保留神经血管束的耻骨后前列腺癌根治术的疗效观察

目的：小结开展保留神经血管束的耻骨后前列腺癌根治术（RRP）的经验和教训。方法：对40例穿刺活检证实的前列腺癌患者行RRP,术前采用新辅助治疗,术中采用保护尿道膜部括约肌和前列腺侧旁神经血管束,并在重建膀胱颈部粘膜充分外翻后的后壁行折叠缝合1针。间断、无张力行残留尿道和外翻的膀胱颈缝合。结果：经3～78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,余38例在6个月内均恢复尿控能力。结论：充分做好耻骨后前列腺癌根治术前的准备工作,有利于手术操作;术中保护好尿道膜部括约肌和前列腺侧旁神经血管束,在充分外翻膀胱粘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。     

腹腔镜前列腺癌根治术中保留神经血管束的疗效观察（附17例报告）

目的评价腹腔镜下前列腺癌根治术(LRP)中保留神经血管束(NVB)的临床意义。方法2005年8月—2008年3月,对17例局限性前列腺癌患者行LRP,术前临床分期T1b3例,T1c8例,T2b2例,T2c3例,T3a1例。术中采用保护尿道膜部括约肌和双侧前列腺旁神经血管束,重建膀胱颈部充分外翻后,间断、无张力行膀胱颈尿道吻合。结果17例手术均获成功,无一例中转开放。手术平均时间290min(190～370min),出血量平均360ml(200～640ml)。其中2例术中因处理阴茎背血管复合体(DVC)不当出现较大出血,分别为600ml和640ml,均未输血。术后随访6～37个月,全部患者排尿通畅,无肿瘤复发。14例术后6个月内恢复尿控能力,2例在术后9个月内恢复,1例术后12个月后尚存在轻度尿失禁。14例患者在术后12月内可以充分或部分勃起,3例不能勃起。结论LRP中保留双侧NVB,保护尿道膜部括约肌,能有效减少根治术后患者尿失禁及勃起障碍的发生。     

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。     

前列腺癌根治术围手术期尿失禁预测因素研究进展

尿失禁严重影响前列腺癌患者术后的生活质量。术前评估并预测患者尿失禁情况不仅有助于临床医生制定个体化手术方案,而且可以给患者一个合理的心理预期。本文主要从术前患者的临床参数,包括年龄、体质指数(BMI)、膜性尿道长度(MUL)、前列腺尖部形态、前列腺突入膀胱度(IPP)等以及术中保留膀胱颈部、神经血管束(NVB)、尿道括约肌等尿控结构保留技术这几个方面,对前列腺癌根治术围手术期的尿失禁预测因素相关研究进展作一综述。     

保留尿控功能在耻骨后前列腺癌根治术的应用

目的:探讨保护耻骨前列腺韧带和保护尿道膜部括约肌群在耻骨后前列腺癌根治术后减少尿失禁的作用.方法:Ⅰ组32例前列腺癌按常规操作行耻骨后前列腺癌根治术,Ⅱ组32例前列腺癌采用保留耻骨前列腺韧带和尿道膜部括约肌群的方法行耻骨后前列腺癌根治术,术后1、3、6、12个月分别随访尿失禁情况.结果:两组年龄和PSA无显著差异,两组前列腺尖端切缘均无肿瘤残留,前列腺侧缘阳性率类似.Ⅱ组术后1、3、6个月尿控效果明显优于I组(P<0.05),但1年随访,Ⅰ组和Ⅱ组尿控效果类似.结论:在耻骨后前列腺癌根治术中保留耻骨前列腺韧带作用和尿道膜部括约肌群有显著提高近期尿控的效果,但1年随访两组尿控率无明显差异.     

保留膀胱颈环状肌和前列腺侧旁神经血管束的前列腺癌根治术

为减少或避免前列腺癌根治术后尿失禁和阳萎的发生，采用保留膀胱颈环状纤维和前列腺侧旁神经血管束的方法行前列腺癌根治术１３例，结果１３例术后无尿失禁９例，轻度可复性尿失禁４例；保留性神经手术８例，术后有性功能７例；术前内分泌疗法９例，术后病理均可见肿瘤细胞退变，萎缩改变。结论：前列腺癌膀胱颈无浸润者适宜作本术式。由于术后保留括约肌功能，尿失禁发生率低。因此，对癌前病变及术前难以定性的高危患者可扩大手术适应证     

尿控技术用于经耻骨后前列腺癌根治术80例分析

目的探索保留尿道括约肌手术技巧在前列腺癌根治术中的应用效果.方法本组80例前列腺癌患者,年龄66岁(范围59~75岁);79例前列腺肿瘤限于T2b期以内,1例T3期;78例因PSA升高行术前经直肠超声波(TRUS)引导下的前列腺穿刺活检,Gleason分级3~7分,另2例为TURP后偶发癌;PSA平均8.5ng/ml(范围2.7~44.5 ng/ml).手术前均无尿失禁情况.手术技巧:处理阴茎背深静脉丛采用集束“8”字缝扎;处理前列腺尖部时紧贴前列腺表面分离,并保留前列腺部尿道0.5~1cm;保留膀胱颈部.结果手术后随访12~48个月,18例生化复发,6例尿失禁.结论尿道外括约肌的保留能够减少前列腺癌根治术后尿失禁的发生.     

减少术后尿失禁及尿道狭窄的前列腺癌根治术(附42例报告)

目的探讨减少前列腺癌根治术后尿道狭窄及尿失禁的术式. 方法采用膀胱颈粘膜外翻固定再与尿道对端吻合及保留膀胱颈环状肌纤维的前列腺癌根治术治疗前列腺癌42例. 结果 42例术后均未发生膀胱尿道吻合口狭窄,尿失禁2例.随诊4～70个月,最大尿流率25.0～30.7 ml/s. 结论采用膀胱颈粘膜外翻固定再与尿道对端吻合及保留膀胱颈环状肌纤维的前列腺癌根治术,术后避免或减少了尿道狭窄,减低尿失禁的发生.     

腹腔镜根治性前列腺切除术中尿控功能保护的方法和手术技巧

目的探讨腹腔镜根治性前列腺切除术中尿控功能的保护,预防术后尿失禁的手术方法及技巧。方法对2008年10月至2012年6月施行的81例腹腔镜前列腺癌根治术资料进行回顾性研究。81例TNM分期为T1C～T2C的前列腺癌患者行腹腔镜前列腺癌根治术,其中经腹膜外径路15例,经腹腔途径66例。术中注重以下策略：①可靠处理背血管复合体;②尽量保留神经血管束,对部分低危患者施行筋膜内根治性前列腺切除术;③保留足够的功能性尿道;④黏膜对黏膜无张力吻合。所有患者于术后1、3、6和12个月随访尿控情况。结果术后留置导尿管7～23d。所有患者均随访满6个月,77例患者随访满12个月。术后6个月,白天62例（76．5％）患者尿控良好,尿失禁19例;夜间68例（84．0％）患者尿控良好,尿失禁13例。术后12个月,白天70例（90．9％）患者尿控良好,尿失禁7例;夜间74例（96．1％）患者尿控良好,仍有尿失禁3例。筋膜内根治性前列腺切除术5例,术后7～11d拔除导尿管后,仅1例白天有尿失禁,随访至术后3个月,已无一例存在尿失禁。随访期间无一例出现尿道狭窄。结论腹腔镜根治性前列腺切除术后的尿控功能恢复是渐进式的,绝大多数患者在术后12个月恢复尿控能力。术野清晰,努力做到解剖性前列腺切除,保留尽可能多的功能性尿道长度,黏膜对黏膜无张力吻合（避免术后尿道狭窄）,将膜部尿道缝合至趾骨后就能获得良好的尿控效果。对低危的前列腺癌患者施行筋膜内根治性前列腺切除术将能获得最佳尿控结果。     

减少术后尿失禁及尿道狭窄的列腺癌根治术（附42 例报告）

目的：探讨减少前列腺癌根治术后尿道狭窄及尿失禁的术式。方法：采用膀胱颈粘膜外翻固定再与尿道对端吻合及保留膀胱颈环状肌纤维的前列腺癌根治术治疗前列腺癌42例。结果：42例术后均发生膀胱尿道吻合口狭窄，尿失禁2例。随诊4－70个月，最大尿流率25．0－30．7ml/s。结论：采用膀胱颈粘膜外翻固定再与尿道对端吻合及保留膀胱颈环肌纤维的前列腺癌根治术，术后避免或减少了尿道狭窄，减低尿失禁的发生。     

Urinary incontinence after robot‐assisted radical prostatectomy: Pathophysiology and intraoperative techniques to improve surgical outcome

Robot‐assisted radical prostatectomy has been shown to have comparable and possibly improved postoperative continent rates compared with retropubic and laparoscopic radical prostatectomy. However, postoperative urinary incontinence has remained one of the most bothersome postoperative complications. The basic concept of the intraoperative technique to improve postoperative urinary continence is to maintain as normal anatomical and functional structure in the pelvis as possible. Therefore, improved knowledge of the normal structure in the pelvis should lead to a greater understanding of the pathophysiology of urinary incontinence, and further development of intraoperative techniques to improve the outcomes of urinary continence. It might be necessary to carry out three steps to realize improvement of the early return of urinary continence after robot‐assisted radical prostatectomy: (i) preservation (bladder neck, neurovascular bundle, puboprostatic ligament, pubovesical complex, and/or urethral length, etc.); (ii) reconstruction (posterior and/or anterior reconstruction, and/or reattachment of the arcus tendineus to the bladder neck, etc.); and (iii) reinforcement (bladder neck plication and/or sling suspension, etc.). On the basis of these steps, further modifications during robot‐assisted radical prostatectomy should be developed to improve urinary continence and quality of life after robot‐assisted radical prostatectomy.     

前列腺癌根治术中保护控尿功能的体会

目的：减少耻骨后前列腺癌根治术患者术后尿失禁发生率。方法：对16例B超前列腺癌患者行保护控尿功能的解剖性耻骨后前列腺癌根治术。结果：16例术后随访3个月-5年，平均13个月。膀胱控尿正常者13例，轻度压力性尿失禁者2例，严重尿失禁者1例。结论：在行耻骨后前列腺癌根治术时，认识尿道括约肌及其支配神经的解剖位置及结构，避免对其损伤可以减少术后尿失禁发生率。     

The management of stress urinary incontinence after radical prostatectomy

Up to 30% of patients complain about urine leakage after radical prostatectomy, but persistent stress incontinence (beyond 1 year) affects <5% of them. This complication is mainly caused by sphincter dysfunction. Some preventive measures have been described to decrease the risk of incontinence after radical prostatectomy, but with conflicting results. The effectiveness of preoperative and early postoperative physiotherapy is controversial. Moreover, while meticulous apical dissection of the prostate significantly improves postoperative continence, the benefit of other surgical techniques, e.g. preserving the bladder neck and the neurovascular bundles, is under debate. The treatment of persistent stress urinary incontinence is mainly based on surgery, as this type of incontinence usually does not respond to physiotherapy and anticholinergic medication. While injection therapy is safe and well tolerated, its effect on postoperative continence is limited and decreases with time. The best results are achieved by implanting an artificial urinary sphincter, but with significant complication and revision rates.     

Intraoperative nerve stimulation with measurement of urethral sphincter pressure changes during radical retropubic prostatectomy: a feasibility study

PURPOSE: We evaluated the feasibility of using intraoperative nerve stimulation and real-time urodynamic monitoring to identify the intrapelvic innervation of the urethral sphincter during radical retropubic prostatectomy. MATERIALS AND METHODS: Using an intraurethral balloon pressure transducer and nerve stimulator changes in urethral pressure were measured in response to stimulation of the neurovascular bundles, pelvic side wall, bladder neck, rectus muscle and other structures in 8 patients undergoing nerve sparing radical retropubic prostatectomy. Intraurethral pressure changes were charted on an urodynamic monitor and correlated with the anatomical location of stimulation. RESULTS: Stimulation of the neurovascular bundles resulted in measurable and significant (greater than 10 cm. H(2)O) increases in intraurethral pressure in all 8 patients. The mean pressure increase was 22 cm. H(2)O. Neither control structure, that is the bladder neck or rectus, resulted in pressure changes with stimulation. In 60% of the subjects pelvic side wall stimulation resulted in urethral pressure increases, while in 40% this stimulation caused pelvic contraction floor but no pressure increase. The mean pressure changes with side wall stimulation was 14 cm. H(2)O. CONCLUSIONS: Intraoperative stimulation of pelvic neural structures and measurement of changes in urethral pressure in response to stimulation are feasible during radical retropubic prostatectomy. Stimulating the neurovascular bundle consistently results in significant increases in urethral pressure. The finding of an intrapelvic urethral innervation supports the previously published observation that nerve sparing radical retropubic prostatectomy may result in improved continence postoperatively.     

Vattikuti Institute prostatectomy: technique

PURPOSE: We have performed more than 250 radical prostatectomies using the da Vinci (Intuitive Surgical, Mountain View, California) surgical system. Our initial cases were done using the classic Montsouris approach. However, after gaining familiarity with the robot we modified our technique to reflect our experience with open radical retropubic prostatectomy. We detail the Vattikuti Institute prostatectomy technique that we currently use. MATERIALS AND METHODS: The robotic technique requires 2 teams, namely a skilled laparoscopic team at the patient and a skilled open surgeon at the console. Dissection is started anterior to the bladder and it continues extraperitoneally. The endopelvic fascia is opened and the dorsal vein complex is secured. The apex of the prostate is dissected free, releasing the neurovascular bundles at the apex. The bladder neck is then incised, and the seminal vesicles and vasa are transected. Posterior dissection is done within the posterior layer of Denonvilliers' fascia, preserving the neurovascular bundles and lateral prostatic fascia. The apex is transected and frozen sections are obtained from the parietal margins. Vesicourethral anastomosis is formed with 2 continuous sutures. RESULTS: In the last 100 cases mean operative time was 2.5 hours and average blood loss was 150 ml. (range 25 to 525 cc.). Median specimen Gleason score was 7 and mean tumor volume was 7 cc. Four patients had a positive surgical margin, which was focal in 3. Of the patients 95% were discharged home within 23 hours. Mean catheterization time was 4.2 days. CONCLUSIONS: Vattikuti Institute prostatectomy is a precise and safe minimally invasive technique of radical retropubic prostatectomy.     

Factors predicting recovery of erections after radical prostatectomy

PURPOSE: Because preservation of functioning penile erections is a major concern for many patients considering treatment for localized prostate cancer, we analyzed various factors determined before and after radical retropubic prostatectomy to identify those significantly associated with recovery of erectile function. MATERIALS AND METHODS: Our prospective database of patients undergoing pelvic lymphadenectomy and radical retropubic prostatectomy was used to determine factors predictive of erection recovery after radical prostatectomy. The study included 314 consecutive men with prostate cancer treated with radical retropubic prostatectomy between November 1993 and December 1996. Preoperative potency satisfactory for intercourse and degree of neurovascular bundle preservation during the operation were documented. RESULTS: Patient age, preoperative potency status and extent of neurovascular bundle preservation but not pathological stage were predictive of potency recovery after radical prostatectomy. At 3 years after the operation 76% of men younger than age 60 years with full erections preoperatively who had bilateral neurovascular bundle preservation would be expected to regain erections sufficient for intercourse. Compared to the younger men, those 60 to 65 years old were only 56% (95% confidence interval [CI] 37 to 84) and those older than 65 years were 47% (95% CI 30 to 73) as likely to recover potency. Patients with recently diminished erections were only 63% (95% CI 38 to 100) as likely to recover potency as men with full erections preoperatively, and those with partial erections were only 47% (95% CI 23 to 96) as likely to recover potency. Resection of 1 neurovascular bundle reduced the chance of recovery to 25% (95% CI 10 to 61) compared to preserving both nerves. CONCLUSIONS: Knowledge of preoperative erectile function and patient age before the operation and the degree of neurovascular bundle preservation afterward may aid in patient counseling regarding potency recovery after radical prostatectomy.     

Bulboprostatic anastomotic urethroplasty with preservation of potency: anatomical study, operative approach and clinical results

OBJECTIVE. To identify the precise anatomy of the membranous and bulbous urethrae and their relation to the neurovascular bundles (cavernous nerves and vessels). Based on the findings, a modified surgical technique was developed to preserve potency by avoiding injury to the neurovascular bundles during surgery on the posterior urethra. MATERIAL AND METHODS: The material for this study consisted of 10 male cadavers. We injected eight cadavers with a mixture of red latex and lead oxide. By means of meticulous dissection we removed the bladder, prostate, urethra, penis, surrounding vessels and nerves. We also identified the anatomical relations between various urogenital structures and the vessels and nerves. We examined the specimens radiologically. In the other two cadavers, we removed the membranous urethrae and subjected them to histological examination. We used haematoxylin-eosin and Verhoeff von Gieson stains to study the elastic tissues. RESULTS: The membranous urethra measured 2.5-3 cm in length. It originated from the lower third of the anterior surface of the prostate (and not from the apex) as a continuation of the prostatic urethra. The wall of the membranous urethra contained abundant elastic fibres. The neurovascular bundles were located posterolateral to the mid-portion of the prostate and prostatic apex. Near the apex the neurovascular bundle divided into two parts: a larger anterior part and a smaller posterior part. The anterior part crossed the membranous urethra, then the bulb of the penis at the 1 and 11 o'clock positions and finally entered the corpus cavernosum. The posterior part crossed the membranous urethra more posteriorly to enter the bulb of the penis. Between 1992 and 2003 we managed 22 patients (age range 16-50 years) with posterior urethral obstruction secondary to pelvic fracture by means of bulboprostatic anastomosis. We managed 17 patients via the perineal route and five via a combined perineoabdominal-transpubic route. All of these patients were potent before the operation, which proved the integrity of the neurovascular bundles. We could spare the anterior divisions of the neurovascular bundles (greater cavernous nerves and vessels) during their crossing of the bulb of the penis by cutting and dissecting within the bulb (not outside it) before dismembering it from the urogenital diaphragm. We also refrained from any dissection of the apex and the posterolateral surfaces of the prostate to avoid injury to the neurovascular bundles. At 6-year follow-up (range 1-10 years) 21/22 patients preserved their potency, giving a success rate of 95.45%. Of the 22 patients, two became temporarily impotent after the operation but regained potency within a period of 4-6 months. CONCLUSION: Our technique of neurovascular bundle preservation during bulboprostatic anastomotic urethroplasty may solve the problem of postoperative impotence.