臺灣博碩士論文加值系統

背景：世界衛生組織報導指出2018年男性癌症佔比前列腺癌是13.5%，佔排名的第二位。台灣衛生福利部106年癌症登記報告男性十大癌症發生率順位前列腺癌是第五位 (衛生福利部統計資料，2020)。當病患透過病理切片證實罹患前列腺癌，經診斷癌細胞仍然屬於侷限性前列腺癌，病患就有可能藉由前列腺根除手術治癒，傳統開腹手術、腹腔鏡手術及達文西機器手臂手術都是治療前列腺癌的手術方式。
目的: 本研究利用實證醫學系統性文獻回顧與統合分析方法，分析前列腺根除手術，亦即傳統開腹手術、腹腔鏡手術還有達文西機器手臂手術三種手術方式，病患手術預後以及因併發症再入院等醫療資源耗用之差異。
方法: 本研究利用系統性的文獻回顧與統合分析的方法，探討前列腺根除術包含傳統開腹手術、腹腔鏡手術及達文西機器手臂手術，對於病患手術預後以及因併發症再住院等醫療資源耗用之差異。搜尋2021年4月以前發表在PubMed、Medline、Cochrane Library、CINAHL、華藝線上圖書館、台灣碩博士論文加值系統等六個中英文資料庫之研究論文。檢索方式以PICO為指引，輸入醫學標題與關鍵字字串進行搜尋，而且用Boolean Logic串聯關鍵詞。文章選入條件:一、研究對象經由醫師診斷為可切除之前列腺癌且做前列腺根除手術，年紀≧18歲之男性。二、前列腺癌組織分期T1至T4，並且無遠端轉移之病患。三、以達文西手臂手術、腹腔鏡手術或傳統開腹手術其中二者以上作為實驗組或對照組之研究。四、成效評估包括病患預後、術後再入院率以及術後醫療花費。五、屬於隨機對照試驗或觀察性實驗之研究。六、結果評估之數據以比例、平均數、標準差、標準誤、p值或改變量呈現。
結果: 搜尋出406篇符合研究主題之文獻。排除161篇重複文獻以及213篇研究標題和摘要不相關之文獻，並排除3篇文獻回顧，1篇統合分析研究及3篇數據無法作為分析之文獻，最後納入25篇文獻進行統合分析。 25篇文獻經由Meta-Analysis統合分析達文西機器手臂手術和傳統開腹手術，術後1年醫療費用差異標準化均數差-0.20 (95% CI -0.28, -0.11)，p＜0.00001，I2＝83%，兩者在統計學上有極顯著差異，達文西機器手臂手術病患術後一年，醫療費用低於傳統開腹手術。達文西機器手臂手術在病患術後尿失禁恢復比率和性功能恢復比率明顯高於腹腔鏡手術，達文西機器手臂手術和腹腔鏡手術比較，術後3個月尿失禁恢復比率差異相對風險0.77 (95% CI 0.66, 0.89)，p＝0.0005，I2＝63%，兩者有極顯著差異。術後6個月尿失禁恢復比率差異相對風險0.62 (95% CI 0.53, 0.72)，p＜0.00001，I2＝42%，兩者有極顯著差異。術後12個月尿失禁恢復比率差異相對風險0.68 (95% CI 0.54, 0.85)，p=0.0006，I2＝56%，兩者有極顯著差異。達文西機器手臂手術和腹腔鏡手術比較，術後3個月勃起功能恢復比率差異相對風險0.84 (95% CI 0.74, 0.95)，p=0.006，I2＝84%，兩者有極顯著差異。術後6個月勃起功能恢復比率差異相對風險0.74 (95% CI 0.60, 0.91)，p=0.004，I2=74%，兩者有極顯著差異。術後12個月勃起功能恢復比率差異相對風險0.67 (95% CI 0.53, 0.84)，p=0.0006，I2=75%，兩者有極顯著差異。
結論: 前列腺根除手術達文西機器手臂手術和腹腔鏡手術相比較，在預後尿失禁恢復比率和勃起功能恢復比率有極顯著差異，證實達文西機器手臂手術在預後尿失禁恢復和勃起功能恢復優於腹腔鏡手術。達文西機器手臂手術和傳統開腹手術，術後1年醫療費用有極顯著差異，證實達文西機器手臂手術術後1年醫療費用低於傳統開腹手術，醫療資源耗用比較少。

Background: According to the WHO report, prostate cancer was the second most prevalent cancer among the men population in 2018, which affected 13.5 percent of population globally. It was also the fifth most prevalent cancer in Taiwan according to the Taiwan's Ministry of Health and Welfare report in 2015 (Ministry of Health and Welfare Statistics, 2020). When patients are diagnosed with localized prostate cancer through pathological report, surgical intervention was indicated. To date, there are three main types of radical prostatectomy, including open retropubic radical prostatectomy (RRP), laparoscopic radical prostatectomy (LRP) and robotic-assisted radical prostatectomy (RARP). There is still a lack of consistent evidence demonstrating which types of surgery had superior prognosis and the least post-operative medical cost.
Objective: We conducted systematic review and meta-analysis to analyze the differences between three types of radical prostatectomy in the post-operative medical cost and the functional outcome, including re-admission rate due to complications, the continence and potency rate in three, six and twelve months after the surgery respectively.
Methods: We performed a systematic review and meta-analysis of randomized controlled trials (RCTs), prospective and retrospective studies that evaluated the post-operative medical cost and the functional outcome among three types of radical prostatectomy. Electronic databases, including PubMed, Medline, Cochrane Library, CINAHL, Airiti Online Library, and National digital library theses and Dissertations in Taiwan (NDLTD) were searched for articles published before April 2021. The main outcomes were post-operative medical cost during one year after the surgery, re-admission rate due to complications, the continence and potency rate in three and six months after the surgery respectively. The searching term is guided by PICO, and Boolean operators were used in MeSH and free-text searches. The inclusion criteria of the studies were listed as following: (1) studies which investigated people older than 18-year-old who were diagnosed with localized prostate cancer by physicians, and had already received radical prostatectomy, (2) localized prostate cancer with pathological stages T1 to T4 and no metastasis, (3) studies which compared more than two types of radical prostatectomy among RRP, LRP, and RARP, (4) studies which assessed the patient's prognosis, the rate of postoperative clinical follow-up, the postoperative re-admissions and the cost of postoperative medical treatment, (5) studies that are randomized controlled trials, prospective studies, and retrospective studies, (6) studies in which the result data was presented in proportion, mean, standard deviation, standard error, p value or change.
Result: Our initial search yielded 406 studies, of which 161 were duplicate documents and 213 were deemed ineligible through title and abstract screening. Of remaining 32 studies, 7 studies were excluded from our final analysis for the following reasons: 3 studies were review article, one was meta-analysis, and 3 studies was excluded because of different comparisons. The remaining 25 studies were included in our analysis. The overall data showed a significant lower post-operative medical cost in RARP groups than RRP groups (weighted mean difference [WMD]= -0.20, 95% confidence interval [CI]= -0.28 to -0.11, p＜0.00001, I2＝83%). RARP groups also showed a significant improve in urinary continence and potency rate than LRP groups in three, six, and twelve months after the surgery (risk ratio [RR] of urinary continence rate in three months after the surgery= 0.77, 95% CI =0.66 to 0.89, p＝0.0005, I2＝63%; RR of urinary continence rate in six month after the surgery =0.62, 95% CI= 0.53 to 0.72, p＜0.00001, I2＝42%; RR of urinary continence rate in twelve months after the surgery= 0.68, 95% CI= 0.54 to 0.85, p=0.0006, I2＝56%; RR of potency rate in three months after the surgery= 0.84, 95% CI= 0.74 to 0.95, p=0.006, I2＝84%; RR of potency rate in six months after the surgery= 0.74, 95% CI= 0.60 to 0.91, p=0.004, I2=74%; RR of potency rate in twelve months after the surgery= 0.67, 95% CI= 0.53 to 0.84, p=0.0006, I2=75%.
Conclusion: Patients who received RARP may have a better prognosis in the urinary functional outcome, including the continence and potency function. Also, people who underwent RARP may have a lower post-operative cost compared to RRP during one year after the surgery due to the lower complication rate.

目錄
誌謝...I
中文摘要...II
Abstract...IV
目錄...VII
表目次...IX
圖目次...X
第一章 緒論...1
第一節 研究背景與動機...1
第二節 研究目的...4
第三節 研究的重要性...5
第二章 文獻探討...6
第一節 前列腺癌的介紹...6
第二節 前列腺癌的診斷與治療...7
第三節 前列腺根除手術...10
第四節 前列腺根除手術併發症...14
第五節 醫療資源耗用相關文獻...15
第三章 研究方法...20
第一節 研究架構...20
第二節 研究目標...21
第三節 資料的蒐集與篩選...22
第四節 研究品質評估...24
第五節 研究資料選取及分析項目...26
第六節 統合分析...27
第四章 研究結果...28
第一節納入統合分析之文獻特性...30
第二節 研究品質...37
第三節 前列腺根除手術術後再入院率差異結果...38
第四節 前列腺根除手術術後一年醫療費用差異結果...44
第五節 前列腺根除手術術後尿失禁恢復與勃起功能恢復比率差異結果...48
第六節 統合分析結果彙整...58
第五章 討論...60
第一節 前列腺根除手術術後再入院率差異統合分析結果討論...61
第二節 前列腺根除手術術後醫療費用差異統合分析結果討論...63
第三節 前列腺根除手術術後尿失禁恢復和勃起功能恢復比率差異統合分析結果討論...66
第四節 結論...69
參考文獻...70
中文文獻...70
英文文獻...71
表目次
表2-1、前列腺癌常用的治療方法...9
表2-2、根除性前列腺切除術比較...13
表3-1、關鍵字搜尋...23
表4-1、統合分析之文獻特性...30
表4-2、達文西機器手臂手術、腹腔鏡手術及傳統開腹手術，90天再入院率和1年再入院率比較...33
表4-3、達文西機器手臂手術、腹腔鏡手術及傳統開腹手術，術後一年醫療費用比較...34
表4-4、達文西機器手臂手術和腹腔鏡手術，尿失禁恢復及勃起功能恢復比較...35
表4-5、以考科藍誤差風險評估工具 (Cochrane risk of bias tool, RoB 2.0) 評估2篇隨機對照試驗的誤差風險...37
表4-6、前列腺根除手術術後再入院率差異統合分析結果...58
表4-7、前列腺根除手術術後1年醫療費用差異統合分析結果...58
表4-8、前列腺根除手術術後尿失禁恢復比率差異統合分析結果...58
表4-9、前列腺根除手術術後勃起功能恢復比率差異統合分析結果...59
圖目次
圖4-1、文獻搜尋流程圖...29
圖4-2、達文西機器手臂手術和傳統開腹手術，術後90天再入院率差異森林圖及漏斗圖...40
圖4-3、達文西機器手臂手術和腹腔鏡手術，術後90天再入院率差異森林圖及漏斗圖...41
圖4-4、腹腔鏡手術和傳統開腹手術，術後90天再入院率差異森林圖及漏斗圖...42
圖4-5、達文西機器手臂手術和傳統開腹手術，術後1年再入院率差異森林圖及漏斗圖...43
圖4-6、達文西機器手臂手術和傳統開腹手術，術後1年醫療費用差異森林圖及漏斗圖...45
圖4-7、達文西機器手臂手術和腹腔鏡手術，術後1年醫療費用差異森林圖及漏斗圖...46
圖4-8、腹腔鏡手術和傳統開腹手術，術後1年醫療費用差異森林圖及漏斗圖...47
圖4-9、達文西機器手臂手術和腹腔鏡手術，術後3個月尿失禁恢復比率差異森林圖及漏斗圖...52
圖4-10、達文西機器手臂手術和腹腔鏡手術，術後6個月尿失禁恢復比率差異森林圖及漏斗圖...53
圖4-11、達文西機器手臂手術和腹腔鏡手術，術後12個月尿失禁恢復比率差異森林圖及漏斗圖...54
圖4-12、達文西機器手臂手術和腹腔鏡手術，術後3個月勃起功能恢復比率差異森林圖及漏斗圖...55
圖4-13、達文西機器手臂手術和腹腔鏡手術，術後6個月勃起功能恢復比率差異森林圖及漏斗圖...56
圖4-14、達文西機器手臂手術和腹腔鏡手術，術後12個月勃起功能恢復比率差異森林圖及漏斗圖...57

中文文獻
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江月萍（2010）。早期攝護腺癌病患接受根除性攝護腺切除手術與晚期攝護腺癌病患接受荷爾蒙治療後復發因子之探討。亞洲大學健康產業管理學系健康管理組在職專班碩士論文，台中市。 取自https://hdl.handle.net/11296/256p85
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