摘要
目的:探讨改良经腹膜外腹腔镜全筋膜内根治性前列腺切除术治疗局限性前列腺癌的疗效和安全性。方法:回顾性分析2013年7月至2020年1月宁波市泌尿肾病医院收治的107例局限性前列腺癌患者的病例资料。患者均行腹腔镜根治性前列腺切除术,根据手术方式分为改良全筋膜内切除组(改良组)59例和常规筋膜间保留血管神经束组(常规组)48例。改良组和常规组的年龄[(61.8±8.9)岁与(62.2±8.1)岁,P=0.71]、体质指数(BMI)[(24.8±1.3)kg/m 2与(24.3±1.4)kg/m 2,P=0.89]、术前总前列腺特异性抗原(tPSA)[(6.8±0.9)ng/ml与(7.2±1.1)ng/ml,P=0.44]、前列腺体积[(47.9±18.4)ml与(48.3±17.9)ml,P=0.67]差异均无统计学意义。两组临床分期均为cT 1~T 2aN 0M 0期,术前穿刺病理Gleason评分均≤7分(P=0.76)。两组术前国际勃起功能评分(IIEF5)均≥22分。改良组术中不打开双侧盆底筋膜、不缝扎背深静脉复合体(DVC),保持Denonvillier筋膜完整,采用筋膜内技术游离前列腺,完整保留双侧血管神经束,并且在吻合尿道和膀胱颈后,将两侧前列腺筋膜、耻骨膀胱/前列腺韧带以及DVC与膀胱颈前壁用3-0倒刺线连续缝合,以解剖性重建前悬吊系统。比较两组的术中情况、术后病理分期、切缘阳性率以及术后6个月内控尿、勃起功能恢复情况。结果:两组手术均顺利完成,均无中转开放手术,术中术后均无输血。改良组和常规组手术时间[(121.8±41.3)min与(106.7±33.8)min,P>0.05]、术中出血量[(105.34±34.1)ml与(90.6±26.4)ml,P>0.05]差异均无统计学意义;术后病理分期pT 2a、pT 2b、pT 2c、pT 3a期分别为14例(23.7%)和11例(22.9%)、25例(42.4%)和18例(37.5%)、17例(28.8%)和5例(31.3%)、3例(5.1%)和4例(8.3%),切缘阳性分别为7例(11.9%)和6例(12.5%),差异均无统计学意义(P>0.05)。改良组和常规组术后6周tPSA分别为(0.09±0.07)ng/ml和(0.08±0.06)ng/ml,差异无统计学意义(P>0.05)。常规组术后出现1例吻合口漏尿,留置尿管2周后顺利拔管,其余患者均于术后12 d拔除尿管。改良组和常规组拔管后1周、1个月、3个月尿控率分别为52.5%(31/59)和16.7%(8/48)、64.4%(38/59)和29.2%(14/48)、52.1%(25/48)和77.9%(46/59),差异有统计学意义(P<0.05);术后1、3个月勃起功能恢复率分别为23.7%(14/59)和8.3%(4/48),49.2%(29/59)和27.1%(13/48),差异有统计学意义(P<0.05);术后6个月的尿控率和勃起功能恢复率差异均无统计学意义(P>0.05)。结论:改良全筋膜内切除在腹腔镜根治性前列腺切除术中完全重建了尿道周围解剖结构,减少了对盆底肌肉、筋膜及血管神经束的损伤,术后早期尿失禁和勃起功能障碍的发生率相对更低。
Objective This paper intends to explore the clinical efficacy and safety of the refined extroperitoneal intrafascial laparoscopic radical prostatectomy in patients with localized prostate cancer.Methods The data of 107 patients with localized prostate cancer who were underwent laparoscopic radical prostatectomy in our hospital from July 2013 to January 2020 were analyzed retrospectively.According to the operation methods,the patients were divided into two groups:the refined intra fascial resection group(59 cases)and the conventional interfascial neurovascular bundle reservation group(48 cases).There was no significant different comparing the age[(61.8±8.9)years vs.(62.2±8.1)years,P=0.71],body mass index(BMI)[(24.8±1.3)kg/m2 vs.(24.3±1.4)kg/m2,P=0.89],preoperative total prostate specific antigen(PSA)[(6.8±0.9)ng/ml vs.(7.2±1.1)ng/ml,P=0.44],prostate volume[(47.9±18.4)ml vs.(48.3±17.9)ml,P=0.67]between the modified group and the conventional group.The clinical stage of the two groups was both in cT1-T2aN0M0,and the preoperative Gleason score was less than or equal to 7(P=0.76).In the improved group,the bilateral pelvic floor fascia was not dissected,the dorsal deep vein complex was not sutured,the denonvillier fascia was kept intact,the prostate was dissected by intrafascial technique,and the bilateral vascular and nerve bundles were completely preserved.After anastomosing the urethra and bladder neck,the bilateral prostate fascia,the pubic bladder-prostate ligament,DVC and the anterior wall of bladder neck were continuously sutured with 3-0 barbed wire in order to anatomically reconstructe the anterior suspension system.The preoperative data,intraoperative condition,postoperative pathological stage,positive margin rate and postoperative 6-month's follow-up,especially incontinence and erectile function were compared between the two groups.Results There was no significant difference between the two groups in the basic clinical data,intraoperative bleeding volume[(90.6±26.4)ml vs.(105.3±34.1)ml,P>0.05],prostate-specific antigen 6 weeks after operation[(0.08±0.06)ng/ml vs.(0.09±0.07)ng/ml,P>0.05],postoperative pathological stage and positive margin rate(12.5%vs.11.9%,P>0.05).In the early postoperative stage,patients performed a significantly better continence.Continence rate in 1 week:16.7%(8/48)vs.52.5%(31/59)(P<0.05),in 1 month:29.2%(14/48)vs.64.4%(38/59)(P<0.05),and in 3 month 52.1%(25/48)vs.77.9%(46/59)(P<0.05).And also a better erectile function recovery rate in 1 month:8.3%(4/48)vs.23.7%(14/59)(P<0.05),in 3 month:27.1%(13/48)vs.49.2%(29/59)(P<0.05),in refined intrafascial group,but that was not significant different between the two groups 6 months after operation.Conclusion The refined intrafascial laparoscopic radical prostatectomy can completely reconstruct the anatomic structure adjacent to urethra,and preserve utmostly the pelvic floor muscle,prostate fascia and neurovascular bundle,which are supposed to facilitate the revovery of urinary incontinence and erectile dysfunction in the early postoperative period.
作者
宋灵敏
王钢
陈特磊
翁国斌
朱伟智
Song Lingmin;Wang Gang;Chen Telei;Weng Guobin;Zhu Weizhi(Department of Urology,Ningbo Urology&Nephrology Hospital,Ningbo 315192,China)
出处
《中华泌尿外科杂志》
CAS
CSCD
北大核心
2021年第8期576-580,共5页
Chinese Journal of Urology
基金
宁波市自然科学基金项目(202003N4296)。
关键词
前列腺肿瘤
前列腺癌
根治性手术
前列腺筋膜
控尿
勃起功能
Prostatic neoplasms
Prostate cancer
Prostatectomy
Prostate fascia
Incontinence
Erectile function
