International Journal of Surgery 13 (2015) 17e22
Contents lists available at ScienceDirect
International Journal of Surgery journal homepage: www.journal-surgery.net
Original research
Comparing robotic surgery with laparoscopy and laparotomy for endometrial cancer management: A cohort study Hung-Yi Chiou a, 1, Li-Hsuan Chiu b, 1, Ching-Hui Chen b, c, Yuan-Kuei Yen b, c, Ching-Wen Chang b, c, Wei-Min Liu b, c, * a b c
School of Public Health, Taipei Medical University, Taipei, Taiwan Department of Obstetrics and Gynecology, Taipei Medical University Hospital, Taipei, Taiwan Department of Obstetrics and Gynecology, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
h i g h l i g h t s Robotic Robotic Robotic Robotic
surgery surgery surgery surgery
has been applied in managing various types of gynecologic cancers. showed favorable short-term results in treating endometrial cancer. showed similar complication rate to laparoscopy and laparotomy. showed comparable survival outcomes to laparoscopy and laparotomy.
a r t i c l e i n f o
a b s t r a c t
Article history: Received 22 September 2014 Received in revised form 8 November 2014 Accepted 17 November 2014 Available online 18 November 2014
Introduction: Robotic surgery has been applied in managing various types of gynecologic cancers. The purpose of this study is to compare the surgical outcomes of robotic surgery, laparoscopy and laparotomy for managing endometrial cancer. Methods: A total of 365 patients received surgical staging for treating IA to IIIC endometrial cancer were retrospectively enrolled. Patient demography, peri-operative parameters, and survival outcomes were studied. Results and discussions: Robotic surgery showed a significant lower blood loss and 24-h pain score as compared to other surgical types. Moreover, compared to laparotomy, robotic and laparoscopic surgeries were associated with reduced operation time, decreased time to full diet resumption, and shortened hospital stay. No significant differences were found between the groups in terms of overall complication rate. Eighteen-month follow-up of the patients indicated no significant differences in disease-free survival and overall survival. Conclusion: Compared to conventional approaches, robotic surgery showed favorable short-term outcomes with comparable survival. It is suggested that robotic surgery is a feasible tool for endometrial cancer management. © 2014 Surgical Associates Ltd. Published by Elsevier Ltd. All rights reserved.
Keywords: Robotic surgery Surgical staging Endometrial cancer
1. Introduction To date, robotic surgery system has been applied in various types of surgeries. For gynecologic cancer management, recent reports have suggested the role of robotic surgery in treating cervical cancer [1e3], endometrial cancer [4e8], early stage and local
* Corresponding author. Department of Obstetrics and Gynecology, Taipei Medical University Hospital and Taipei Medical University, No.252, Wu-Xin St., Sinyi District, Taipei, 11031, Taiwan. E-mail address: [email protected] (W.-M. Liu). 1 Hung-Yi Chiou and Li-Hsuan Chiu contribute equally to this work. http://dx.doi.org/10.1016/j.ijsu.2014.11.015 1743-9191/© 2014 Surgical Associates Ltd. Published by Elsevier Ltd. All rights reserved.
recurrent ovarian cancer [9,10]. Robotic surgery showed shortened hospital stay, decreased blood loss, and lower transfusion rates of the patients for treating stage IA to IIB cervical cancer [1,2,11e13]. Other reports also demonstrated that robotic approach is found to associate with lower blood loss, shorter hospital stay, fewer major complications, higher lymph node yield, and lower laparotomy conversion in treating endometrial cancer patients [6e8,14,15]. However, large perspective study is still lacking. In our prior work, we elucidated surgical outcome of robotic surgery for treating stage IA to IIB cervical cancer. The data indicated that robotic surgery has favorable short-term surgical results without compromise of the survival [13]. In this current study, we further examined the peri-operative parameters as well as 1.5-year
18
H.-Y. Chiou et al. / International Journal of Surgery 13 (2015) 17e22
survival of endometrial cancer patients received robotic, laparoscopic, and laparotomy staging surgery. As perspective data is still lacking, by comparing short-term surgical performance also long term results, the feasibility of robotic surgery in managing endometrial cancer were further elucidated in this current study. 2. Materials and methods This study was conducted in compliance with the protocol approved by the Joint Institutional Review Board of Taipei Medical University (TMUJIRB-201301048). A total of 377 endometrial cancer cases were done grouped and retrospective analyzed by medical chart review. The period of enrollment for the laparoscopic and laparotomy group was from 2005 to 2013; and the period of enrollment for the robotic group was from 2011 to 2013, due to that the robotic surgical system was available in our hospital since 2011. All enrolled cases had their pathological diagnosis confirmed before operation, and received complete surgical staging procedures by one surgeon in single center. The inclusion criteria were endometrial cancer with disease staging between FIGO stage IA to IIIC, without preoperative brachytherapy or chemotherapy. Patient demography including age, BMI, disease stage, histologic type, and prior surgical histories were examined for each cohort. Peri-operative parameters including blood loss, operation time, hemoglobin level, lymph node yield, surgical stress, laparotomy conversion, postoperative pain score, time to full-diet resumption, and hospital stay were compared between groups. Blood loss was defined as the total volume of suctioned fluids. The operative time was measured from the time of skin incision until all surgical staging procedures were completed. Surgical stress was defined as the ratio of intra-operative mean arterial pressure (MAP) to preoperative baseline MAP, which is closely associated with the
physical stress induced by surgical procedures during the operation [16,17]. All patients received pain control with patient-controlled analgesia (PCA) or non-steroidal anti-inflammatory drugs (NSAIDs) during postoperative care. Postoperative pain scores were obtained 24-h after the operation. All the pain score data were measured using the adult pain score numerical rating scale (0e10). Time for full diet resumption was defined as postoperative days until the patients could tolerate solid food. Patients admitted two days before the operation day for colon preparation and preoperative CT examination. Hospital stay was defined as the number of postoperative days until discharge. For long-term surgical outcomes, perioperative complications according to ClaveineDindo classification and survival outcomes were analyzed for each cohort as well. For static analysis, all obtained data were analyzed using SPSS statistics (version 21.0, IBM). The descriptive analysis including the mean, standard deviation (SD), median, and range of each perioperative parameter were reported and presented as mean ± SD. The statistical analysis was performed with One-way ANOVA and Turkey HSD post-hoc analysis, and a p value of less than 0.05 was considered statistically significant between the groups. 3. Results Fig. 1 showed the inclusion flow chart of this study. Based on the pathological report as endometrial cancer, 377 women were reviewed for their medical records in this study. Patients received complete surgical staging procedures, which consisted of ascites cytology, bilateral salpingo-oophorectomy, bilateral pelvic lymph node dissection, and total hysterectomy, were included in this study. For patients with disease in advanced stages, paraaortic lymph node dissection was also included for staging procedure.
Recruitment of patients based on their pathology report as endometrial cancer (n=377) Not eligible to receive surgical intervention (n=7)
Patient received surgical intervention for disease management (n=370)
Patient received additional major procedures (n=5)
Study population (n=365)
Robotic surgery (n=86)
Laparoscopic surgery (n=150) Fig. 1. Inclusion flowchart of all enrolled patients.
Laparotomy (n=129)
H.-Y. Chiou et al. / International Journal of Surgery 13 (2015) 17e22 Table 1 Baseline characteristics of the enrolled patients were summarized. Data were presented as mean (SD) or percentage (case number). The statistical analysis was performed with one-way ANOVA and Duncan post-hoc analysis, or Chi-Square analysis. Robotic approach (n ¼ 86) Age (years) 53.6 (11.1) BMI (kg/m2) 26.0 (5.2) Cases with positive 7.0% (6/86) lymph nodes, % (n) Pathological stage, % (n) Stage I 83.7% (72/86) Stage II 2.3% (2/86) Stage III 14.0% (12/86) Histologic type, % (n) Endometrioid 86.1% (74/86) Mixed type 11.6% (10/86) Serous 2.3% (2/86) Clear cell 0% (0/86) Mucinous 0% (0/86) Other types 0% (0/86)
Laparoscopic approach (n ¼ 150)
Laparotomy approach (n ¼ 129)
pvalue
51.4 (14.2) 25.6 (5.6) 6.7% (10/150)
53.6 (11.3) 26.1 (5.7) 11.6% (12/129)
0.73 0.85 0.69
80.7% (121/150) 6.0% (9/150) 13.3% (20/150)
72.9% (94/129) 7.8% (10/129) 19.4% (25/129)
0.12 0.24 0.34
84.7% (127/150) 10.7% (16/150) 0.7% (1/150) 2.0% (3/150) 1.3% (2/150) 0.7% (1/150)
79.1% (102/129) 18.6% (24/129) 0% (0/129) 0.8% (1/129) 0.8% (1/129) 0.8% (1/129)
0.32 0.13 0.17 0.33 0.55 0.73
Data presented as mean (SD) or percentage (case number).
Patients received additional major procedures including intestinal resection, sigmoid colon resection, colectomy, colorectal anastomosis, colostomy, ureterostomy were excluded. Among the 377 reviewed cases, 7 cases not eligible to receive surgical intervention and 5 cases received additional major procedures were excluded. Among the 365 cases included, 86 women received robotic surgical staging, 150 women received laparoscopic surgical staging, and 129 women received laparotomy surgical staging. Table 1 lists the baseline characteristics of the enrolled patients. The mean ages were 53.6 ± 11.1 for robotic group, 51.4 ± 14.2 for laparoscopic group, and 53.6 ± 11.3 for laparotomy group, with no significant difference found between the groups. The mean BMIs
19
were 26.0 ± 5.2 kg/m2 for robotic group, 25.6 ± 5.6 kg/m2 for laparoscopic group, and 26.1 ± 5.7 kg/m2 for laparotomy group, showed no significant difference among the groups. The percentages of cases with positive lymph node findings from each group were 7.0% (robotic approach), 6.7% (laparoscopic approach), and 11.6% (laparotomy approach), were not significantly different. The percentage and case number of each disease stage and histological type were also reported in Table 1. The differences in various disease stages and histological types were all found to be not significant between the groups, indicating that the study population of each group was comparable. Table 2 showed the intraoperative parameters. The operation time was significantly reduced in robotic group (155.6 min ± 45.7 min) and laparoscopic group (178.6 min ± 58.7 min) as compared with the laparotomy (195.3 min ± 67.0 min). The volume of blood loss during the operation was significantly decreased in robotic group (94.8 mL ± 78.6 mL) than laparoscopic (174.2 mL ± 229.6 mL) and laparotomy group (234.4 mL ± 178.2 mL). As to the average number of pelvic lymph nodes retrieved in each group, no significant difference was found between the groups. Table 2 also lists postoperative evaluation factors. As postoperative pain control was given, postoperative pain score were found to be similar between the groups. However, significant lower 24-h pains score (1.9 ± 1.1) was found for robotic surgery as compared to laparoscopy (2.5 ± 0.7) and laparotomy (2.5 ± 1.0). Furthermore, compared with the laparotomy (1.7d ± 0.6d), laparoscopic (1.6d ± 0.7d) and robotic surgery (1.4d ± 0.5d) showed a significantly reduced time of patients to return to full diet after surgery. The duration of the hospital stay was also reduced significantly in the robotic (3.1d ± 1.1d) and laparoscopic (3.7d ± 2.2d) group compared with laparotomy (5.8d ± 5.5d) groups. The total complication rate for each group was presented in Table 3. For intraoperative complications, 1 case of postoperative ileus and 2 case of pelvic infection were examined in the
Table 2 Intra-operative and post-operative parameters for each surgical group were listed. Data were presented as mean (SD). The median and range of each data set were listed as well. The statistical analysis was performed with one-way ANOVA and Duncan post-hoc analysis. Robotic approach (n ¼ 86) Operation time (min) Mean 155.6 (45.7) Median 145.0 Range 94e333 Blood loss (mL) Mean 94.8 (78.6) Median 50 Range 50e500 Lymph node yield Mean 26.5 (10.7) Median 26 Range 10e58 Pain score(postoperative) Mean 2.8 (1.0) Median 3.0 Range 1e4 Pain score(24 h) Mean 1.9 (1.1) Median 2.0 Range 1e5 Receiving full diet (days) Mean 1.4 (0.5) Median 1.0 Range 1e2 Hospital stay (days) Mean 3.1 (1.1) Median 3.0 Range 2e6
Laparoscopic approach (n ¼ 150)
Laparotomy approach (n ¼ 129)
Post-hoc analysis
p-value
195.3 (67.0) 175.0 146e319
LAPA > LPS ¼ ROBO
ROBO
ROBO
LPS ¼ ROBO
LPS¼ROBO
Contents lists available at ScienceDirect
International Journal of Surgery journal homepage: www.journal-surgery.net
Original research
Comparing robotic surgery with laparoscopy and laparotomy for endometrial cancer management: A cohort study Hung-Yi Chiou a, 1, Li-Hsuan Chiu b, 1, Ching-Hui Chen b, c, Yuan-Kuei Yen b, c, Ching-Wen Chang b, c, Wei-Min Liu b, c, * a b c
School of Public Health, Taipei Medical University, Taipei, Taiwan Department of Obstetrics and Gynecology, Taipei Medical University Hospital, Taipei, Taiwan Department of Obstetrics and Gynecology, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
h i g h l i g h t s Robotic Robotic Robotic Robotic
surgery surgery surgery surgery
has been applied in managing various types of gynecologic cancers. showed favorable short-term results in treating endometrial cancer. showed similar complication rate to laparoscopy and laparotomy. showed comparable survival outcomes to laparoscopy and laparotomy.
a r t i c l e i n f o
a b s t r a c t
Article history: Received 22 September 2014 Received in revised form 8 November 2014 Accepted 17 November 2014 Available online 18 November 2014
Introduction: Robotic surgery has been applied in managing various types of gynecologic cancers. The purpose of this study is to compare the surgical outcomes of robotic surgery, laparoscopy and laparotomy for managing endometrial cancer. Methods: A total of 365 patients received surgical staging for treating IA to IIIC endometrial cancer were retrospectively enrolled. Patient demography, peri-operative parameters, and survival outcomes were studied. Results and discussions: Robotic surgery showed a significant lower blood loss and 24-h pain score as compared to other surgical types. Moreover, compared to laparotomy, robotic and laparoscopic surgeries were associated with reduced operation time, decreased time to full diet resumption, and shortened hospital stay. No significant differences were found between the groups in terms of overall complication rate. Eighteen-month follow-up of the patients indicated no significant differences in disease-free survival and overall survival. Conclusion: Compared to conventional approaches, robotic surgery showed favorable short-term outcomes with comparable survival. It is suggested that robotic surgery is a feasible tool for endometrial cancer management. © 2014 Surgical Associates Ltd. Published by Elsevier Ltd. All rights reserved.
Keywords: Robotic surgery Surgical staging Endometrial cancer
1. Introduction To date, robotic surgery system has been applied in various types of surgeries. For gynecologic cancer management, recent reports have suggested the role of robotic surgery in treating cervical cancer [1e3], endometrial cancer [4e8], early stage and local
* Corresponding author. Department of Obstetrics and Gynecology, Taipei Medical University Hospital and Taipei Medical University, No.252, Wu-Xin St., Sinyi District, Taipei, 11031, Taiwan. E-mail address: [email protected] (W.-M. Liu). 1 Hung-Yi Chiou and Li-Hsuan Chiu contribute equally to this work. http://dx.doi.org/10.1016/j.ijsu.2014.11.015 1743-9191/© 2014 Surgical Associates Ltd. Published by Elsevier Ltd. All rights reserved.
recurrent ovarian cancer [9,10]. Robotic surgery showed shortened hospital stay, decreased blood loss, and lower transfusion rates of the patients for treating stage IA to IIB cervical cancer [1,2,11e13]. Other reports also demonstrated that robotic approach is found to associate with lower blood loss, shorter hospital stay, fewer major complications, higher lymph node yield, and lower laparotomy conversion in treating endometrial cancer patients [6e8,14,15]. However, large perspective study is still lacking. In our prior work, we elucidated surgical outcome of robotic surgery for treating stage IA to IIB cervical cancer. The data indicated that robotic surgery has favorable short-term surgical results without compromise of the survival [13]. In this current study, we further examined the peri-operative parameters as well as 1.5-year
18
H.-Y. Chiou et al. / International Journal of Surgery 13 (2015) 17e22
survival of endometrial cancer patients received robotic, laparoscopic, and laparotomy staging surgery. As perspective data is still lacking, by comparing short-term surgical performance also long term results, the feasibility of robotic surgery in managing endometrial cancer were further elucidated in this current study. 2. Materials and methods This study was conducted in compliance with the protocol approved by the Joint Institutional Review Board of Taipei Medical University (TMUJIRB-201301048). A total of 377 endometrial cancer cases were done grouped and retrospective analyzed by medical chart review. The period of enrollment for the laparoscopic and laparotomy group was from 2005 to 2013; and the period of enrollment for the robotic group was from 2011 to 2013, due to that the robotic surgical system was available in our hospital since 2011. All enrolled cases had their pathological diagnosis confirmed before operation, and received complete surgical staging procedures by one surgeon in single center. The inclusion criteria were endometrial cancer with disease staging between FIGO stage IA to IIIC, without preoperative brachytherapy or chemotherapy. Patient demography including age, BMI, disease stage, histologic type, and prior surgical histories were examined for each cohort. Peri-operative parameters including blood loss, operation time, hemoglobin level, lymph node yield, surgical stress, laparotomy conversion, postoperative pain score, time to full-diet resumption, and hospital stay were compared between groups. Blood loss was defined as the total volume of suctioned fluids. The operative time was measured from the time of skin incision until all surgical staging procedures were completed. Surgical stress was defined as the ratio of intra-operative mean arterial pressure (MAP) to preoperative baseline MAP, which is closely associated with the
physical stress induced by surgical procedures during the operation [16,17]. All patients received pain control with patient-controlled analgesia (PCA) or non-steroidal anti-inflammatory drugs (NSAIDs) during postoperative care. Postoperative pain scores were obtained 24-h after the operation. All the pain score data were measured using the adult pain score numerical rating scale (0e10). Time for full diet resumption was defined as postoperative days until the patients could tolerate solid food. Patients admitted two days before the operation day for colon preparation and preoperative CT examination. Hospital stay was defined as the number of postoperative days until discharge. For long-term surgical outcomes, perioperative complications according to ClaveineDindo classification and survival outcomes were analyzed for each cohort as well. For static analysis, all obtained data were analyzed using SPSS statistics (version 21.0, IBM). The descriptive analysis including the mean, standard deviation (SD), median, and range of each perioperative parameter were reported and presented as mean ± SD. The statistical analysis was performed with One-way ANOVA and Turkey HSD post-hoc analysis, and a p value of less than 0.05 was considered statistically significant between the groups. 3. Results Fig. 1 showed the inclusion flow chart of this study. Based on the pathological report as endometrial cancer, 377 women were reviewed for their medical records in this study. Patients received complete surgical staging procedures, which consisted of ascites cytology, bilateral salpingo-oophorectomy, bilateral pelvic lymph node dissection, and total hysterectomy, were included in this study. For patients with disease in advanced stages, paraaortic lymph node dissection was also included for staging procedure.
Recruitment of patients based on their pathology report as endometrial cancer (n=377) Not eligible to receive surgical intervention (n=7)
Patient received surgical intervention for disease management (n=370)
Patient received additional major procedures (n=5)
Study population (n=365)
Robotic surgery (n=86)
Laparoscopic surgery (n=150) Fig. 1. Inclusion flowchart of all enrolled patients.
Laparotomy (n=129)
H.-Y. Chiou et al. / International Journal of Surgery 13 (2015) 17e22 Table 1 Baseline characteristics of the enrolled patients were summarized. Data were presented as mean (SD) or percentage (case number). The statistical analysis was performed with one-way ANOVA and Duncan post-hoc analysis, or Chi-Square analysis. Robotic approach (n ¼ 86) Age (years) 53.6 (11.1) BMI (kg/m2) 26.0 (5.2) Cases with positive 7.0% (6/86) lymph nodes, % (n) Pathological stage, % (n) Stage I 83.7% (72/86) Stage II 2.3% (2/86) Stage III 14.0% (12/86) Histologic type, % (n) Endometrioid 86.1% (74/86) Mixed type 11.6% (10/86) Serous 2.3% (2/86) Clear cell 0% (0/86) Mucinous 0% (0/86) Other types 0% (0/86)
Laparoscopic approach (n ¼ 150)
Laparotomy approach (n ¼ 129)
pvalue
51.4 (14.2) 25.6 (5.6) 6.7% (10/150)
53.6 (11.3) 26.1 (5.7) 11.6% (12/129)
0.73 0.85 0.69
80.7% (121/150) 6.0% (9/150) 13.3% (20/150)
72.9% (94/129) 7.8% (10/129) 19.4% (25/129)
0.12 0.24 0.34
84.7% (127/150) 10.7% (16/150) 0.7% (1/150) 2.0% (3/150) 1.3% (2/150) 0.7% (1/150)
79.1% (102/129) 18.6% (24/129) 0% (0/129) 0.8% (1/129) 0.8% (1/129) 0.8% (1/129)
0.32 0.13 0.17 0.33 0.55 0.73
Data presented as mean (SD) or percentage (case number).
Patients received additional major procedures including intestinal resection, sigmoid colon resection, colectomy, colorectal anastomosis, colostomy, ureterostomy were excluded. Among the 377 reviewed cases, 7 cases not eligible to receive surgical intervention and 5 cases received additional major procedures were excluded. Among the 365 cases included, 86 women received robotic surgical staging, 150 women received laparoscopic surgical staging, and 129 women received laparotomy surgical staging. Table 1 lists the baseline characteristics of the enrolled patients. The mean ages were 53.6 ± 11.1 for robotic group, 51.4 ± 14.2 for laparoscopic group, and 53.6 ± 11.3 for laparotomy group, with no significant difference found between the groups. The mean BMIs
19
were 26.0 ± 5.2 kg/m2 for robotic group, 25.6 ± 5.6 kg/m2 for laparoscopic group, and 26.1 ± 5.7 kg/m2 for laparotomy group, showed no significant difference among the groups. The percentages of cases with positive lymph node findings from each group were 7.0% (robotic approach), 6.7% (laparoscopic approach), and 11.6% (laparotomy approach), were not significantly different. The percentage and case number of each disease stage and histological type were also reported in Table 1. The differences in various disease stages and histological types were all found to be not significant between the groups, indicating that the study population of each group was comparable. Table 2 showed the intraoperative parameters. The operation time was significantly reduced in robotic group (155.6 min ± 45.7 min) and laparoscopic group (178.6 min ± 58.7 min) as compared with the laparotomy (195.3 min ± 67.0 min). The volume of blood loss during the operation was significantly decreased in robotic group (94.8 mL ± 78.6 mL) than laparoscopic (174.2 mL ± 229.6 mL) and laparotomy group (234.4 mL ± 178.2 mL). As to the average number of pelvic lymph nodes retrieved in each group, no significant difference was found between the groups. Table 2 also lists postoperative evaluation factors. As postoperative pain control was given, postoperative pain score were found to be similar between the groups. However, significant lower 24-h pains score (1.9 ± 1.1) was found for robotic surgery as compared to laparoscopy (2.5 ± 0.7) and laparotomy (2.5 ± 1.0). Furthermore, compared with the laparotomy (1.7d ± 0.6d), laparoscopic (1.6d ± 0.7d) and robotic surgery (1.4d ± 0.5d) showed a significantly reduced time of patients to return to full diet after surgery. The duration of the hospital stay was also reduced significantly in the robotic (3.1d ± 1.1d) and laparoscopic (3.7d ± 2.2d) group compared with laparotomy (5.8d ± 5.5d) groups. The total complication rate for each group was presented in Table 3. For intraoperative complications, 1 case of postoperative ileus and 2 case of pelvic infection were examined in the
Table 2 Intra-operative and post-operative parameters for each surgical group were listed. Data were presented as mean (SD). The median and range of each data set were listed as well. The statistical analysis was performed with one-way ANOVA and Duncan post-hoc analysis. Robotic approach (n ¼ 86) Operation time (min) Mean 155.6 (45.7) Median 145.0 Range 94e333 Blood loss (mL) Mean 94.8 (78.6) Median 50 Range 50e500 Lymph node yield Mean 26.5 (10.7) Median 26 Range 10e58 Pain score(postoperative) Mean 2.8 (1.0) Median 3.0 Range 1e4 Pain score(24 h) Mean 1.9 (1.1) Median 2.0 Range 1e5 Receiving full diet (days) Mean 1.4 (0.5) Median 1.0 Range 1e2 Hospital stay (days) Mean 3.1 (1.1) Median 3.0 Range 2e6
Laparoscopic approach (n ¼ 150)
Laparotomy approach (n ¼ 129)
Post-hoc analysis
p-value
195.3 (67.0) 175.0 146e319
LAPA > LPS ¼ ROBO
ROBO
ROBO
LPS ¼ ROBO
LPS¼ROBO
