机器人辅助腹腔镜与传统腹腔镜行子宫全切手术安全性和有效性的系统评价

Safety and efficacy of robot-assisted laparoscopic hysterectomy vs. traditional laparoscopic hysterectomy：a systematic review

摘要:

目的：比较机器人辅助腹腔镜与传统腹腔镜行子宫全切手术的安全性和有效性。方法：检索PubMed、Cochrane Library、EMBASE、Medline、万方、知网、维普等数据库，查找机器人辅助腹腔镜与传统腹腔镜行子宫全切手术的随机对照试验（random－ized controlled trials，RCTs）和非随机对照试验（non-randomized controlled trials，NRCTs）。按纳入排除标准进行筛选并进行质量评价，将纳入文献的患者分为机器人辅助腹腔镜组和传统腹腔镜组，提取数据后用RevMan5．3软件进行Meta分析，比较2种手术方式行子宫全切术的安全性及有效性。二分类变量采用优势比（OR）及95％可信区间（95％CI）表示，连续性变量采用加权均数差（WMD）及可信区间（95％CI）表示。结果：共纳入5个RCTS及26个 NRCTs，共计需行子宫全切术患者4 235例，其中机器人辅助腹腔镜组1 870例，传统腹腔镜组2 365例。Meta分析结果显示：与传统腹腔镜组比较，机器人辅助腹腔镜组的围手术期并发症发生率低（OR=0．71，95%CI=0.57~0.89，Z=2.97，P=0.003）、住院时间短（WMD=-0．42，95%CI=-0.65~-0.20，Z=3.67，P=0.000 2）、术中出血少（WMD=-81.04，95%CI=-104.50~-57.58，Z=6.77，P=0.000）、中转开腹率低（OR=0．38，95%CI=0.25~0.58，Z=4.60，P=0.000）；2组患者手术时间（WMD=15.38，95%CI=-4.48~35.23，Z=1.52，P=0.130）、淋巴结清除数目[盆腔淋巴结（WMD=-1.09，95%CI=-2.61~0.43，Z=1.40，P=0.160）；血管旁淋巴结（WMD=-0．19，95%CI=-2.93~2.56，Z=0.13，P=0.890）]比较，差异无统计学意义。亚组分析显示：对于子宫重量小于200 g的患者，机器人辅助腹腔镜组术中出血更少（WMD=-88.78，95%CI=-98.03~-79.52，Z=18.80，P=0.000），差异有统计学意义。结论：与传统腹腔镜相比，机器人辅助腹腔镜手术行子宫全切术时围手术期并发症发生率低、住院时间短、术中出血少（尤其对于子宫重量较小的患者）、中转开腹率低，但手术时间及淋巴结清除数目无差异。不过，考虑到原始研究质量不高以及明显的异质性，本研究结论论证强度有限。

Abstract:

Objective：To compare the safety and efficacy of robot-assisted laparoscopic hysterectomy and traditional laparoscopic hys－terectomy． Methods：Databases including Pubmed，Cochrane Library，EMBASE，Medline，Wanfang，CNKI and VIP were searched． Randomized controlled trials（RCTs） and non-randomized controlled trials（NRCTs） focusing the comparison between robot-assisted laparoscopic hysterectomy and traditional laparoscopic hysterectomy were collected． All the literatures retrieved were screened accord－ing to preset standards，and the patients were divided into robotic group and laparoscopic group． A Meta analysis on safety and efficacy of two kinds of hysterectomy was carried out using the RevMan 5.3 software． Categorical variables were presented by odds ratio（OR） and 95％confidence interval（95％CI），continuous variables were presented by weighted mean difference（WMD） and 95％ confidence interval（95％CI）． Results：5 RCTs and 26 NRCTs including 4 235 patients undergo hysterectomy were screened out and there were 1870 patients in the robotic group and 2 365 patients in the laparoscopic group. Meta analysis suggest that compared with conventional laparoscopic surgery，lower rate of perioperative period complication（OR=0．71，95%CI=0.57 to 0.89，Z=2.97，P=0.003），shorter length of hospital stay（WMD=-0．42，95%CI=-0.65 to -0.20，Z=3.67，P=0.000 2），less operative blood loss（WMD=-81.04，95%CI=-104.50 to -57.58，Z=6.77，P=0.000），lower rate of conver－sion to laparotomy（OR=0.38，95%CI=0.25 to 0.58，Z=4.60，P=0.000） were observed in the robotic group．There were no significant dif－ferences in operation time（WMD=15.38，95%CI=-4.48 to 35.23，Z=1.52，P=0.130） and the number of lymph node dissected[pelvic lymph node group（WMD=-1.09，95%CI=-2.61 to 0.43，Z=1.40，P=0.160）；perivascular lymph node group（WMD=-0．19，95%CI=-2.93 to 2.56，Z=0.13，P=0.890）] between two groups． Subgroup analysis suggest that the robotic group has less operative blood loss（WMD= -88.78，95%CI=-98.03 to -79.52，Z=18.80，P=0.000），there were significant differences between two groups. Conclusion：compared with conventional laparoscopic surgery，the robotic group has lower rate of perioperative period complication，shorter length of hospital stay，less operative blood loss（especially suitable for patients with small uterus），lower rate of conversion to laparotomy，However，there were no significant differences in operation time and the number of lymph node dissected. Whereas，considering the quality of the original literatures with obvious heterogeneity is not high，the present conclusions demonstrate strength is limited.