开放性耻骨后前列腺癌根治术的手术技巧进展

当前,前列腺癌根治术是治疗局限性前列腺癌的标准方法.自上世纪90年代初期血清PSA检测被广泛用于临床实践之后,越来越多前列腺癌患者得以早期确诊.前列腺癌根治术的手术技巧历经漫长的发展历程,迄今已渐趋成熟.     

腹腔镜下前列腺癌根治术的应用进展

腹腔镜手术具有手术创伤小、术后恢复快、能直视下放大和清晰观察组织结构等优点,正在全世界范围内广泛开展,已成为目前手术发展的主要趋势。1997年Schuessler 等［1］首次报道9例腹腔镜下前列腺癌根治术（ LRP）。随着手术器械的完善并经Guil-lonneau等［2,3］标准化手术过程以后,手术效果与开放手术相比已无明显差异。2000年Abbou等［4］首次报道了机器人辅助下的前列腺癌根治术（ RALP ）,揭开了前列腺癌治疗的新篇章,而后美国Vattikuti研究所将其进一步完善。目前上万例的RALP手术结果表明,其较常规腔镜手术表现出明显优势,已成为欧美国家前列腺癌手术治疗的主要方法。国内于2006年开始逐渐引进da Vinci 机器人系统。2008年Kaouk等［5］首次报道了单孔LRP （ LESS ）,目前我国也有少数学者报道该种术式,整个操作过程空间更小、操作难度增加,但目前并未见其较常规腔镜手术有特殊优势,仍在进一步发展中。短短十几年,LRP治疗技术取得了飞速地提升。现就LRP的应用进展情况综述如下。     

前列腺癌根治术后尿失禁的预防

耻骨后前列腺癌根治术后的并发症较多，其中术后尿失禁是一个比较棘手的问题。2000年1月到2004年6月，我们对30例B期前列腺癌患者施行保护控尿功能的耻骨后前列腺癌根治术，术后仅2例有尿失禁。现报告如下。     

前列腺癌根治术切缘阳性的影响因素

目的 探讨前列腺癌根治术后切缘阳性与相关临床参数的关系.方法 回顾性分析118例行前列腺癌根治术的前列腺癌患者的临床资料,分析术前血清PSA、临床分期、体重指数(BMI)、前列腺体积及术后Gleason评分与术后切缘阳性的相关性.结果 不同BMI、前列腺体积及血清PSA水平,切缘阳性与切缘阴性差异无统计学意义(P＞0.05),而切缘阳性与切缘阴性在不同临床分期及Gleason评分中差异显著(P＜0.05).临床分期和Gleason评分与术后切缘阳性均呈现正相关(r=0.94和0.83,均P＜0.05).结论 Gleason评分和病理分期与术后切缘阳性呈正相关,Gleason评分越高,临床分期越晚,术后切缘阳性的发生率也就越大.     

机器人辅助腹腔镜下前列腺癌根治术的疗效及观察

目的 探讨机器人辅助腹腔镜下前列腺癌根治术的疗效及其对护理的影响.方法 比较2018年12月-2019年12月期间在复旦大学附属华东医院进行治疗的20例达芬奇机器人辅助腹腔镜下前列腺癌根治术患者(RALP组)与20例行腹腔镜下前列腺癌根治术患者(LRP组)的手术时间、围术期输血率、引流管拔除时间、术后住院天数、术后尿控...     

老年前列腺癌经腹膜外腹腔镜根治术的护理

目的探讨老年前列腺癌经腹膜外腹腔镜根治术围手术期的护理要点与方法。方法对5例老年前列腺癌患者经腹膜外腹腔镜根治术围手术期护理过程进行总结分析。结果由于术前重视心理护理,指导适应术后的功能锻炼,加强饮食调节和切实做好肠道的充分准备,故手术过程顺利,出血少;术后注意加强生命体征的监测,保持各引流管的通畅,恢复快,减少了并发症的发生。5例均获手术成功,随访2～24个月,未见局部复发或生化复发。结论加强围手术期的整体护理是老年前列腺癌经腹膜外腹腔镜根治术手术成功和完全康复的重要保证。     

谈耻骨后前列腺癌根治术

前列腺癌根治术已有一百多年的历史,由于严重的手术并发症限制其临床应用。20世纪的80年代初,Walsh等提出解剖性前列腺癌根治术的概念,使人们了解盆腔的解剖结构,手术并发症因而大幅度下降。前列腺根治性切除已经是公认的早期前列腺癌最佳治疗方法。解剖性耻骨后前列腺癌根治术可以完整切除肿瘤,保留血管神经索,减少术后勃起功能障碍（ED）的发生率以及有效保护尿道外括约肌,90％以上的患者能保留控尿功能。     

前列腺癌根治术中生理功能的保护

目的　保护前列腺癌根治术后患者的排尿和阴茎勃起功能 ,提高术后病人的生活质量。方法　选择 1 4例早期前列腺癌患者 (T1 )。在前列腺癌根治术中 ,采用解剖式手术方法 ,通过保护尿道外括约肌、膀胱颈成形保护患者的排尿功能。对 4例患者保留支配阴茎勃起的神经血管束 ,以保护勃起功能。结果　术后随访 6～ 2 6个月 (平均 1 2 .7个月 ) ,1 4例患者排尿功能恢复良好。 4例保留血管神经束患者 ,3例恢复性功能。结论　保护尿道外括约肌、膀胱颈成形术可有效地保护排尿功能。保留血管神经束可有效地保留性功能 ,提高生活质量。     

耻骨后前列腺癌根治术中切缘阳性的相关因素分析

目的探讨相关临床参数对前列腺癌根治术切缘阳性率的影响。方法研究对象为128例经病理证实并实施前列腺癌根治术的前列腺癌患者,通过回顾性研究了解病理分期、术前血清前列腺特异性抗原（PSA）、穿刺后Gleason评分、穿刺针数阳性百分率对手术切缘阳性的影响。结果128例前列腺癌患者术后切缘阳性率为17.19％（22／128）。病理分期与手术切缘阳性战正相关（r=0．352,P=0．001）,且对手术切缘阳性有统计学意义（χ^2=18．732,P=0．001）。对于手术切缘阳性率,术前血清PSA〈10ng／mL组与血清PSA≥10ng／mL组比较,差异有统计学意义（χ^2=7．130,P=0．008）;穿刺后Gleason评分〈7分组与Gleason评分≥7分组差异无统计学意义（χ^2=0．456,P=0．500）;对比穿刺针数阳性百分率,≤33．3％组与〉33．3％组差异有统计学意义（χ^2=5．113,P=0.024）。结论穿刺后Gleason评分对前列腺癌根治术中切缘阳性无影响,而病理分期、血清PSA、穿刺阳性百分率对手术切缘阳性有意义,同时手术者经验和手术技能对手术切缘阳性有一定影响。     

保留性神经的前列腺癌根治术

近年来，我们采用保留性功能的根治性前列腺切除术治疗5例前列腺癌，均治愈。现报道如下。临床资料：本组年龄55～62岁，术前均经CT及前列腺穿刺活检诊为前列腺癌。均施行保留性神经的前列腺癌根治术，其中3例保留双侧血管神经束，2例因肿瘤侵犯一侧血管神经束而仅保留单侧，术后均治愈。术后病理诊断为腺癌4例，移行细胞癌1例。B_1期1例，B_2期4例。手术方法：手术切口同经耻骨后前列腺切除术。先于盆内筋膜表面向下分离到筋膜向内返折处，在此处切开；再钝性分离扩大切口，分别切断左右侧耻骨前列腺韧带，使前列腺侧表面充分暴露。然后…     

Esophageal diverticulum: New perspectives in the era of minimally invasive endoscopic treatment

Esophageal diverticula are rare conditions that cause esophageal symptoms, such as dysphagia, regurgitation, and chest pain. They are classified according to their location and characteristic pathophysiology into three types: epiphrenic diverticulum, Zenker's diverticulum, and Rokitansky diverticulum. The former two disorders take the form of protrusions, and symptomatic cases require interventional treatment. However, the esophageal anatomy presents distinct challenges to surgical resection of the diverticulum, particularly when it is located closer to the oral orifice. Since the condition itself is not malignant,minimally invasive endoscopic approaches have been developed with a focus on alleviation of symptoms. Several types of endoscopic devices and techniques are currently employed, including peroral endoscopic myotomy(POEM). However,the use of minimally invasive endoscopic approaches, like POEM, has allowed the development of new disorder called iatrogenic esophageal diverticula. In this paper, we review the pathophysiology of each type of diverticulum and the current state-of-the-art treatment based on our experience.     

Efficacy and safety of barbed suture in minimally invasive radical prostatectomy: A systematic review and meta-analysis

As one of the earliest surgeries applying knotless barbed suture, the minimally invasive radical prostatectomy (MIRP) was reported to have various effects on the patients and the surgeons. This study reviewed the available evidence about the efficacy and safety of barbed sutures in MIRP. We searched ClinicalTrials.gov, Cochrane Register of Clinical Studies, PubMed, and Embase to identify randomized controlled trials (RCTs) and cohort studies addressing the application of barbed sutures and conventional sutures in MIRP (until August 2016). Quality assessment was performed according to Cochrane recommendations. The data were analyzed using Review Manager (Version 5.3), and sensitivity analysis was performed by sequentially omitting each study. A total of 12 studies, including three RCTs (low to moderate risk of bias, 211 patients) and nine cohort studies (low to moderate risk of bias, 698 patients), fulfilled the study criteria. The pooling of trials did not show statistical difference. Pooling data of cohort studies showed that suture time [mean difference (MD) = ?8.52, 95% confidence interval (CI) = ?12.60 to ?4.43, p < 0.0001] and length of hospital stay (MD = ?0.96, 95% CI = ?1.80 to ?0.11, p = 0.03) were significantly shorter in the barbed group. Results of continence rate varied according to different studies. Subgroup analysis by type of MIRP suggested that patients who underwent barbed suture during robot-assisted surgeries had a shorter hospital stay (MD = ?1.13, 95% CI = ?1.82 to ?0.45, p = 0.001). During the laparoscopic surgery, patients in the barbed suture group had fewer postoperative complications [odds ratio = 0.29, 95% CI = 0.08–0.98, p = 0.05). However, more evidence is needed to validate this state-of-the-art technology.     

微创冠状动脉旁路移植术的新进展

近几年来,随着造影技术、血管吻合装置、稳定器、心肺转流等技术的进步,微创冠状动脉旁路移植术有了相当的发展.微创冠状动脉旁路移植术,包括微创直视冠状动脉旁路移植术(MIDCAB)、非体外循环心脏不停跳冠状动脉搭桥术(OPCAB)、完全内镜下机器人辅助下的冠状动脉旁路移植术(TECAB),以及"杂交"技术(Hvbrid,PTCA+MIDCAB)等.     

Early esophageal and gastric cancers: surgery in the era of minimally invasive treatment

Surgery represents today the standard treatment of oesophageal and gastric cancer. Associated morbidity remain however significant in term of incisional access and functional sequels after organ resection and extended lymphadenectomy. Retrospective reviews of surgical series have defined indications for which more conservative treatment appears to provide similar survival without the need for lymph node resection. Endoscopic resection is now accepted for the treatment of well-differentiated tumors restricted to the mucosa. The expansion of this technique to deeper lesions or to lesions developed on a background of metaplasia is associated with an increased morbidity and significant risk of recurrence as well as a lifelong, close endoscopic surveillance. The role of surgery as primary treatment or rescue therapy to extend the resection will rely on an accurate preoperative and pathological staging of the lesion. Laparoscopy can play a central role in the management of early oesophageal and gastric cancer as it can permit from localized to extensive resection associated to lymph node dissection with the advantage of minimal invasive surgery. Its association to function-preserving operations awaits the demonstrated efficacy of targeted lymph node dissection. Those new techniques should be restricted to centres with extensive expertise and need to be validated in long-term controlled studies.     

Relative advantages and disadvantages of radical perineal prostatectomy versus radical retropubic prostatectomy

In recent years prostate cancer has become the predominant malignancy in men. With the introduction of prostate specific antigen (PSA) the disease can be diagnosed at an early stage, at which surgical therapy can be curative. In the past century, the retropubic and the perineal routes were established as alternatives of surgical access to the gland for clinically localized prostate cancer. The selection of the operative route is mostly decided individually on the basis of surgical training and experience. The revived interest in perineal radical prostatectomy is explained by the fact that this technique has been associated with low morbidity. The differences of both surgical approaches of radical prostatectomy are elucidated and compared regarding tumor control and short and long term complication rates. Taking these results into consideration, specific advantages and disadvantages of radical perineal prostatectomy are emphasized.     

New approaches to the minimally invasive treatment of lung cancer

PURPOSE OF REVIEW: The momentum for minimally invasive thoracic surgery has been growing. Thousands of video-assisted thoracoscopic surgery lobectomies have been performed since the first video-assisted thoracoscopic surgery lobectomy was performed in 1992, but currently most lobectomies are still performed via a thoracotomy. Although most lobectomies could be performed with video-assisted thoracoscopic surgery, less than 5% are currently performed that way. Compared with a thoracotomy, video-assisted thoracoscopic surgery offers patients a shorter length of stay, less pain, and a quicker recovery, without compromising the adequacy of the operation. The purpose of this review is to identify the current uses for minimally invasive procedures in thoracic surgery and to present the current data regarding these procedures. RECENT FINDINGS: Complete anatomic resections and node dissections are routinely being performed at several centers internationally. The median length of stay after video-assisted thoracoscopic surgery lobectomy is 3 days, and 84.7% of patients had no complications. Studies comparing video-assisted thoracoscopic surgery and thoracotomy suggest that minimally invasive surgery causes less pain, has a smaller impact on postoperative pulmonary function, and provides a quicker return to regular activity, with at least comparable survival for cancer patients. SUMMARY: Current data suggest that, compared with a thoracotomy, video-assisted thoracoscopic surgery has advantages for anatomic pulmonary resections.