经耻骨后前列腺根治性切除术的改进

前列腺癌是欧美国家最常见的男性肿瘤,是危害男性健康的第一肿瘤杀手。在我国,前列腺癌的发病率亦逐年上升。前列腺根治性切除术作为早期局限性前列腺癌最重要的治疗方法,可有效降低癌症的死亡率[1]。其术式包括经耻骨后前列腺根治性切除术,经会阴前列腺根治性切除术,经腹腔镜前列腺根治性切除术和机器人前列腺根治性切除术。近年来,随着我国诊疗技术的提高,每年早期局限性前列腺癌的病例数不断增加,手术例数亦逐年递增。耻骨后途径的前列腺根治性切除术仍是我国最为常用的术式。本文结合文献就近年来耻骨后前列腺根治性切除术的改进作一简…     

根治性耻骨后前列腺切除术后腹股沟疝：风险因素分析

据报道根治性耻骨后前列腺切除术后腹股沟疝的发生率为7％～21％。作者分析同时行盆腔淋巴结清扫、术前合并腹股沟疝、术后吻合口狭窄、手术时间和患者年龄等因素对根治性前列腺切除术后发生腹股沟疝的影响,比较回顾性病例调查和前瞻性问卷调查腹股沟疝的发现率。     

西地那非治疗根治性前列腺切除术后勃起功能障碍的疗效

勃起功能障碍是根治性前列腺切除术后并发症，发生率高（10％-90％）。为了研究西地那非治疗根治性前列腺切除术后ED患者的疗效，Lima Pompeo AC等人调查了71例勃起功能正常的患者，平均年龄65岁（Revista Brasileira de Medic-ina，2005，62（5）：186-189）。他们因临床局灶性前列腺癌接受耻骨后根治性前列腺切除术，61例患者接受了保留一侧或双侧勃起神经末梢的手术。     

耻骨后根治性前列腺切除术10年体会

目的:总结近10年来100例耻骨后根治性前列腺切除术的经验和教训。方法:1999年7月至2009年7月笔者行耻骨后根治性前列腺切除术100例,对其中84例随访3~120个月,统计术前年龄、PSA,术中输血量、手术时间,术后尿控能力、阴茎勃起功能,吻合口狭窄情况和最大尿流率。结果:患者平均年龄、PSA、输血量及手术时间分别为66.8岁、20.1 ng/ml、585.7 ml和198.9 min。术后3、6、12个月尿控分别为65.5%、81.7%和92.4%,术后12个月有42.2%恢复阴茎勃起功能,吻合口狭窄5例,最大尿流率平均20.5 ml/s,生化复发13例,死于前列腺癌1例。结论:耻骨后根治性前列腺切除术治疗局限性前列腺癌效果好,采用先结扎耻骨前列腺韧带和前列腺静脉丛后再离断耻骨前列腺韧带的方法有利于提高尿控能力,要得到术后好的阴茎勃起效果,应注意保护神经血管束和副阴部动脉,良好的尿道粘膜和膀胱粘膜对合可减少吻合口狭窄,对T3a或伴局部淋巴结转移患者术后外放疗可减缓生化复发。     

耻骨后保留尿道前列腺切除术67例报告

报告采用经耻骨后保留尿道前列腺切除术治疗前列腺增生６７便，术后随访３￣１８个月，疗效满意，认为本手术具有不损伤尿道，术后恢复快，并发症少，保留顺行射精，简单易行等优点，适用于除外前列腺纤维化，前列腺肿瘤的前列腺增生患者。     

125例耻骨后根治性前列腺切除术并发症分析

<正>根治性前列腺切除术是目前局限性前列腺癌(PCa)有效的标准治疗方法[1-3],但有一定的手术并发症,围手术期死亡率为0～2.1%[2]。本文总结1999年7月至2010年10月近11年125例耻骨后根治性前列腺切除术(radical retropublic prostatectomy,RRP)的并发症。     

西地那非治疗保留神经耻骨后前列腺根治性切除术后ED

耻骨后前列腺根治术对患者性功能会产生不同程度的影响,可引起勃起功能障碍(ED)。治疗ED的一线口服药西地那非对此类人群是否有效呢?Shimizu T等人回顾性评价了保留神经耻骨后前列腺根治性切除术(RRP)后的勃起功能,以及西地那非治疗RRP后ED的疗效。1996年1月到2001年12月,研究者利用专为本研究设计的问卷,对48例接受保留神经耻骨后前列腺     

前列腺、精囊

耻骨后解剖性根治性前列腺切除术的技术改进;同期手术治疗良性前列腺增生并膀胱结石27例报告;良性前列腺增生症与阴茎勃起功能障碍的相关性研究;伽玛刀治疗高危前列腺增生症的临床应用;经尿道前列腺电切术患者转开放手术的危险因素分析     

根治性前列腺切除术的进展

前列腺癌是欧美国家常见的男性肿瘤。前列腺癌发病率在我国各地呈逐年上升趋势。手术是前列腺癌治疗的重要手段 ,本文对近年来耻骨后、经会阴根治性前列腺切除术、标准腹腔镜和机器人腹腔镜根治性前列腺切除术研究等进展作一概述 ,包括根治术的必要性、手术方法与经验、神经保留技术和勃起功能障碍问题、并发症、手术效果、各种手术途径的优缺点及手术效果之间的比较     

三孔六步法经腹膜外途径腹腔镜下根治性前列腺切除术(附光盘)

前列腺癌是男性泌尿系统最常见的恶性肿瘤之一。根治性前列腺切除术是治愈局限性前列腺癌最有效的方法之一。根治性前列腺切除的手术入路包括经会阴、经耻骨后、腹腔镜和机器人辅助的腹腔镜手术。随着外科技术的进步,腹腔镜和机器人辅助的腹腔镜根治性前列腺切除已经很大程度上取代了传统的开放性手术。我们在传统腹腔镜下根治性前列腺切除术的基础上,结合自身的手术经验与心得,对手术过程进行简化和调整,将其归纳为三孔六步法,本文将简要回顾前列腺癌的外科治疗并对三孔六步法的手术步骤及技术要点进行具体介绍。     

Identification and conservative management of a distal ureteral injury occurring during robotic-assisted laparoscopic radical prostatectomy

Iatrogenic ureteric injury following open radical prostatectomy and laparoscopic radical prostatectomy is a rare but known complication. We report a unique case of ureteric injury diagnosed postoperatively following robot-assisted laparoscopic radical prostatectomy (R-LRP). Conservative management of the injury using percutaneous drainage and anterograde ureteral stenting allowed for complete resolution of the ureteral injury.     

A low incidence of positive surgical margins in prostate cancer at high risk of extracapsular extension after a modified anterograde radical prostatectomy

OBJECTIVES: To evaluate the incidence of positive surgical margins (and associated risk factors) in patients with localized prostate cancer at high preoperative risk of extracapsular disease treated using a modified anterograde radical retropubic prostatectomy technique. Positive surgical margins are an important risk factor for disease recurrence after radical prostatectomy, particularly in patients with extracapsular disease. PATIENTS AND METHODS: In total, 84 patients with clinically localized prostate cancer and a preoperative prostate-specific antigen (PSA) level > 10 ng/mL and/or a biopsy Gleason score > or = 7 were evaluated. The surgical technique allows easy, wide resection of the posterolateral prostatic pedicles, and good mobilization and exposure of the apex before the urethra transection. Prostatectomy specimens were examined for extracapsular tumour spread and positive surgical margins. Differences in putative risk factors (Gleason score, preoperative PSA level, prostate weight) between the positive- and negative-margin groups were evaluated using the Mann-Whitney test. RESULTS: Overall, 11 of the 84 (13%) patients had positive surgical margins and of these a single site was involved in six. In total, 15 positive-margin sites were identified (five apical, four basal, three posterolateral, two anterior and one posterior). All patients with positive margins had histological extracapsular disease. The preoperative PSA level and Gleason score were significantly higher in the positive- than in the negative-margin group (P = 0.025 and 0.035, respectively). CONCLUSIONS: The anterograde radical prostatectomy minimizes the incidence of positive surgical margins in patients at high risk of extracapsular disease.     

Laparoscopic radical prostatectomy: the Montsouris technique

PURPOSE: Laparoscopic radical prostatectomy has become standard at our institution based on experience with 260 consecutive cases operated on between January 1998 and December 1999. In view of the favorable short-term outcomes we describe our standardized laparoscopic radical prostatectomy technique. MATERIALS AND METHODS: Two urologists trained in open retropubic radical prostatectomy and laparoscopy combined their experience to develop a specific technique of nonincisional radical prostatectomy for localized prostate cancer. Patients presented with clinical stages T1b to T2 prostate cancer and tumor size was approximately 18 to 130 gm. Operations were performed by 1 senior surgeon and 1 assistant, with the help of a voice controlled robot and with the patient under general anesthesia. The 2, 10 mm. ports and 3, 5 mm. ports were placed in the umbilicus and iliac fossa. The laparoscopic procedure was performed transperitoneally, combining anterograde and retrograde approaches in 7 standardized steps. Urethrovesical anastomosis was performed with 3-zero interrupted sutures tied intracorporeally. Technical details were compiled, summarized and illustrated with schematic views. RESULTS: Operating time was approximately 3 hours for the last 120 cases. Estimated average blood loss was 250 ml. with a transfusion rate of less than 1%. The conversion rate was 0%. Postoperative pain was minimal and analgesics were generally not required by postoperative day 2. The accuracy of dissection and sutures allowed patients to be discharged home without urethral catheterization starting on postoperative day 3. CONCLUSIONS: Laparoscopic radical prostatectomy is now not only feasible, but more importantly reproducible. Each step has been checked and validated, and the procedure is standardized and has definitively replaced the retropubic approach in our practice.     

Open versus laparoscopic radical prostatectomy: a prospective comparison of postoperative urinary incontinence rates

PURPOSE: We compared the 12-month postoperative urinary incontinence rates of open radical retropubic and laparoscopic radical prostatectomy. MATERIALS AND METHODS: This prospective study included all men with clinically localized prostate cancer scheduled for radical prostatectomy (open retropubic or laparoscopic) at the University of Alberta between October 1999 and July 2002. Preoperative evaluation included a 24-hour pad test, fluid volume voiding diary and International Prostate Symptom Score questionnaire. Postoperative evaluation included a 24-hour pad test at 3 and 12 months, as well as a voiding diary and International Prostate Symptom Score questionnaire at 3, 6, 9 and 12 months. RESULTS: A total of 239 patients met the eligibility criteria and consented to participate (172 open radical retropubic prostatectomy, 67 laparoscopic radical prostatectomy). Of the patients 87% (148) treated with open radical retropubic prostatectomy and 88% (57) of those treated with laparoscopic radical prostatectomy completed 12-month followup (p = 0.50). According to 24-hour pad testing 13% of those treated with open radical retropubic prostatectomy and 17% of those treated with laparoscopic radical prostatectomy remained incontinent at 1 year (p = 0.26). There was no difference in 24-hour pad weight, urinary symptom score and urinary quality of life at 1 year between the open and laparoscopic groups overall, or when stratified according to 12-month continence status. The majority of subjects in both groups described mild symptoms and a general satisfaction with urinary quality of life. CONCLUSIONS: Based on objective and subjective measures, there were no differences in urinary functional outcomes 1 year after open radical retropubic prostatectomy or laparoscopic radical prostatectomy. Urinary incontinence was found to affect a similar proportion of patients who underwent open (13%) and laparoscopic (17%) radical prostatectomy 12 months postoperatively.     

Laparoscopic radical prostatectomy: review and assessment of an emerging technique

Background Several recent reports have affirmed the feasibility of the laparoscopic approach for radical prostatectomy. In this review, we discuss the morbidities associated with this technique and compare outcomes and convalescence with standard open radical prostatectomy.Methods We reviewed all currently published data on laparoscopic radical prostatectomy and our series of 45 robotic-assisted radical prostatectomies and compared them to several landmark series of open retropubic and perineal radical prostatectomies.Results Although the initial series reported long operating times, these times have been significantly reduced in more recent series. Data on blood loss, convalescence, impotence, and incontinence rates have also been promising.Conclusions Although follow-up has been short thus far, laparoscopic radical prostatectomy has been shown to be similar to open radical prostatectomy in several areas.     

Laparoscopic radical prostatectomy for localized prostate cancer: a systematic review of comparative studies

PURPOSE: We compared the safety and efficacy of laparoscopic and open radical prostatectomy through a systematic assessment of the literature. MATERIALS AND METHODS: Literature databases were searched from 1996 to December 2004 inclusive. Studies comparing transperitoneal laparoscopic radical prostatectomy, extraperitoneal endoscopic radical prostatectomy or robot assisted radical prostatectomy with open radical retropubic prostatectomy or radical perineal prostatectomy for localized prostate cancer were included. Comparisons between different laparoscopic approaches were also included. RESULTS: We identified 30 comparative studies, of which none were randomized controlled trials. There were 21 studies comparing laparoscopic with open prostatectomy with a total of 2,301 and 1,757 patients, respectively, and 9 comparing different laparoscopic approaches with a total of 1,148 patients. In terms of safety there did not appear to be any important differences in the complication rate between laparoscopic and open approaches. However, blood loss and transfusions were lower for laparoscopic approaches. In terms of efficacy operative time was longer for laparoscopic than for open prostatectomy but length of stay and duration of catheterization were shorter. Positive margin rates and recurrence-free survival were similar. Continence and potency were not well reported but they appeared similar for the 2 approaches. There were no important differences between laparoscopic approaches. CONCLUSIONS: Laparoscopic radical prostatectomy is emerging as an alternative to open radical prostatectomy but randomized, controlled trials considering patient relevant outcomes, such as survival, continence and potency, with sufficient followup are required to determine relative safety and efficacy.     

The lymph node positive prostate cancer. A case for radical prostatectomy

Lymph node positive carcinoma of the prostate (stage pN +/D1) is generally considered to be systemic disease that cannot be cured by radical prostatectomy. Treatment options in these minimally metastasized tumors are the wait and watch strategy, hormonal therapy, radiotherapy and radical prostatectomy alone or in combination. At present, there are no prospective randomized trials available regarding the value of these treatment modalities. In retrospective studies, the results of radical prostatectomy seem to be superior to conservative management. In several studies comparing radical prostatectomy vs. pelvic lymphadenectomy alone, a higher tumor burden in the lymphadenectomy alone groups is present. In general, radical prostatectomy reduces local complications of prostate carcinoma and improves quality of life. In conclusion, patients with single or low volume lymph node metastases as well as patients with low tumor grade or favorable Gleason score and diploid tumors seem to benefit from radical prostatectomy. However, the definitive role for radical prostatectomy has to be stated as uncertain.     

腹腔镜与开腹手术治疗局限性前列腺癌的比较研究

目的:比较腹腔镜与开腹手术治疗局限性前列腺癌的临床效果。方法:回顾分析经腹膜外途径腹腔镜前列腺癌根治术19例和耻骨后前列腺癌根治术14例的临床资料,比较两种术式的手术时间、术中出血量、术后胃肠功能恢复时间、术后住院天数、围手术期并发症等指标。结果:两组在手术时间和盆腔引流管保留时间差异无统计学意义(P>0.05)。腹腔镜组比开放组术中出血少、胃肠功能恢复快、术后住院时间短且并发症发生率低(P<0.05)。结论:与耻骨后前列腺癌根治术相比,腹膜外途径腹腔镜前列腺癌根治术具有患者创伤小、术后康复快、并发症发生率低等优点,值得临床推广应用。     

Radical prostatectomy: geographic and demographic variation

OBJECTIVES: Previous reports have documented a geographic variation in the use of radical prostatectomy. We examined whether this phenomenon can be explained by factors other than geography alone. METHODS: This study was based on the data from nine geographic regions of the Surveillance, Epidemiology, and End Results (SEER) program for the years 1983 through 1994. Patients with localized or regional prostate cancer were included in the analysis. Logistic regression analysis was used to investigate the influence of geographic and demographic factors on the use of radical prostatectomy. The squared multiple correlation coefficient R(2) was used to measure the proportion of variation in the selection of radical prostatectomy explained by each factor of interest. RESULTS: As previously reported, the use of radical prostatectomy was significantly associated with geographic location; the degree of geographic variation varied as a function of age and was most dramatic in the youngest (younger than 45 years) and the oldest (75 years or older) groups. Overall, however, geography explained less than 2% of the total variation in the use of radical prostatectomy. Age was the most important factor that influenced the use of radical prostatectomy. CONCLUSIONS: Geography explains only a small proportion of the variation in the use of radical prostatectomy. In fact, of the factors examined, only age appeared to meaningfully explain the variation in the use of radical prostatectomy. Overall, our ability to explain the variation in the use of radical prostatectomy remains meager, and new factors must be identified if we are to better understand how patients and physicians make clinical decisions.     

Seminal vesicle-sparing radical prostatectomy: a novel concept to restore early urinary continence

OBJECTIVES: Urinary incontinence after radical prostatectomy continues to be a distressing problem, even with preservation of the neurovascular bundles and meticulous apical dissection. Recent studies suggest that motor and sensory components of the pelvic nerve may be affected by surgery, since both components are anatomically located in intimate contact with the seminal vesicles. We propose seminal vesicle-sparing radical prostatectomy to preserve pelvic innervation and improve the rate of urinary continence. METHODS: Fifty-four patients were enrolled in this prospective study. A standard retropubic radical prostatectomy was performed in 34 patients. A seminal vesicle-sparing radical prostatectomy was performed in a pilot series of 20 consecutive patients. The seminal vesicle tip and surrounding tissue were preserved and carefully handled. In all patients, a modified pad test and posterior urethral sensory threshold test were performed preoperatively and 6 weeks and 6 months postoperatively and correlated with urinary continence. RESULTS: The intraoperative preservation of the seminal vesicle tip was possible in all patients in this pilot series (n = 20). In the seminal vesicle-sparing radical prostatectomy group, the continence rate was 60% after 6 weeks and 95% after 6 months. These rates were significantly higher than the continence rates in the standard prostatectomy group (18% and 82% at 6 weeks and 6 months, respectively). The sensory threshold levels in the seminal vesicle-sparing group were similar to the preoperative values and were significantly lower than the postoperative threshold levels in the standard prostatectomy group. CONCLUSIONS: Seminal vesicle tip-sparing radical prostatectomy may be a surgical option to preserve pelvic innervation and maintain urinary continence after radical prostatectomy. Further randomized studies are necessary to elucidate the impact of seminal vesicle-sparing radical prostatectomy on restoration of urinary continence.