 33.4±15.6h,respectively.The postoperative hospital stay was 5.5±1.6d and 6.8±1.5d,respectively.The mean follow-up time was 24.1±10.4d and 25.8±7.3d,respectively.There were no significant differences between the two groups in age,BMI,preoperative e GFR,side profile,maximum tumor diameter,intraoperative blood loss,postoperative VAS score,abdominal drainage tube retention time,follow-up time,tumor metastasis or recurrence,and postoperative complications(P>0.05).There were statistically significant differences in operation time,postoperative gastrointestinal function recovery time and hospital stay(P<0.05).Estimated glomerular filtration rate(e GFR)was measured within 1 week before surgery,with study group:81.0±37.1 ml/min·1.73m~2,and control group:86.0±30.2ml/min·1.73m~2,There was no statistically significant difference in preoperative and postoperative mean baseline e GFR levels between the two groups(p>0.05);Postoperative renal function of patients undergoing total upper urinary tract resection was significantly lower than that before surgery(p<0.05),Study group is superior to control group.1.Complications:1 patient had complications during operation,and the incidence rate was 2.5%.All surgeries in the study group were successfully completed without complications.In the control group,1 patient undergoing radical surgery for left renal cancer underwent right common iliac artery repair and blood transfusion due to intraoperative right iliac vessel rupture and hemorrhage,resulting in bilateral gastrocnemius vein thrombosis,which was cured after antithrombotic therapy.There were 6 patients with postoperative complications,and the incidence was 17.5%,mainly grade I complications.In the study group,there was 1 case of urinary tract infection and 1 case of fever,and the incidence of complications was 12.5%.In the control group,there were 2cases of vaginal infection,1 case of fever,1 case of blood transfusion and bilateral gastrocnemius venous thrombosis,and the incidence of complications was 16.7%.There was no death in either group.2.Changes in renal function:The e GFR group was 74.1±30.1 ml/min·1.73m~2and the control group was 65.5±21.9 ml/min·1.73m~2.EGFR of the study group was 71.5±25.1 ml/min·1.73m~2,68.5±25.1 ml/min·1.73m~2,70.2±18.9ml/min·1.73m~2at 3,6 and 12 months postoperatively,respectively.In the control group,e GFR was 68.3±25.1 ml/min·1.73m~2,65.6±24.4 ml/min·1.73m~2and63.1±27.2ml/min·1.73m~2at 3,6 and 12 months after operation,respectively.There was no significant difference in preoperative and postoperative mean baseline e GFR levels between the two groups(P>0.05).3.Tumor control:1 patient in the study group was found to be lipomatous hamartoma with grade I pathological stage.The postoperative pathological results of the 5 patients in the control group were renal clear cell carcinoma,and the pathological grade of tumor was grade I in 3 cases and Grade II in 2 cases.The pathological margin of all tumor patients was negative.There were no tumor recurrence or metastasis in all the 6 patients with urologic enhanced CT.4.Sexual function changes:8 patients had no sexual life,and 2 patients received invalid questionnaire.Finally,30 patients received complete FSFI score questionnaire,including 13 cases of RA-HTV-NOTES-N and 17 cases of HTV-NOTES-N.The study group included 12 cases of nephrectomy and 1 case of radical nephrectomy,while the control group included 14 cases of nephrectomy and 3 cases of radical nephrectomy.FSFI scores of the study group were 27.8±1.4 points,27.7±1.5 points,27.8±1.5 points,27.9±1.7 points respectively 1 week before surgery,3 months after surgery,6 months after surgery and 12 months after surgery.FSFI scores of the control group were27.2±1.6,27.3±1.9,27.3±2.0 and 27.5±1.8,respectively,1 week before operation,3 months after operation,6 months after operation and 12 months after operation.There was no significant difference in total FSFI score between the study group and the control group in four time dimensions(P>0.05),and the scoring results are shown in Figure 7.There was no statistically significant difference between the study group and the control group in the six dimensions of sexual desire,orgasm,vaginal lubrication,sexual arousal,satisfaction and pain(P>0.05).In patients with two different types of surgery,according to the mean menopausal age of women,<There were no significant differences in sexual function FSFI score and all dimensions score between and within groups between patients aged48 years and≥48 years(P>0.05).According to patients’subjective feelings about sexual function,22 patients showed no significant change in sexual function before and after surgery,2 patients showed decreased conscious function,and 8 patients showed improvement in conscious function.5.Postoperative pregnancy and fertility:a total of 30 patients were visited,24 of whom had birth control.Among the other 6 patients,1 was pregnant again after surgery,1 was in the second trimester,and the other 1 patient had oral misoprostol abortion after 5 weeks of accidental pregnancy.The pregnancy patient had a vaginal birth and was naturally conceived without drugs and artificial assisted fertility technology.The gestation period was 276 days,and the mother and baby were healthy after delivery.The duration of pregnancy was 5-13months,with an average of 10.3 months.The gestational age ranged from 21 to42 years,with an average of 31.3 years6.Postoperative incision scar:the mean total PSAQ scores of the study group at 3,6 and 12 months after surgery were respectively 41.1±1.3、41.5±4.4and 40.3±0.6,the mean total PSAQ scores of the control group at 3,6 and 12months after surgery were respectively 42.3±2.9、42.6±3.1 and 41.4±1.9.There were no significant differences in the four dimensions of appearance,symptom satisfaction,scar awareness and appearance satisfaction and the total PSAQ score between the two groups of patients at the same time period after surgery(p>0.05).Conclusions:1.RA-HTV-NOTES-N technology is safe and feasible,with exact curative effect,mild postoperative pain,good cosmetic effect,low incidence of postoperative complications,and does not affect the postoperative sexual function and pregnancy of patients;2.RA-HTV-NOTES-N exert the advantages of NOTES technology to a greater extent and is worthy of clinical use;... |
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