筋膜内切除法在腹腔镜下前列腺癌根治术中的应用

目的 探讨筋膜内切除法在腹腔镜下根治性前列腺切除术中的应用.方法 前列腺癌患者23例,平均年龄65岁.术前PSA 4.5～8.6(6.25 ±2.1)ng/ml;临床分期T1 16例、T2 7例;活检组织Gleason评分:5分3例、6分11例、7分9例.有性生活者18例.行腹腔镜下根治性前列腺切除术.不打开盆内筋膜,自前列腺基底部沿前部正中线纵形切开前列腺筋膜,贴前列腺包囊分离前列腺前面、两侧、尖部.保留神经血管束.保护前列腺尖尿道相连处括约肌.结果 23例手术顺利.平均手术时间125(110～170)min.出血量320～1500(550±210)ml,输血3例.平均留置尿管12(9～15)d.术后随访12个月,完全尿控20例(87%).有轻微压力性尿失禁3例(13%).18例术前有性生活的患者能充分勃起完成性交13例(72%).随访期间出现生化复发2例(9%).结论 腹腔镜下筋膜内切除法剥离前列腺对前列腺周围筋膜、附着于筋膜的神经血管束以及尿道外括约肌损伤小.手术方法可行.     

Robot-assisted laparoscopic radical prostatectomy: an athermal anterior approach to the seminal vesicle dissection

The seminal vesicles, particularly the lateral aspect and tips, are among the closest structures to the cavernous nerves and pelvic plexus. Given this proximity it is essential that the seminal vesicle dissection be performed in an athermal and atraumatic fashion during robot-assisted laparoscopic prostatectomy (RALP). Traditionally the seminal vesicle dissection during RALP is performed by dividing the vas deferens and following it proximally to locate the tip of the seminal vesicle. Here we describe a modification to the traditional anterior approach to seminal vesicle dissection. Our modification allows the dissection to be performed athermally and efficiently with use of minimal traction. The dissection proceeds medially between the two terminal vas deferens to identify the medial surface of one of the seminal vesicles. This medial surface is avascular and can be developed easily along the length of the vesicle using blunt dissection. Once its tip is identified it is elevated with the fourth arm medially between the two vas deferens. The ipsilateral vas can then be clipped and divided below the level of the elevated seminal vesicle. The vascular supply to the seminal vesicle is then simply identified entering the lateral aspect of its tip. A hemolock clip is placed directly beneath the tip of the seminal vesicle to control its vasculature. The remainder of the dissection can be performed with sharp dissection. Using this technique the seminal vesicle can be excised entirely with minimal traction and no thermal energy. By elevating the tip medially away from the location of the pelvic plexus and cavernous nerves, inadvertent damage to these neural structures is avoided when placing the hemolock clips. Electronic supplementary material  The online version of this article (doi:) contains supplementary material, which is available to authorized users.     

病理复查并前列腺癌根治术后早期前列腺特异抗原监测的临床意义

目的：结合病理复查结果，监测前列腺癌根治术后早期的前列腺特异抗原(PSA)水平，指导术后的进一步治疗。方法：对25例前列腺癌根治术患者于术后1、2、4周时测定PSA水平，尔后每个月测定一次，随访5～17个月，平均11个月；并对术后标本的手术切缘及包膜浸润程度行病理复查。结果：病理报告T1～T2期17例，15例获根治，PSA水平均降至0．2μg／L以下，随访12个月无复发；2例PSA一直未降至正常，2个月后复升高而加用辅助治疗，其病理观察发现手术切缘有肿瘤残留。T3a或T3b期8例，4例获根治，PSA在3个月内降至0．2μg／L以下，随访9个月无复发，病理特征为肿瘤浸润包膜但未穿透；4例在1个月后因PSA回升分别加用辅助治疗，病理示肿瘤均穿透包膜。结论：T1～T2期患者，因手术切缘残留等原因，肿瘤可能早期复发；T3期患者，特别是那些侵犯包膜但未穿透者，手术可能达到根治，并可以延迟应用雄激素阻断治疗，延长治疗的有效时间。     

前列腺癌患者根治术后尿失禁的预防

目的探讨保护尿道膜部括约肌和神经血管束及重建膀胱颈部对前列腺癌根治术后尿失禁的预防作用。方法对32例前列腺癌采用保护尿道膜部括约肌和前列腺旁神经血管束,并在重建膀胱颈部黏膜充分外翻后的后壁行折叠缝合1针的方法,进行前列腺癌根治术,观察术后尿失禁发生情况。结果经6～72个月随访,全部患者排尿通畅,无肿瘤复发,除2例发生轻度尿失禁外,其余30例在6个月内均恢复尿控能力。结论保护尿道膜部括约肌和前列腺旁神经血管束,在充分外翻膀胱黏膜的重建膀胱颈后壁折叠缝合,能减少前列腺癌根治术后尿失禁的发生。     

腹腔镜下经腹膜外径路行前列腺癌根治术(附7例报告)

目的:探讨腹腔镜下经腹膜外径路行前列腺癌根治术的手术方法和临床效果。方法:7例前列腺癌患者,腹腔镜下经腹膜外径路分离前列腺,切开膀胱颈部,分离前列腺尖部、游离精囊后顺行前列腺切除术,膀胱颈成形后与尿道吻合。结果:平均手术时间为6.7h,术中平均出血量为1385ml。术后24～48h恢复肠道功能,2～3周后拔除尿管,2例出现轻度尿失禁,无术后出血、直肠损伤、尿路狭窄等其他并发症发生。结论:腹腔镜下腹膜外途径前列腺癌根治术创伤小、视野清晰、出血少、康复快,是早期前列腺癌根治术的方法之一。     

Predictors of seminal vesicle invasion before radical prostatectomy

AIM: To predict whether or not seminal vesicle invasion is present before radical prostatectomy, the relationships between clinical parameters and seminal vesicle invasion were analyzed. METHODS: A review was conducted of 187 patients who had been clinically diagnosed with stages A(2), B(0), B(1), B(2) or C prostate cancer and who had undergone radical prostatectomy without neoadjuvant therapy. The parameters analyzed for potential predictors of seminal vesicle invasion before radical prostatectomy included age, clinical stage, serum prostate-specific antigen (PSA) level at biopsy, tumor differentiation of biopsy specimens and percentage of cancer positive cores by biopsy. For percentage of cancer positive cores by biopsy, 143 of 187 patients who underwent transrectal sextant biopsy or more than six transrectal ultrasound guided core biopsies were evaluated. These parameters were subjected to univariate and multivariate logistic regression analyses to identify predictors for seminal vesicle invasion. RESULTS: The median age was 66.8 years (range 51-77 years). Of 187 patients, 27 (14.4%) had seminal vesicle invasion confirmed pathologically. There were significant differences in all parameters except for age between patients with positive and negative seminal vesicle invasion on univariate analysis. Multivariate analysis revealed that serum PSA level, tumor differentiation of biopsy specimens and percentage of cancer positive cores were significant independent predictors of seminal vesicle invasion. CONCLUSIONS: The results showed serum PSA level, tumor differentiation of biopsy specimens and percentage of cancer positive cores by biopsy before radical prostatectomy may be useful predictors for seminal vesicle invasion.     

前列腺癌根治术中保护控尿功能的技巧

目的：探讨改进前列腺癌根治术的手术技巧，促进患者术后控尿功能的恢复。方法：对T1～T2期前列腺癌患者36例行保护控尿功能的解剖性耻骨后前列腺癌根治术。结果：手术平均时间3h20min．术中平均出血量420ml，输血19例。术后病理检查肿瘤局限于包膜内者34例，切缘阳性1例．盆腔淋巴结微转移1例。随访11～58个月．平均26个月，均生存。术后拔除导尿管1周内立即控尿23例(63．9％)．3个月时控尿30例(83．3％)，6个月时控尿33例(91.7％)．12个月时全部恢复控尿(100％)。结论：解剖性耻骨后前列腺癌根治术中注意肿瘤切除原则．保护控尿神经、肌肉和筋膜．可缩短术后控尿功能的恢复时间，提高控尿率。     

Individualized estimation of the benefit of radical prostatectomy from the Scandinavian Prostate Cancer Group randomized trial

Background

Although there is randomized evidence that radical prostatectomy improves survival, there are few data on how benefit varies by baseline risk.

Objective

We aimed to create a statistical model to calculate the decrease in risk of death associated with surgery for an individual patient, using stage, grade, prostate-specific antigen, and age as predictors.

Design, setting, and participants

A total of 695 men with T1 or T2 prostate cancer participated in the Scandinavian Prostate Cancer Group 4 trial (SPCG-4).

Intervention

Patients in SPCG-4 were randomized to radical prostatectomy or conservative management.

Outcome measurements and statistical analysis

Competing risk models were created separately for the radical prostatectomy and the watchful waiting group, with the difference between model predictions constituting the estimated benefit for an individual patient.

Results and limitations

Individualized predictions of surgery benefit varied widely depending on age and tumor characteristics. At 65 yr of age, the absolute 10-yr risk reduction in prostate cancer mortality attributable to radical prostatectomy ranged from 4.5% to 17.2% for low- versus high-risk patients. Little expected benefit was associated with surgery much beyond age 70. Only about a quarter of men had an individualized benefit within even 50% of the mean. A limitation is that estimates from SPCG-4 have to be applied cautiously to contemporary patients.

Conclusions

Our model suggests that it is hard to justify surgery in patients with Gleason 6, T1 disease or in those patients much above 70 yr of age. Conversely, surgery seems unequivocally of benefit for patients who have Gleason 8, or Gleason 7, stage T2. For patients with Gleason 6 T2 and Gleason 7 T1, treatment is more of a judgment call, depending on patient preference and other clinical findings, such as the number of positive biopsy cores and comorbidities.     

经腹与经腹膜外腹腔镜下前列腺癌根治术的效果比较

目的 比较经腹与经腹膜外途径腹腔镜下手术治疗前列腺癌的临床效果.方法前列腺癌患者33例行腹腔镜下前列腺癌根治术,其中经腹21例,经腹膜外12例.对2组患者手术时间、术中出血量、术中并发症、肠功能恢复时间、术后住院时间、术后并发症等资料进行比较分析.结果 33例手术均成功.经腹与经腹膜外2组手术时间分别为(299±46)和(309±64)min,出血量分别为(618±448)和(677±469)ml,2组比较差异无统计学意义(P＞0.05).经腹组术中发生大出血3例、膀胱损伤2例、单侧输尿管损伤1例,经腹膜外组术中发生大出血1例、闭孔神经损伤1例、腹膜损伤1例、膀胱三角损伤1例.2组术后留置导尿时间分别为(14.6±3.8)和(12.3±2.9)d,肠功能恢复时间分别为(2.7±0.7)和(2.1±0.5)d,术后住院时间分别为(17.0±3.6)d和(11.2±3.5)d,2组比较差异均有统计学意义(P＜0.05).结论 腹腔镜下前列腺癌根治术经腹膜外比经腹途径具有视野清晰、对腹腔器官影响小、术后恢复快、术后住院短等优点.     

Robotic radical prostatectomy at a teaching community hospital: outcomes and safety

Objectives:

This study describes the early experience of robotic prostatectomy exclusively at a teaching community hospital.

Methods:

This is a retrospective report of 153 consecutive patients on whom 4 physicians were the operating surgeon.

Results:

The average hospital stay was 1.5 days, the mean operative time was 175 minutes, and the estimated operative blood loss was <300mL. The perioperative complication rate was 7.8% (12/153). The prostate-specific antigen failure rate was 2% (2/114). Urinary continence was maintained in 98% of patients 9 months after surgery. Postoperative Gleason scores differed significantly from preoperative biopsy results (P<0.001). Pathological records reported positive margins in 35% (54/153) of specimens. T3 tumors had positive margins more than twice as often as T2 tumors (P<0.002). Surgeon experience correlated with shorter operative times (P<0.001), but not with positive margins. Increasing body mass index was associated with increased operating time (P=0.001).

Conclusions:

Robotic prostatectomy appears to be a safe and successful option for prostate cancer treatment in a teaching community hospital.     

机器人辅助腹腔镜下根治性前列腺切除术16例报告

目的 总结机器人辅助腹腔镜下根治性前列腺切除手术效果及安全性. 方法 使用da Vinci S手术机器人系统完成机器人辅助腹腔镜下根治性前列腺切除术16例.患者年龄62～76岁,平均69岁.实验室检查t-PSA 0.2～79.2 ng/ml,前列腺体积9.8～232.9 ml,前列腺穿刺活检病理证实为前列腺腺癌15例,Gleason评分平均7(4～9)分,术前临床分期T2aN0M0 3例、T2hN0M04例、T2cN0M08例;前列腺上皮内瘤Ⅲ级1例.术后随访血清t-PSA变化及患者控尿效果. 结果 16例手术均成功,无机械故障或其他原因导致的术式改变.术前机器人准备时间64(60～90)min,手术时间236(190～390)min.患者术中出血量231(50～500)ml,术后2～3 d下床活动,10～14 d拔除留置尿管,术后平均住院时间13(6～19)d.2例术后病理切缘阳性,病理分期均为pT3bN0M0.术后1个月复查t-PSA均<0.2 ng/ml.随访6～12个月,平均9个月,t-PSA均无升高.术后3、6个月控尿有效率分别为94%(15/16)和100%(16/16),其中75%(12/16)和88 0A(14/16)完全脱离尿垫.结论 机器人辅助腹腔镜下根治性前列腺切除术创伤小,安全可靠,是泌尿外科微创手术的发展方向.     

提高前列腺癌根治术后尿控能力的临床研究

目的：探讨提高前列腺癌根治术后尿控能力的方法。方法：对15例前列腺癌采用保留尿道膜部括约肌及前列腺侧旁神经血管束的方法进行前列腺癌根治术。结果：经6—45个月随访，15例患者排尿通畅，无肿瘤复发，除1例有轻度尿失禁外，余14例6个月内均恢复尿控能力。结论：保留尿道膜部括约肌及前列腺侧旁神经血管束的方法能减低前列腺癌根治术后尿失禁。     

个体化改良术式防止前列腺癌根治术后尿失禁

目的：探讨前列腺癌根治术中保护控尿功能的方法。方法：对51例临床局限性前列腺癌患者(TNM分期为T1a～3hN0M0)，采用个体化改良术式行耻骨后根治性前列腺切除术，术中为保留控尿功能仔细解剖前列腺尖部并作无张力膀胱颈一尿道残端吻合。结果：术后12～14d拔除尿管时22例(43．1％)控尿满意，术后1个月45例(88．2％)控尿满意．术后3个月至今，所有患者控尿满意。平均随访14个月(3～24个月)，随访期间无生化复发及尿道狭窄发生。结论：术中注意以下几点可提高耻骨后根治性前列腺切除术后的控尿功能：①良好控制背静脉丛以获得无血手术视野；②在保证尖部切除范围前提下，尽量延长功能性尿道长度；③根据术中具体解剖情况再造膀胱颈口；④膀胱黏膜外翻并与尿道残端无张力吻合(7针或9针缝合法)，减少术后漏尿及尿道狭窄发生。     

Prostate cancer with bladder neck involvement: Pathologic findings with application of a new practical method for tumor extent evaluation and recurrence-free survival after radical prostatectomy

Background: Recent studies have questioned the high risk for disease recurrence in cases of bladder neck involvement by prostate cancer (pT4 disease). Design: The study was based on 141 patients submitted to radical prostatectomy. PSA-recurrence was defined as 0.5 ng/ml or rising at three different examinations. Bladder neck invasion was correlated to Gleason score (<7 or 7), urethral or lateral positive surgical margins, tumor size (extensive or not extensive) using a new simple point-count method, race and preoperative PSA levels (<10 or 10 ng/ml). The mean and median follow-up periods were 17.2 and 15 months (range 3–55). Recurrence-free survival curves were constructed using the Kaplan–Meier survival method with tests of significant differences based on the log-rank statistic. Results: Bladder neck invasion was seen in 30/141 (21.27%) patients; 9 (6.38%) had also concomitant positive surgical margins in the sections. Extraprostatic extension was seen in 39/141 (27.65%) and seminal vesicle invasion in 18/141 (12.76%) patients. Patients with bladder neck invasion significantly correlated to Gleason score (P=0.04), preoperative PSA (P < 0.001), and tumor extension (P=0.04). No correlation was found to age (P=0.44), race (P=0.12) and positive urethral or lateral margins (P=0.32). The PSA-recurrence relative risk in patients with bladder neck invasion was 0.17 (P=0.68), with extraprostatic extension 0.53 (P=0.47) and with seminal vesicle invasion 5.76 (P=0.02). Conclusions: Bladder neck involvement correlates with pathologic unfavorable findings on radical prostatectomy specimens as well as to preoperative PSA levels. However, the PSA-recurrence risk associated with bladder neck involvement (pT4) was similar to extraprostatic extension (pT3a) and substantially lower than seminal vesicle invasion (pT3b). The findings favor a need for downstaging of bladder neck involvement in the next version of the TNM system. The method proposed for tumor extent evaluation is simple and accessible to all pathologists working in routine pathology laboratories.     

Perioperative outcomes of robot-assisted radical prostatectomy compared with open radical prostatectomy: results from the nationwide inpatient sample

Background

Prior to the introduction and dissemination of robot-assisted radical prostatectomy (RARP), population-based studies comparing open radical prostatectomy (ORP) and minimally invasive radical prostatectomy (MIRP) found no clinically significant difference in perioperative complication rates.

Objective

Assess the rate of RARP utilization and reexamine the difference in perioperative complication rates between RARP and ORP in light of RARP's supplanting laparoscopic radical prostatectomy (LRP) as the most common MIRP technique.

Design, setting, and participants

As of October 2008, a robot-assisted modifier was introduced to denote robot-assisted procedures. Relying on the Nationwide Inpatient Sample between October 2008 and December 2009, patients treated with radical prostatectomy (RP) were identified. The robot-assisted modifier (17.4x) was used to identify RARP (n = 11 889). Patients with the minimally invasive modifier code (54.21) without the robot-assisted modifier were classified as having undergone LRP and were removed from further analyses. The remainder were classified as ORP patients (n = 7389).

Intervention

All patients underwent RARP or ORP.

Measurements

We compared the rates of blood transfusions, intraoperative and postoperative complications, prolonged length of stay (pLOS), and in-hospital mortality. Multivariable logistic regression analyses of propensity score–matched populations, fitted with general estimation equations for clustering among hospitals, further adjusted for confounding factors.

Results and limitations

Of 19 462 RPs, 61.1% were RARPs, 38.0% were ORPs, and 0.9% were LRPs. In multivariable analyses of propensity score–matched populations, patients undergoing RARP were less likely to receive a blood transfusion (odds ratio [OR]: 0.34; 95% confidence interval [CI], 0.28–0.40), to experience an intraoperative complication (OR: 0.47; 95% CI, 0.31–0.71) or a postoperative complication (OR: 0.86; 95% CI, 0.77–0.96), and to experience a pLOS (OR: 0.28; 95% CI, 0.26–0.30). Limitations of this study include lack of adjustment for tumor characteristics, surgeon volume, learning curve effect, and longitudinal follow-up.

Conclusions

RARP has supplanted ORP as the most common surgical approach for RP. Moreover, we demonstrate superior adjusted perioperative outcomes after RARP in virtually all examined outcomes.     

Improving the preservation of the urethral sphincter and neurovascular bundles during open radical retropubic prostatectomy

OBJECTIVES: To describe a technique for open nerve-sparing radical retropubic prostatectomy. METHODS: The technique basically implies incising the levator and prostatic fasciae high anteriorly (1 and 11 o'clock positions) over the prostate, developing the plane between the prostatic capsule and prostatic fascia, and displacing the neurovascular network localized between the two fasciae laterally. This allows for a minimal-touch dissection of the external urethral sphincter and a very efficient dissection of the neurovascular bundles at the level of membranous urethra and prostatic apex. RESULTS: Forty-two patients underwent a bilateral nerve-sparing operation and were followed- up for 6 months. Six patients (14.3%) had positive margins: 4 patients had pT2 disease (in all, the positive margin was monofocal) and 2 patients had pT3 disease (both had multifocal positive margins). Continence (defined as being dry or having one pad remain dry for 24 hours) was achieved in 44% of patients at catheter removal, and in 60%, 72%, and 90% of patients at the 1-, 3-, and 6-month follow-up visits. Potency (defined as an erectile function domain score > or =26) was obtained in 15%, 40%, and 52% of patients at the 1-, 3-, and 6-month follow-up visits. All patients used a PDE5-inhibitor during the investigation period. CONCLUSIONS: These preliminary results suggest that the high incision of the levator and prostatic fasciae may facilitate efficient preservation of the external urethral sphincter and the neurovascular bundles innervating the corpora cavernosa and the sphincter.     

耻骨后前列腺癌根治术的技术改进(附32例报告)

目的　改进耻骨后前列腺癌根治术的手术技术 ,减少并发症。　方法　临床诊断为T1和T2 期前列腺癌患者 32例 ,平均年龄 6 8岁。改进耻骨后前列腺癌根治技术 ,包括广泛盆腔淋巴结清扫、保护神经血管束、缝扎背深静脉、多保留尿道后壁组织、膀胱尿道吻合时的膀胱颈部套叠等。　结果　手术时间平均 3.5h ,术中平均出血量 4 5 0ml,输血 1 7例。术后病理报告 :肿瘤局限于包膜内者30例 ,切缘阳性 1例 ,盆腔淋巴结转移 1例。随访 8～ 4 8个月 ,平均 2 2个月 ,均存活。PSA <1ng/ml者2 8例 ,1～ 3ng/ml者 4例。术后 3～ 6个月患者均恢复完全控尿。术后恢复勃起功能者 1 0 / 1 8(5 6 % )例。　结论　耻骨后前列腺癌根治术可有效切除肿瘤、保护控尿功能、保留性功能 ,是局限性前列腺癌的首选治疗方法。     

机器人经腹腔镜行前列腺根治性切除术60例的初步结果

目的评价机器人经腹腔镜行前列腺根治性切除术的可行性和效果。方法利用da Vinci机器人外科手术系统对60例局限性前列腺癌患者施行机器人经腹腔镜行前列腺根治性切除术。患者年龄53～75岁，平均63．7岁；Gleason评分5～9，平均6；术前前列腺特异性抗原(PSA)5．5～38．3ng／ml，平均9．4ng／ml。结果术前机器人准备时间平均28(10～90)min，手术平均时间200(95～330)min。术中平均失血量355(50—1200)ml，输血7例(12％)。术后平均1d恢复正常饮食。术后平均导尿管留置时间7d，平均住院时间3d。1例发生吻合口漏尿者紧急手术探查和重新吻合，1例因膀胱颈挛缩行经尿道膀胱颈切开，1例因严重尿路感染行静脉输入抗生素。30例术前有性生活的患者术后6个月内自动恢复或经PDE5抑制剂或PGEl药物治疗后恢复性功能。术后3个月随访38例，完全控尿21例(55％)，轻度尿失禁9例(24％)，中度尿失禁8例(21％)。随访至术后6个月24例，完全控尿17例(71％)，轻度尿失禁4例(17％)，中度尿失禁3例(12％)。结论机器人经腹腔镜前列腺根治性切除术术中失血少、术后患者疼痛小、恢复快、住院时间短，使盆腔内难以进行的腹腔镜手术变得简单、方便，更加灵巧和准确。