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。     

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。     

比较两种保留神经的腹膜外腹腔镜前列腺癌根治术的疗效

目的比较筋膜间和筋膜内保留神经的腹腔镜前列腺癌根治术的治疗效果。方法选取开封市中心医院泌尿外科收治的前列腺癌患者86例,均接受保留神经的腹膜外腹腔镜前列腺癌根治术。随机分成2组,每组43例。对照组经筋膜间施术,观察组经筋膜内施术,比较2组的手术指标,术后6、12个月的勃起功能恢复情况及控尿功能。结果 2组手术时间、术中出血量、Gleason评分、尿管留置时间、术后住院时间及切缘阳性率比较,差异无统计学意义(P0.05)。术后6个月,观察组患者控尿功能显著优于对照组,差异有统计学意义(P0.05)。术后12个月,2组患者控尿功能差异无统计学意义(P0.05)。术后6、12个月,观察组患者总体勃起功能恢复率明显高于对照组,其中2组≤65岁患者差异有统计学意义(P0.05),但2组65岁患者差异无统计学意义(P0.05)。结论筋膜内和筋膜间保留神经的腹膜外腹腔镜前列腺癌根治术的临床疗效相当,但筋膜内术式对术后勃起功能和控尿功能的恢复效果较好,尤其是年轻患者。     

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。     

机器人辅助完全后入路筋膜内前列腺癌根治术5例经验总结

目的简要介绍机器人辅助完全后入路筋膜内前列腺癌根治术的初步经验。方法回顾性分析浙江大学医学院附属邵逸夫医院泌尿外科2016年8月至10月间5例机器人辅助完全后入路筋膜内前列腺癌根治术患者的临床资料。结果所有手术均顺利完成,手术时间为124~155分钟,平均(139.8±13.9)分钟;术中出血量30~80ml,平均(52.0±19.2)ml。无切缘阳性患者。术后6周复查PSA均达到根治标准。3例患者术后拔除导尿管后即能完全控尿,未使用尿垫,其余2例在术后1个月内控尿完全恢复。2例患者术后1个月内恢复勃起功能,其余3例随访1个月未见明显性功能恢复。结论机器人辅助完全后入路筋膜内前列腺癌根治术是可行的。患者的肿瘤控制、术后尿控以及性功能恢复均较为满意。有条件的单位可选择合适患者施行。     

前列腺癌根治术132例临床分析

目的总结行前列腺癌根治术的经验和教训,对手术疗效和影响患者生活质量的因素进行分析。方法1993年1月至2005年3月共开展前列腺癌根治手术132例,按照手术的时间,将患者分为早期组（2000年前,34例）和近期组（2001年后,98例）,分别统计围手术期各指标情况,对近期组中63例患者的随访结果进行分析;对78例患者的阴茎勃起功能状况进行跟踪调查,其中19例行阴茎夜间生物电阻抗体积测定（NEVA）检查。结果近期组和早期组相比,与手术技术相关的指标逐渐优化。随访的病例中无死于前列腺癌者;以血清前列腺特异抗原（PSA）〉0．4μg／L为标准,有9例生化复发。50例在术后6个月内恢复正常排尿,压力性尿失禁8例,完全性尿失禁5例。4例出现膀胱颈部尿道狭窄。56例保留双侧神经患者中,33例（58．9％）恢复勃起功能;22例保留单侧神经患者中,7例（31．8％）恢复勃起功能;19例行NEVA检查者中,动脉供血不足者14例,4例恢复勃起功能;静脉漏者5例,均未恢复勃起功能。结论前列腺癌根治术治疗局限性前列腺癌效果较好。熟悉前列腺解剖,保护血管神经束以及良好的手术技巧,是手术成功的关键,也是影响患者术后生活质量的重要因素。     

机器人辅助筋膜内前列腺癌根治术对术后尿控影响的研究

目的总结21例行机器人辅助筋膜内前列腺癌根治术的患者资料,探讨该方法对患者术后尿控功能的影响。方法 2012年4月至2014年10月,长海医院单一术者实施机器人辅助的腹腔镜下前列腺癌根治术100例,其中筋膜内前列腺癌根治术21例,21例中4例在前列腺切除术后行盆内筋膜重建。4例患者术前临床分期均低于T2期,平均PSA为11.1 ng/ml。在成功进行双侧筋膜内前列腺切除术后,应用尿道吻合剩余的倒刺线,自尿道吻合位置,将两侧剩余的盆内筋膜缝合,使膀胱颈口在两侧的盆内筋膜的挤压下形成一定长度的功能性尿道。结果患者术中出血量50~600 ml,平均260 ml,术中输血1例,术后14 d拔除导尿管。术后住院天数为6~19 d,平均9 d。术后病理切缘阳性5例,其中4例为尖部阳性,包膜侵犯2例,精囊腺侵犯1例。术后4周血清PSA0.2 ng/ml 2例,0.2 ng/ml 19例。随访1~22个月,平均随访时间12.4个月。本组21例,术后2周拔管排尿可控6例,术后1个月、3个月尿控有效率(以每天应用尿垫≤1块为标准)分别为61.9%(13/21)和90.5%(19/21)。结论选择肿瘤分期较早的患者,掌握一定的操作技巧,机器人辅助筋膜内前列腺癌根治术可提高患者术后尿控。     

24例保留性神经的前列腺癌根治术后疗效观察

目的：探讨施行保留性神经的前列腺癌根治术后患者性功能及控尿情况的变化。方法：随访我院24例施行保留性神经前列腺癌根治术患者的性功能及控尿情况,并结合临床资料进行统计分析。结果：术后患者IIEF-5评分均不同程度降低,但仍有54．2％（13／24）的患者IIEF～5评分可达12分以上;术后勃起功能及控尿情况的恢复与患者年龄相关,年龄越低,恢复越好。结论：对于前列腺癌患者实行保留神经的前列腺癌根治术有助于患者术后性功能和控尿功能的恢复,尤其对于较年轻的患者效果更佳。     

免缝扎背深静脉复合体技术在30例筋膜内保留神经腹腔镜根治性前列腺切除术中的应用

目的探讨双侧筋膜内腹腔镜前列腺癌根治术(INLRP)中免缝扎背深静脉复合体(DVC)的手术技巧和临床疗效。方法回顾性分析我院2015年1月至2018年06月30例双侧筋膜内腹腔镜前列腺癌根治术的患者资料,术中免缝扎DVC,统计手术时间、术中出血量、围术期输血率、手术切缘阳性率、术后生化复发、术后尿失禁(拔除尿管后即刻、1个月、3个月、6个月)及术后6个月性功能等数据。结果 30例患者均在腹腔镜下顺利完成手术。手术时间(123.57±53.63)min,术中出血量(225.00±300.77)mL,手术切缘阳性率3/30(10.0%),输血率2/30(6.67%)。平均留置尿管11(8～15)d。拔除导尿管后即刻、1个月、3个月、6个月尿垫使用≤1块/d的患者占比分别为13.33%、53.33%、83.33%、96.67%。25例术前有性生活的患者术后6个月能勃起完成性交17例(68.0%)。随访期间术后6个月出现2例生化复发(6.67%)。结论双侧筋膜内腹腔镜前列腺癌根治术中免缝扎DVC安全有效,有利于术后控尿功能及性功能的早期恢复。     

筋膜内与筋膜间保留神经的腹腔镜前列腺癌根治术后的功能恢复情况比较

目的比较筋膜内与筋膜间保留神经的腹腔镜前列腺癌根治术后的功能恢复情况。方法纳入前列腺癌患者180例,按照2∶1的比例进行配对研究,分为进行筋膜间组和筋膜内组。筋膜间组采用筋膜间保留神经的腹腔镜前列腺癌根治术;筋膜内组采用筋膜内保留神经的腹腔镜前列腺癌根治术。结果两组在年龄、BMI、血清PSA、手术时间、术中出血量、尿管留置时间及病理分期比较,差异均无统计学意义(P0.05)。术后3月两组间控尿功能比较,差异有统计学意义(P0.05)。术后6月两组间控尿功能、勃起功能(筋膜内组45.0%vs.筋膜间组28.3%)比较,差异均有统计学意义(P0.05)。术后12月两组间勃起功能(筋膜内组61.7%vs.筋膜间47.5%)比较,差异有统计学意义(P0.05)。筋膜内组切缘阳性率(18.3%)高于筋膜间组(15.8%),差异有统计学意义(P0.05)。结论在术前诊断明确,无明显手术禁忌证的前提下,筋膜内组术后控尿和勃起功能恢复优于筋膜间组,对于临床中行LRP的患者,我们建议采用筋膜内保留神经的腹腔镜前列腺癌根治术。     

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.     

腹腔镜筋膜内前列腺癌根治性切除术对尿控恢复的影响及相关因素分析

目的:通过总结我院腹腔镜筋膜内前列腺癌根治性切除术的方法及患者术后尿控恢复的随访记录,对影响尿控恢复的相关因素进行分析。方法:2009年9月至2012年11月共为128例患者行腹腔镜筋膜内前列腺癌根治性切除术,患者43~78岁,平均(57.0±11.4)岁,术前血PSA 4.1~18.8 ng/ml,平均(9.9±6.1)ng/ml;临床分期T185例、T243例;活检组织Gleason评分:5分13例、6分38例、7分77例,术中不打开盆底筋膜,自膀胱颈口1点及11点位置纵行切开前列腺筋膜,紧贴前列腺包膜分离前列腺前面、两侧、尖部,最大限度保留盆底神经及肌肉组织,术后随访患者尿控变化12个月。结果:128例手术均顺利完成,无中转筋膜外前列腺癌根治性切除术,手术时间45~118 min,平均(84.0±24.6)min;术中出血量15~220 ml,平均(140.0±52.1)ml;无输血,留置尿管7~15 d,平均(11.0±3.8)d。术后随访12个月,完全尿控96例(75.0%),轻微尿失禁28例(21.9%),中度尿失禁4例(3.1%),无重度及完全尿失禁病例。结论:腹腔镜筋膜内前列腺癌根治性切除术最大限度地保留了盆底肌肉、神经组织,使术后尿控得到更好的恢复,值得推广应用。     

Intrafascial nerve-sparing endoscopic extraperitoneal radical prostatectomy

OBJECTIVES: Based on our recently published anatomic studies, we present the most recent refinement of the endoscopic extraperitoneal radical prostatectomy (EERPE), the intrafascial nerve-sparing EERPE (nsEERPE). METHODS: As part of the intrafascial technique, the dissection plane is directly on the prostatic capsule, freeing the prostate laterally from its thin surrounding fascia that contains small vessels and nerves. The technique enables puboprostatic ligament preservation, leaving intact endopelvic fascia, periprostatic fascia, and neurovascular bundles. The operation was performed in 150 patients with indications for nerve-sparing procedure. RESULTS: The mean operative time was 131 min (range: 50-210 min) and the mean catheterization time was 5.9 d (range: 4-20 d). Twelve months postoperatively, 94.3% of the patients were continent (no need for pads), 4.6% had minimal stress incontinence, and one patient required >2 pads/d. At the 12-mo follow-up, the potency rates (erections sufficient for intercourse with or without the use of phosphodiesterase 5 [PDE5] inhibitors) of the patients who underwent bilateral intrafascial nsEERPE were 89.7% (age: 44-55 yr), 81.1% (age: 56-65 yr), and 61.9% (age: >65 yr). Positive surgical margins in pT2 and pT3 tumors were 4.5% and 29.4%, respectively. CONCLUSIONS: The intrafascial nsEERPE enables the dissection of the prostate with limited trauma to the surrounding fascias and the enclosed neurovascular bundles. We propose that the preserved neurovascular bundles with intrafascial nsEERPE are more viable. The results advocate this proposition.     

A matched-pair comparison between bilateral intrafascial and interfascial nerve-sparing techniques in extraperitoneal laparoscopic radical prostatectomy

The aim of this study was to validate the advantages of the intrafascial nerve-sparing technique compared with the interfascial nerve-sparing technique in extraperitoneal laparoscopic radical prostatectomy. From March 2010 to August 2011, 65 patients with localized prostate cancer (PCa) underwent bilateral intrafascial nerve-sparing extraperitoneal laparoscopic radical prostatectomy. These patients were matched in a 1∶2 ratio to 130 patients with localized PCa who had undergone bilateral interfascial nerve-sparing extraperitoneal laparoscopic radical prostatectomy between January 2008 and August 2011. Operative data and oncological and functional results of both groups were compared. There was no difference in operative data, pathological stages and overall rates of positive surgical margins between the groups. There were 9 and 13 patients lost to follow-up in the intrafascial group and interfascial group, respectively. The intrafascial technique provided earlier recovery of continence at both 3 and 6 months than the interfascial technique. Equal results in terms of continence were found in both groups at 12 months. Better rates of potency at 6 months and 12 months were found in younger patients (age ≤65 years) and overall patients who had undergone the intrafascial nerve-sparing extraperitoneal laparoscopic radical prostatectomy. Biochemical progression-free survival rates 1 year postoperatively were similar in both groups. Using strict indications, compared with the interfascial nerve-sparing technique, the intrafascial technique provided similar operative outcomes and short-term oncological results, quicker recovery of continence and better potency. The intrafascial nerve-sparing technique is recommended as a preferred approach for young PCa patients who are clinical stages cT1 to cT2a and have normal preoperative potency.     

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.     

Preservation of periprostatic autonomic nerves during total perineal prostatectomy by intrafascial dissection

A modification of Young's total perineal prostatectomy technique is described to prevent damage to the apical branches of the cavernous nerves. Based on anatomic relationships between investing prostatic fascial layers and the neurovascular bundle, emphasis is placed on division of the apical prostatic urethra between the anterolateral endopelvic fascia and Denonvilliers fascia (intrafascial dissection) in avoidance of the apical nerves. Vertical incision in the fused distal portion of Denonvilliers fascia is necessary to make this dissection atraumatic regarding the adjacent paraprostatic neurovascular bundle. Clinical application of this completely intrafascial prostatic dissection is exemplified. It is concluded that careful modification of Young's technique of total perineal prostatectomy may result in increased postoperative potency rates.     

Anatomical landmarks of radical prostatecomy

INTRODUCTION: In the present study, we review current literature and based on our experience, we present the anatomical landmarks of open and laparoscopic/endoscopic radical prostatectomy. METHODS: A thorough literature search was performed with the Medline database on the anatomy and the nomenclature of the structures surrounding the prostate gland. The correct handling of puboprostatic ligaments, external urethral sphincter, prostatic fascias and neurovascular bundle is necessary for avoiding malfunction of the urogenital system after radical prostatectomy. RESULTS: When evaluating new prostatectomy techniques, we should always take into account both clinical and final oncological outcomes. The present review adds further knowledge to the existing "postprostatectomy anatomical hazard" debate. It emphasizes upon the role of the puboprostatic ligaments and the course of the external urethral sphincter for urinary continence. When performing an intrafascial nerve sparing prostatectomy most urologists tend to approach as close to the prostatic capsula as possible, even though there is no concurrence regarding the nomenclature of the surrounding fascias and the course of the actual neurovascular bundles. After completion of an intrafascial technique the specimen does not contain any periprostatic tissue and thus the detection of pT3a disease is not feasible. This especially becomes problematic if the tumour reaches the resection margin. DISCUSSION: Nerve sparing open and laparoscopic radical prostatectomy should aim in maintaining sexual function, recuperating early continence after surgery, without hindering the final oncological outcome to the procedure. Despite the different approaches for radical prostatectomy the key for better results is the understanding of the anatomy of the bladder neck and the urethra.     

经腹膜外腹腔镜下前列腺癌根治术（附151例报告）

目的：探讨经腹膜外腹腔镜下前列腺癌根治术（ELRP）的手术技巧和疗效。方法：回顾分析2006年1月～2011年1月,行ELRP151例患者的临床资料。术前均经病理检查确诊,患者平均年龄69（53～78）岁,盆腔CT、MRI和核素全身骨扫描无盆腔淋巴结、精囊和骨转移。结果：术前TPSA平均16．40（3．27～165．00）μg／L,Gleason评分〈7分63例（41．7％）,7分58例（38．4％）,〉7分30例（19．9％）。平均手术时间178（60～390）min,平均出血量260（20～1000）ml,术中输血5例（3．3％）。直肠损伤1例（0．67％）,术后病理检查切缘阳性14例（9．3％）,局部闭孔淋巴结转移5例（3．3％）。术后留置导尿平均13．5（6～69）天,平均住院时间14．4（4～74）天。术后随访平均27（4~62）个月,不同程度尿失禁31例（20．5％）。尿道狭窄2例（1．3％）,均行尿道狭窄冷刀切开。单侧腹股沟斜疝2例（1．3％）,出现生化复发15例（9．9％）。结论：ELRP是安全可行的,创伤小,术后恢复快。镜下吻合技术和控制出血是手术成功的关键。     

The endoscopic extraperitoneal radical prostatectomy (EERPE): technique and initial experience

Using the experiences of the extraperitoneal (endoscopic pelvic lymphadenectomy and inguinal hernia repair) and the transperitoneal approach (laparoscopic radical prostatectomy), we developed a totally extraperitoneal approach to endoscopic radical prostatectomy. In view of the favourable short-term outcome, we describe the technique of totally extraperitoneal endoscopic radical prostatectomy (EERPE) as a now standardised procedure. After creating the preperitoneal space by balloon dissection, five trocars were placed in the hypogastrium, allowing immediate access to the space of Retzius. The surgical technique of EERPE replicates the steps of the classical retropubic descending radical prostatectomy with slight modifications. The procedure starts with exposing the Retzius space and pelvic lymph node dissection. After that, the endopelvic fascia and the puboprostatic ligaments are incised, followed by ligating the Santorini plexus. The actual prostate dissection is similar to the open descending approach: bladder neck dissection, freeing of the seminal vesicles, transsectioning of the prostatic vesicles (with or without preserving the neurovascular bundles) and, finally, apical dissection. A water-tight urethrovesical anastomosis is performed with interrupted sutures. There were 20 patients who underwent EERPE. Mean operating time was 170 min with no conversion. No major complications occurred. Only one patient required a blood transfusion. The catheter could be removed on postoperative day 6 (n = 17) or on postoperative day 12 (n = 3). Final pathologic evaluations were 4 stage pT2a, 10 stage pT2b, 5 stage pT3a, and 1 pT3b. Surgical margins were negative in 17 patients. By avoiding entry into the peritoneal cavity, therefore, obviating intra-abdominal complications, such as bowel injury, ileus, or intestinal adhesions, the extraperitoneal endoscopic access provides a safe and minimally invasive approach to the prostate, combining the advantages of minimally invasive laparoscopy and retropubic open prostatectomy.     

Endoscopic extraperitoneal radical prostatectomy: initial experience after 70 procedures

PURPOSE: After our initial experience with 70 transperitoneal laparoscopic radical prostatectomies we developed a totally extraperitoneal retropubic approach to radical prostatectomy using laparoscopic instruments. We report our initial experience with 70 endoscopic extraperitoneal radical prostatectomy procedures. MATERIALS AND METHODS: A total of 70 patients underwent endoscopic extraperitoneal radical prostatectomy. Mean patient age was 63.4 years (range 49 to 76). Mean preoperative prostate specific antigen was 12.48 ng./ml. (range 1.4 to 50.7). There were no specific selection criteria for the procedure. The steps of the procedure are preparation of the preperitoneal space with the help of a balloon trocar, trocar placement (a 3 x 5 and a 2 x 12 mm. port), pelvic lymph node dissection, exposure of the prostate and the bladder neck, incision of the endopelvic fascia, ligation of Santorini's plexus, bladder neck dissection, mobilization of the seminal vesicles, incision of Denonvilliers' fascia, sectioning of the prostatic pedicles with or without preservation of the neurovascular bundles, dissection of Santorini's plexus and apex, urethrovesical anastomosis with 7 to 9 interrupted sutures and removal of the specimen via an extraction bag. During the 70 endoscopic prostatectomies 11 hernia defects were treated in 9 patients concomitantly. RESULTS: There was no conversions and no re-interventions. Mean operative time was 155 minutes (range 90 to 260). One patient required transfusion with 2 units of blood cells. Pathological stage was pT2a in 19 patients, pT2b in 14, pT3a in 25, pT3b in 9 and pT4 in 3. Positive surgical margins were found in 2 of the 33 patients (6.1%) with pT2 tumors and in 13 of the 37 (35.1%) with pT3 and pT4 tumors. Postoperatively edema and hematoma of the penis in 10 cases was treated conservatively. Furthermore, 4 patients had asymptomatic lymphoceles, 1 required lymphocele drainage and 2 had partial obturator nerve paralysis, which resolved spontaneously. In 1 patient deep venous thrombosis developed. CONCLUSIONS: The preliminary results of this series are promising. Operative and perioperative morbidity was low. Functional results and oncological control were similar to the results of laparoscopic radical prostatectomy. The data demonstrate that endoscopic extraperitoneal radical prostatectomy can be performed with efficacy and results equal to those of laparoscopic radical prostatectomy, while providing the benefits of a totally extraperitoneal approach. Therefore, totally endoscopic extraperitoneal radical prostatectomy represents a technical improvement of laparoscopic technique because it completely obviates intra-abdominal complications and combines the advantages of minimally invasive laparoscopy and the retropubic open approach.