Roboterassistierte Harnblasendivertikelresektion (RAHDR)

Zusammenfassung

Ziele Seit Oktober 2018 werden Harnblasendivertikelresektionen in der Klinik für Urologie, Kinderurologie und roboterassistierte minimalinvasive Urologie der Sozialstiftung Bamberg roboterassistiert und minimalinvasiv, mit dem DaVinci-Operationssystem^®, durchgeführt. Das Ziel dieser Arbeit ist die operativen Ergebnisse unserer Patienten zu objektivieren und mit anderen Daten zu vergleichen, um ggf. die Diagnostik und Therapie zu optimieren.

Methoden In dieser retrospektiven Analyse haben wir alle Patienten, die zwischen Oktober 2018 und Mai 2020 eine RAHDR erhalten haben, eingeschlossen. Die primären Endpunkte waren: der intraoperative bzw. postoperative Blutverlust (Hämoglobin-Abfall postoperativ), die Operationszeit (min), die Hospitationsdauer (Tage), der postoperative Restharn, das Auftreten von Anastomoseninsuffizienzen, die postoperative Lebensqualität und die postoperative Zufriedenheit mit den Miktionsverhältnissen.

Ergebnisse Es konnten insgesamt 11 Patienten eingeschlossen werden. Das mittlere Alter betrug 64,8 Jahre (52–82) und alle Patienten waren männlich. Der durchschnittliche BMI war 26,5 kg/m² (19–37). 3 Patienten wurden mit ASA-Score III eigestuft, 5 mit II und 3 mit I. Der durchschnittliche Restharnwert präoperativ lag bei 183 ml (90–240). 7 von 11 Patienten bekamen simultan eine oder 2 weitere Operationen. Ein Zystogramm zum Ausschluss einer Extravasation erfolgte am fünften bzw. sechsten postoperativen Tag. Die mittlere Operationszeit war 212 min (148–294) und die mittlere Hospitationsdauer betrug 7,6 Tage (6–10). Der durchschnittliche postoperative Restharnwert war 25 ml (10–60). Die durchschnittliche postoperative maximale Harnflussrate (max. Flow) wurde mit 27,7 ml/s (11–55) gemessen. Bei keinem der Patienten wurde eine Kontrastmittelextravasation im Zystogramm nachgewiesen. Die Komplikationen nach Clavien waren nicht objektivierbar. Der mittlere postoperative Hb-Abfall betrug 1,61 g/dl (0–3,2).

Schlussfolgerungen In den meisten Fällen ist die Entfernung eines oder mehrerer Blasendivertikel über die minimalinvasive roboterassistierte Technik möglich. Dabei ist die Möglichkeit gegeben verschiedene Operationen wie YV-Blasenhalsplastik, Prostataadenomenukleation, Blasensteinsanierung, Leistenherniotomie u. a. simultan durchzuführen. Eine roboterassistierte Harnblasendivertikelresektion ist ein effektives und schonendes Verfahren, welches aber, durch fehlende DRG-Abbildung, finanzielle Nachteile für den Leistungserbringer verursachen kann.

Abstract

Aims Since October 2018, urinary bladder diverticulum resections at our Department of Urology have been carried out with robot assistance and with minimal invasivion, Paediatrical urological and robot-assisted minimally invasive urological surgery for the Bamberg Social Foundation were performed with the DaVinci robotic system^TM. The aim of the present study was to record the surgical results of our patients and to compare these if necessary with available data on optimal diagnostic and therapy.

Methods In this retrospective analysis, we included all patients who received RAHDR between October 2018 and March 2020. The primary endpoints were postoperative blood loss (postoperative haemoglobin decrease), the operation time (min), complications according to the Clavien-Dindo classification, length of hospital stay (days), postoperative residual urine, postoperative urine extravasation at the anastomosis of the bladder, postoperative quality of life and postoperative satisfaction with micturition.

Results We reviewed a total of 11 patients, all of whom were male. Mean age was 64.8 years (52–82). Average BMI was 26.5 (19–37). 3 patients were ranked with ASA score III, 5 with II and 3 with I. The average residual urine value preoperatively was 183 ml (90–240). A cystogram to rule out extravasation was performed on day 6 postoperatively. The mean duration of surgery was 212 min (148–294) and the mean duration of hospitalisation was 7.6 days (6–10). The mean residual urinary value after surgery was 25 ml (10–60). The mean postoperative maximum of flow was measured at 27.7 ml/s (11–55). No contrast agent extravasation in the cystogram was detected in any of the patients. The complications according to Clavien were not measurable. The mean postoperative haemoglobin decrease was 1.61 g/dl (0–3. 2).

Conclusions In most cases, the removal of one or more bladder diverticula is possible using the minimally invasive robotic technique. Various surgeries such as YV-bladder neck plastic, prostate adenoma enucleation, bladder stone restoration, and inguinal herniotomy can be carried out simultaneously. A robot-assisted urinary bladder diverticulum resection is an effective and gentle procedure. However, it must be considered that it brings financial disadvantages due to the lack of adequate representation within the German DRG-system (Diagnosis Related Groups).

Schlüsselwörter

Roboterassistierte laparoskopische Harnblasendivertikelresektion - roboterassistierte Operation - Harnblasendivertikel

Keywords

Robotic-assisted laparoscopic bladder diverticulum resection - robotic surgery - bladder diverticulum

Publication History

Article published online:
11 May 2021

• Literatur

• 1 Blane CE, Zerin JM, Bloom DA. Bladder diverticula in children. Radiology 1994; 190: 695-697 DOI: 10.1148/radiology.190.3.8115613.
• 2 Hutch JA, Ayres RD, Loquvam GS. The bladder musculature with special reference to the ureterovesical junction. J Urol 1961; 85: 531-539 DOI: 10.1016/s0022-5347(17)65374-6.
• 3 Garat JM, Angerri O, Caffaratti J. et al. Primary congenital bladder diverticula in children. Urology 2007; 70: 984-988 DOI: 10.1016/j.urology.2007.06.1108.
• 4 Linke C, Mongiat-Artus P. [Management of vesical diverticula]. Ann Urol (Paris) 2004; 38: 103-111 DOI: 10.1016/j.anuro.2004.03.002.
• 5 Psutka SP, Cendron M. Bladder diverticula in children. J Pediatr Urol 2013; 9: 129-138 DOI: 10.1016/j.jpurol.2012.02.013.
• 6 Wein AJ, Kavoussi LR, Partin AW. et al. Campbell-Walsh urology. Eleventh edition. Philadelphia (PA/USA): Saunders Elsevier; 2015
• 7 Idrees MT, Alexander RE, Kum JB. et al. The spectrum of histopathologic findings in vesical diverticulum: implications for pathogenesis and staging. Hum Pathol 2013; 44: 1223-1232 DOI: 10.1016/j.humpath.2012.11.005.
• 8 Chiang PH, Chou YH, Chiang CP. et al. Verrucous carcinoma of vesical diverticulum. Br J Urol 1991; 68: 320-321 DOI: 10.1111/j.1464-410x.1991.tb15333.x.
• 9 Kong MX, Zhao X, Kheterpal E. et al. Histopathologic and clinical features of vesical diverticula. Urology 2013; 82: 142-147 DOI: 10.1016/j.urology.2013.02.015.
• 10 Walker NF, Gan C, Olsburgh J. et al. Diagnosis and management of intradiverticular bladder tumours. Nat Rev Urol 2014; 11: 383-390 DOI: 10.1038/nrurol.2014.131.
• 11 Morioka H, Aoki J, Fujino K. et al. A case of ileus surgery using the water pressure method against ileus caused by incarceration into the inverted bladder diverticulum. Surg Case Rep 2020; 6: 9 DOI: 10.1186/s40792-019-0766-7.
• 12 Thüroff JW, Schulte-Wissermann H. Kinderurologie in Klinik und Praxis. Stuttgart: Thieme; 2002. 2. Auflage 293-299
• 13 Das S. Laparoscopic removal of bladder diverticulum. J Urol 1992; 148: 1837-1839 DOI: 10.1016/s0022-5347(17)37044-1.
• 14 Parra RO, Jones JP, Andrus CH. et al. Laparoscopic diverticulectomy: preliminary report of a new approach for the treatment of bladder diverticulum. J Urol 1992; 148: 869-871 DOI: 10.1016/s0022-5347(17)36748-4.
• 15 Kaouk JH, Bertolo R. Single-site robotic platform in clinical practice: first cases in the USA. Minerva Urol Nefrol 2019; 71: 294-298 DOI: 10.23736/S0393-2249.19.03384-8.
• 16 Roslan M, Markuszewski M, Klacz J. et al. Suprapubic transvesical laparoendoscopic single-port bladder diverticulectomy: points of technique with medium-term surgical outcomes. J Endourol 2013; 27: 688-692 DOI: 10.1089/end.2012.0674.
• 17 Thiel DD, Young PR, Wehle MJ. et al. Robotic-assisted bladder diverticulectomy: tips and tricks. Urology 2011; 77: 1238-1242 DOI: 10.1016/j.urology.2010.07.542.
• 18 Pham KN, Jeldres C, Hefty T. et al. Endoscopic Management of Bladder Diverticula. Rev Urol 2016; 18: 114-117 DOI: 10.3909/riu0701.
• 19 Gerridzen RG, Futter NG. Ten-year review of vesical diverticula. Urology 1982; 20: 33-35 DOI: 10.1016/0090-4295(82)90532-5.
• 20 Nadler RB, Pearle MS, McDougall EM. et al. Laparoscopic extraperitoneal bladder diverticulectomy: initial experience. Urology 1995; 45: 524-527 DOI: 10.1016/S0090-4295(99)80029-6.
• 21 Aaron D, Berger MDS. Robotic Bladder Diverticulectomy: Initial Experience. Journal of Urology 2006; 175: 162-163 DOI: 10.1016/S0022-5347(18)33929-6.
• 22 Gurung PM, Witthaus M, Campbell T. et al. Transvesical Versus Transabdominal - Which is the Best Approach to Bladder Diverticulectomy Using the Single Port Robotic System?. Urology 2020; 142: 248 DOI: 10.1016/j.urology.2020.05.018.
• 23 Roslan M, Przudzik M, Borowik M. et al. Single-session Transvesical Laparoendoscopic 1-Port Removal of 2 Bladder Diverticula in a Female Patient. Urology 2018; 120: 264-265 DOI: 10.1016/j.urology.2018.06.015.
• 24 Meeks JJ, Hagerty JA, Lindgren BW. Pediatric robotic-assisted laparoscopic diverticulectomy. Urology 2009; 73: 299-301 , discussion 301 DOI: 10.1016/j.urology.2008.06.068.
• 25 Christman MS, Casale P. Robot-assisted bladder diverticulectomy in the pediatric population. J Endourol 2012; 26: 1296-1300 DOI: 10.1089/end.2012.0051.
• 26 Altunrende F, Autorino R, Patel NS. et al. Robotic bladder diverticulectomy: technique and surgical outcomes. Int J Urol 2011; 18: 265-271 DOI: 10.1111/j.1442-2042.2010.02716.x.
• 27 Yoshimura I, Uchida H, Nakayama A. et al. Robot-assisted bladder diverticulectomy sequentially followed by robot-assisted radical prostatectomy: a case series. J Robot Surg 2019; 13: 227-230 DOI: 10.1007/s11701-018-0840-3.
• 28 Tufek I, Mourmouris P, Argun OB. et al. Robot-Assisted Bladder Diverticulectomy with Concurrent Management of Bladder Outlet Obstruction. Urol Int 2016; 96: 432-437 DOI: 10.1159/000443799.
• 29 Eyraud R, Laydner H, Autorino R. et al. Robot-assisted laparoscopic bladder diverticulectomy. Curr Urol Rep 2013; 14: 46-51 DOI: 10.1007/s11934-012-0290-9.
• 30 Cacciamani G, De Luyk N, De Marco V. et al. Robotic bladder diverticulectomy: step-by-step extravesical posterior approach - technique and outcomes. Scand J Urol 2018; 52: 285-290 DOI: 10.1080/21681805.2018.1492965.
• 31 Ploumidis A, Skolarikos A, Sopilidis O. et al. Sequential robotic-assisted bladder diverticulectomy and radical prostatectomy. Technique and review of the literature. Int J Surg Case Rep 2013; 4: 81-84 DOI: 10.1016/j.ijscr.2012.10.002.
• 32 Porpiglia F, Tarabuzzi R, Cossu M. et al. Sequential transurethral resection of the prostate and laparoscopic bladder diverticulectomy: comparison with open surgery. Urology 2002; 60: 1045-1049 DOI: 10.1016/s0090-4295(02)01985-4.
• 33 Myer EG, Wagner JR. Robotic assisted laparoscopic bladder diverticulectomy. J Urol 2007; 178: 2406-2410 , discussion 2410 DOI: 10.1016/j.juro.2007.08.012.
• 34 Rifaioglu MM, Warman I, Rassweiler J. et al. Robotic-assisted bladder diverticulectomy. Cent European J Urol 2016; 69: 238 DOI: 10.5173/ceju.2016.689.