机器人辅助腹腔镜前列腺癌根治术联合新辅助内分泌治疗高危前列腺癌的临床研究

目的:探讨术前机器人辅助腹腔镜前列腺癌根治术(Robot-assisted laparoscopic radical prostatectomy,RALP)联合新辅助内分泌治疗(Neoadjuvant hormone therapy,NHT)治疗高危前列腺癌患者的临床疗效。方法:回顾性分析甘肃省人民医院泌尿外科自2018年6月-2020年12月前通过PSA、穿刺活检及MRI确诊的35例高危前列腺癌患者临床资料,其中术前行RALP+NHT治疗组25例,年龄为56~81(70.28±7.07)岁;RALP治疗组10例,年龄为49~86(69.20±8.77)岁。比较两组患者的手术时间、术中出血量、术后住院时间、术后切缘阳性率及术中和术后并发症等情况。结果:所有患者手术均获成功,无中转开放及二次手术。与RALP治疗组相比,RALP+NHT治疗组在手术时间[237.88±68.99d Vs (277±76.69)d,P=0.541]、术中出血量[(149.60±149.84)ml Vs (225±268.56)ml,P=0.266]、术后住院时间[(11±4.31) d Vs(11.7±4.86) d,P=0.402]、术后留置尿管时间[(28±6.81) d Vs (28±6.81) d,P=0.464]和术前PSA值[(49.97±32.22)ng/ml Vs (47.41±23.14)ng/ml,P=0.089]等方面差异均无统计学意义;RALP+NHT治疗组在总住院时间[(18.08±4.44)d Vs (25.5±10.82)d,P<0.005]和术后留置引流管时间[(10.12±3.36)d Vs(11.10±5.17)d,P=0.014]明显低于RALP组,差异具有统计学意义;RALP+NHT治疗组在Gleason评分(24%Vs10%)、肿瘤切缘阳性(12%Vs 20%)及并发症(4%Vs 10%)等方面下降明显。结论:术前RALP联合NHT可降低高危前列腺癌切缘阳性、改善病理分级,使高危患者受益。     

高危前列腺癌的术前新辅助内分泌治疗进展

<正>前列腺癌(prostate cancer,PCa)是我国男性发病率第二位的泌尿系统肿瘤,估计每年新发病例 60.3 万 ,死 亡 病 例 26.6 万 ,且 呈 逐 年 上 升 趋势^[1]。PCa 具有明显的异质性,从惰性到高侵袭性表型的自然病程完全不同,高危 PCa 局部和远处进展风险明显增加。尽管相应的研究层出不穷,但高危 PCa 患者的最佳治疗方法尚无定论^[2]。为了较好地控制这类患者的症状,许多学者对根治性前列腺切除术前行雄激素剥夺治疗(andro‐gen deprivation therapy,ADT)的 效 果 进 行 了 研究,包括促黄体生成素释放激素(luteinizing hor‐mone releasing hormone,LhRH)激动剂或拮抗剂及抗雄激素药物。相比单纯根治性前列腺切除术,术前给予 ADT 可降低术后 pT3 分级和手术切缘阳性率,以及淋巴结侵犯发生率。然而这种     

新辅助治疗的优势:机器人辅助腹腔镜下前列腺癌根治术治疗局部进展期前列腺癌

目的探讨术前新辅助内分泌治疗(NHT)是否能使接受机器人辅助腹腔镜前列腺癌根治术(RLRP)治疗的局部进展期前列腺癌患者临床获益。方法回顾性研究中国医科大学附属第一医院泌尿外科自2018年5月至2019年8月根治术前通过穿刺活检及MRI诊断为局部进展期前列腺癌患者31例。其中术前行新辅助内分泌治疗12例,年龄(65.67±5.123)岁,未经内分泌治疗19例,年龄(66.58±8.520)岁。比较两组患者手术时间、术中出血量、术后住院时间、术后切缘阳性率、淋巴结阳性率、术后吻合口漏尿等情况。结果 31例手术均无中转开放及二次手术。新辅助治疗组手术时间[(176.84±54.875)min vs.(66.58±8.520)min,P=0.032]和术后住院时间[(9.50±2.505)min vs.(13.87±5.987)min,P=0.048]缩短,术中失血量[(165.68±79.746)mL vs.(13.87±5.987)mL,P=0.013]减少。治疗组肿瘤切缘阳性率(8.33%vs.26.32%,P=0.001)和清扫淋巴结阳性率(17.14%vs.38.18%,P=0.037)也明显低于对照组。术前辅助内分泌治疗并不能降低术后Gleason评分和临床分期(P>0.05)。结论术前新辅助内分泌治疗在RLRP治疗局部进展期前列腺癌患者中可能在一定程度上降低手术难度并且减少术中出血,使患者受益。     

机器人辅助腹腔镜根治性前列腺切除术130例

目的 评估da Vinci S机器人辅助腹腔镜根治性前列腺切除术（RARP）的疗效和安全性.方法 回顾分析2009年7月至2013年9月,复旦大学附属中山医院应用da Vinci S手术系统（da Vinci Intuitive Surgical Inc.,Sunnyvale,CA,USA.）完成RARP术130例的情况.年龄48～76岁,平均（67±6）岁;PSA水平为2.16～ 78.20 ng/ml,平均（26.05±8.41）ng/ml;Gleason评分6～10;肿瘤临床分期均为局限性前列腺癌.结果 130例均经腹腔途径,采用机器人3臂或4臂,5～6枚troc ar完成RARP,无机器人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20 ～ 90 min,平均（48.5±15.4） min;手术时间90 ～ 300 min,平均（143.6±22.9） min;术中出血量50 ～ 600 ml,平均（158.2±59.6） ml,2例（1.5％）术后输血400ml.术后2～3d下床活动,平均（2.2±0.6）d;术后住院5～21d,平均（6.6±1.9）d;4～21d拔除导尿管,平均（6.1±2.0）d.术后主要并发症包括：漏尿6例（4.6％）,漏尿于术后3～15d停止.术后淋巴瘘8例（6.2％）,术后2～3周停止,未发现淋巴囊肿.术后下肢静脉栓塞、肺栓塞和附睾炎各1例,治疗后好转.术后病理切缘阳性12例（9.2％）,精囊见癌侵犯10例（7.7％）,闭孔淋巴结转移4例（3.1％）.术后1～12个月复查PSA均＜ 0.2 ng/ml,术后6个月和1年完全控尿率达86％和95％.结论RARP安全、可靠,具有出血更少、恢复更快等优势,是根治性前列腺切除术的首选方式.     

新辅助内分泌治疗联合腹腔镜前列腺癌根治术治疗高危及局部晚期前列腺癌的临床研究

目的:探讨新辅助内分泌治疗联合腹腔镜前列腺癌根治术治疗高危及局部晚期前列腺癌的可行性及临床效果。方法:回顾性分析2015年1月～2017年1月临沂市中心医院确诊的36例高危及局部晚期前列腺癌患者临床资料,先行3个月辅助内分泌治疗,再行腹腔镜前列腺癌根治术,术后即刻给予辅助内分泌治疗。结果:手术均获得成功,无中转开放手术。平均手术时间为(201±21) min,平均出血量为(240±122) ml,平均住院时间为(20.6±2.3) d,平均术后留置尿管和引流管时间分别为(14.8±3.8) d和(5.6±2.8) d,切缘阳性5例(13.9%),淋巴结阳性11例(30.6%),术后尿失禁2例,尿瘘1例,勃起功能障碍22例。术后随访12～36个月,平均24个月,术后1年尿控满意率为91.6%(33/36),术后1、2年生化复发率分别为25.0%(9/36)和38.9%(14/36)。结论:新辅助内分泌治疗联合腹腔镜下前列腺癌根治术治疗高危及局部晚期前列腺癌安全、可行,但有较高的淋巴结阳性率和生化复发率,术后需要进一步治疗及随访观察。     

高危前列腺癌腹腔镜根治性前列腺切除术后切缘阳性的危险因素

目的:探讨高危前列腺癌患者腹腔镜根治性前列腺切除术(LRP)后手术切缘阳性(PSM)的危险因素。方法:回顾性分析2012年1月至2020年7月行LRP的202例高危前列腺癌患者的病例资料,其中北京朝阳医院111例,中国医学科学院肿瘤医院91例。年龄(67.7±6.5)岁,体质指数(25.65±3.21)kg/m ...     

机器人腹腔镜根治性前列腺切除术2年经验总结

目的:评估机器人腹腔镜根治性前列腺切除术(rLRP)的围手术期结果及开展该手术2年来的100例经验。方法:2003年1月-2005年5月对100例患者实施了达.芬奇机器人手术系统的rLRP。所有患者经前列腺穿刺活组织病理检查确诊为前列腺癌,骨扫描无转移灶。由专人负责收集术后早期及功能康复结果的资料。结果:患者平均年龄(63.5±5.4)岁,Gleason评分为6分,治疗前PSA为(9.4±6.9)μg/L。机器人准备时间和手术时间分别为(24±14)min和(182±52)min;平均失血量(272±240)ml,输血率7%。留置导尿时间(8.4±4.1)天,住院时间(2.9±1.5)天。无围手术期死亡和中转开放手术患者。严重并发症包括需要再手术的膀胱尿道吻合口漏、脑血管意外、暂时性输尿管梗阻。轻微并发症包括轻度漏尿、膀胱颈部狭窄、尿路感染。平均随访时间(6.6±5.0)个月。术后标本病理分期pT2为55%,pT3为45%。切缘阳性率为12.7%。结论:机器人腹腔镜根治性前列腺切除术可以明显减少术中出血,降低输血率,缩短住院时间。机器人将复杂的盆腔腹腔镜手术变得简单易行,提高了手术的精细度和灵巧性。     

手术时间分段分析法在机器人辅助腹腔镜前列腺癌根治性切除术难度因素分析中的应用

目的:探索从前列腺穿刺活检到行机器人辅助腹腔镜前列腺癌根治性切除术(RALP)的时间间隔能否影响手术过程中每个步骤,验证利用手术时间分段分析法评估手术难度的可行性,并对影响RALP难度的因素进行分析.方法:纳入2016年1月-2017年9月在上海长海医院接受单一术者RALP治疗的209例局限性和局部晚期前列腺癌患者的临...     

内分泌联合前列腺电切术治疗高危前列腺癌的体会

前列腺癌是欧美国家男性最常见的恶性肿瘤,死亡率居第2位.随着我国人口老龄化的加重,前列腺癌发生率、诊断率均明显上升,其中有些由于合并较严重的心、脑、肺、肾等合并症而被列为高危患者常不能耐受根治手术.为解除这类患者的膀胱出口梗阻症状,提高生活质量,控制病情,延长生命,我们采用前列腺电切术加双侧睾丸切除联合内分泌治疗,效果满意.现将体会报告如下.     

机器人辅助腹腔镜根治性前列腺切除术34例报告

目的:探讨机器人辅助腹腔镜根治性前列腺切除术的可行性及安全性。方法:利用da Vinci S机器人手术系统对34例局限性前列腺癌患者经腹路径施行机器人辅助腹腔镜根治性前列腺切除术。结果:34例手术成功,手术时间198(135~340)min,失血量257(50~700)ml,输血1例,无手术并发症发生。3例术后病理切缘阳性。术后1个月复查tPSA,2例术后4周PSA0.2μg/L,提示术后肿瘤残留,行雄激素去除治疗,其余32例均0.2μg/L。随访平均时间7.5(3~10)个月,tPSA均无升高。术后3、6个月控尿有效率分别为94%(32/34)和97%(33/34),其中77%(26/34)和88%(30/34)完全脱离尿垫。结论:机器人辅助腹腔镜根治性前列腺切除术失血少、切缘阳性率低、尿控良好,安全有效。     

Midterm outcomes of four-port extraperitoneal laparoscopic radical prostatectomy for high-risk prostate cancer within Asian population

ObjectiveAsian patients tend to have higher stage prostate cancer at diagnosis compared with patients of other races. This article aims to investigate the use of four-port extraperitoneal laparoscopic radical prostatectomy (EPLRP) as the first step in a multimodality treatment strategy for Asian patients with high-risk prostate cancer (HRPC).Materials and methodsA cohort of 202 patients underwent EPLRP between January 2006 to January 2016, of whom 122 (60.3%) had HRPC as defined by D'Amico classification: clinical T stage ≥ cT2c or PSA level ≥ 20 ng/mL or biopsy Gleason sum ≥ 8). All patients underwent proper preoperative staging. The median age was 68 years (48–82), PSA level 17.8 ng/mL (3.3–191.1), and biopsy Gleason sum 7 (6–10). All patients underwent pelvic lymphadenectomy, and some underwent neurovascular bundle preservation according to their risk category.ResultsPerioperative outcomes included a median operative time of 185 min (65–380), total blood loss 150 ml (30–500), postoperative hospitalization 10 days (6–25), and urethral catheterization time 7 days (4–22). No patient was converted to open surgery. Median specimen weight was 42 g (19–124), lymph node yield was 10 (0–35) with 11.5% positivity and a positive surgical resection margin rate of 28.7%. The median follow-up period was 37 months (6–129). 96.7% of patients achieved continence and 53.8% of the 39 potent patients prior to surgery maintained their sexual potency at one year after EPLRP. The 5-year cancer-specific, overall, and biochemical recurrence-free survival rates were 98.8%, 92.2%, and 68.7%, respectively.ConclusionExtraperitoneal laparoscopic radical prostatectomy has low morbidity, and can provide fair functional and oncological outcomes as the first step of a multimodality treatment strategy for high-risk prostate cancer in Asian.     

8-month neoadjuvant hormonal therapy before radical prostatectomy for high-risk prostate cancer

PURPOSE: To evaluate the clinicopathological outcomes of 8 months of neoadjuvant hormonal therapy (NHT) prior to radical prostatectomy for high-risk prostate cancer. PATIENTS AND METHODS: A multi-institutional prospective trial was performed between July 2000 and May 2003 involving high-risk prostate cancer patients without metastasis, including 21 who received 8 months of NHT before radical prostatectomy. High-risk group was defined as clinical stage > or =T2c and/or prostate-specific antigen (PSA) >20 ng/ml and/or Gleason score > or =8. PSA values were considered elevated (biochemical failure) if values of 0.1 ng/ml or greater were obtained. RESULTS: Median of initial PSA levels before prostate biopsy was 27.6 ng/ml (8.5-80.7 ng/ml), and median of pre-operative PSA levels after NHT was 0.28 ng/ml (0.02-4.2 ng/ml). There were 5 patients (23.8%) with lower limit of PSA detection (less than 0.02 ng/ml) in 8 months after NHT. The clinical T stage was T1c in 9 patients (42.9%), T2a-b in 8 patients (38.1%), T2c in 3 patients (14.3%), and T3a in 1 patient (4.8%). The median follow-up was 25 months (range 4 to 37). There were 2 patients (9.5%) in pT0, 5 patients (23.8%) with positive surgical margin, 5 patients (23.8%) with extracapsular extension (ECE) and 3 patients (14.3%) with seminal vesicle involvement (SVI). Biochemical failure was occurred in 9 of 21 (42.9%) including of one pT0. Range of time to postoperative biochemical failure was 2 to 25 months (median 6 months) and most of biochemical failure was found within 12 months after surgery. Biochemical failure rate was significantly higher in patient with positive SVI (p = 0.0308) and higher in patients with pre-operative PSA levels of more than 0.1 ng/ml (p = 0.0836), positive ECE (p = 0.0545) and positive surgical margin (p = 0.0545). CONCLUSION: Biochemical failure was frequent after this combined treatment, even in a pT0 case. Long-term follow-up of patients is needed to assess the impact of this therapy on mortality.     

三孔法经腹膜外腹腔镜根治性前列腺切除术联合辅助疗法治疗局限高危前列腺癌

目的探究三孔法经腹膜外腹腔镜前列腺根治性切除术(ELRP)联合辅助疗法治疗局限高危前列腺癌的临床效果。方法对2018年4月至2020年1月我院行三孔法ELRP联合辅助疗法治疗的11例局限高危前列腺癌患者的临床资料进行回顾性分析。观察手术时间、术中出血量、围手术期及远期并发症、尿控恢复和术后生化复发。结果 11例患者ELRP均顺利完成,无一例中转开放手术。手术时间为(126±32)min;术中出血量(60±41)ml。围手术期2例患者出现尿漏,1例患者出现切口脂肪液化,给予对症处理后均痊愈。11例患者随访(21.9±6.7)个月,无一例远期发症发生。术后12个月9例(81.8%)患者达到完全控尿。截至末次随访,1例(9.1%)患者出现生化复发。结论三孔法ELRP联合辅助疗法治疗局限高危前列腺癌是安全可行的。     

Pathological effects of neoadjuvant hormonal therapy help predict progression of prostate cancer after radical prostatectomy

BACKGROUND: It is not clear whether pathological changes following neoadjuvant hormonal therapy (NHT) prior to radical prostatectomy have any value as predictors of progression in prostate cancer. METHODS: We conducted a study of 100 patients with prostate cancer who underwent radical prostatectomy following NHT. We used the Japanese general rule as the criterion to assess the biochemical recurrence rate and pathological changes after NHT. RESULTS: In terms of preoperative risk factors, the probability of recurrence was significantly higher for patients with more than 20 ng/mL of pretreatment serum prostate-specific antigen (PSA) and/or a Gleason score of 7 or higher for biopsy specimens. We defined these pretreatment findings as high-risk factors. Among 65 patients with high-risk factors, patients with a post-NHT pathological effect of grade 3 according to the Japanese general rule showed no recurrence, whereas patients with a grade 0 had a poor prognosis. Patients with a PSA nadir 0.5 ng/mL or less tended to have a better prognosis. CONCLUSION: Despite preoperative high-risk factors, patients showing good pathological effects after NHT tend to have a favorable prognosis after radical prostatectomy. Therefore; assessment of the pathological effects of NHT using the Japanese general rule as the criterion proved to be useful for the prediction of biochemical recurrence.     

新辅助内分泌治疗联合腹腔镜根治性前列腺切除术治疗高危前列腺癌体会

目的 探讨先行新辅助内分泌治疗后行腹腔镜前列腺癌根治术治疗高危前列腺癌的可行性及效果.方法 收集2013年10月至2016年1月本院先行新辅助内分泌治疗后,再行腹腔镜根治性前列腺切除术治疗14例高危前列腺癌患者的临床资料,术前病检诊断明确,完成Gleason评分,MRI增强扫描完成临床分期,行骨扫描及相关辅助检查排除远处转移,术前辅助内分泌治疗3～6个月控制PSA＜4μg/L后行腹腔镜根治性前列腺切除术,术后观察患者排尿情况及PSA控制情况等.结果 大部分患者手术时间为130～290 min,无输血、无直肠穿孔患者,术后平均15 d拔除尿管,术后3个月均能自行控尿,术后3例病检切缘阳性,术后3个月复查PSA＜0.2μg/L.结论 高危前列腺癌患者经内分泌治疗后行腹腔镜根治性前列腺切除术是安全可行,但术前需充分评估风险及并发症情况.     

“深肌松”在肥胖患者行机器人辅助腹腔镜下根治性前列腺癌切除术中的应用观察

目的 探讨“深肌松”方案在肥胖患者行机器人辅助腹腔镜下根治性前列腺癌切除术中的应用效果及优势。方法 择期行机器人辅助腹腔镜下根治性前列腺癌切除术的肥胖患者48例,随机分为常规（中度）肌松组（M组）和深肌松组（D组）。两组采用统一的镇静镇痛方案,其中M组诱导时予顺式阿曲库铵0.15~0.2 mg/kg iv,之后每间隔约45 min~1 h单次静推顺式阿曲库铵5 mg维持;D组诱导时则予罗库溴铵0.6 mg/kg静注,PTC=1~2时行气管插管;麻醉维持采用连续输注,切皮前予罗库溴铵0.6 mg/kg iv,当神经肌肉阻滞开始恢复时以5~10 μg/（kg·min）泵注。比较两组诱导插管时间、苏醒时间、拔管后视觉模拟评分法VAS评分及躁动发生率;分别于诱导前（T₀）、手术开始1小时（T₁）、术毕时（T₂）及离开PACU前（T3）抽取动脉血2 mL行血气分析,比较两组患者乳酸、血糖等结果的差异。结果 与M组相比,D组插管时间、苏醒时间较短,拔管后VAS疼痛评分及躁动发生率较低,两组差别有统计学意义（P<0.05）。同时刻相比,T₂、T₃时刻D组的乳酸、血糖值较低,与M组比较差别有统计学意义（P<0.05）。结论 与常规肌松组相比,“深肌松”麻醉方案可缩短该类患者插管时间,加速苏醒,减轻术后疼痛和躁动应激,或可改善总体麻醉质量。     

Outcomes after robot-assisted laparoscopic radical prostatectomy

Robot-assisted laparoscopic radical prostatectomy （RALRP） using the da Vinci surgical system is now in widespread use in many countries where economic conditions allow the installation of this expensive technology. Controversy has surrounded the procedure since it was first performed in 2000, with many critics highlighting the lack of evidence to support its use. However, despite the lack of level I evidence, many large studies of patients have confirmed that the procedure is feasible and safe, with low morbidity. Available longer-term oncological data seem to show that outcomes from the robotic approach at least match those of traditional open radical prostatectomy. Functional outcomes also seem satisfactory, although randomized controlled trials are lacking. This paper reviews the current status of RALRP with respect to perioperative data and complications and oncologic and functional outcomes.     

Salvage radical prostatectomy for recurrent prostate cancer after radiation therapy

Salvage radical prostatectomy is considered for patients with locally recurrent prostate cancer after external beam radiotherapy. Between 2001 and 2004, 32 men treated with curative intent with radiotherapy for prostate cancer were subsequently treated with salvage surgery for clinically localized prostate cancer. We assessed the morbidity associated with this procedure and the outcome of the patients. Thirty-two patients underwent salvage radical prostatectomy. Initial pre-radiation median prostate-specific antigen was 13 ng/ml. Pre-radiation disease was clinical stage T1b in five cases, T2a in 10, T2b in 10 and T3a in seven. Mean operative time was 122 minutes, intraoperative blood loss was 550 ml and hospital stay and catheterization time were 5 and 12 days, respectively. There was biochemical failure in eight patients after salvage radical prostatectomy and 24 patients are biochemical non evidence of disease (bNED). In recurrent prostate local disease with prostate-specific antigen <10 ng/ml and life expectancy greater than 10 years, salvage radical prostatectomy is a reasonable treatment option.