腹腔镜辅助直肠癌根治术对盆腔自主神经保护的操作要点

目的 探讨腹腔镜辅助保留盆腔自主神经直肠癌根治术的临床疗效.方法 2011年3月至2013年3月经病理确诊的149例病人进行保留自主神经的直肠癌根治术,其中腹腔镜组84例,开腹组65例.术后1年内通过门诊和问卷方式观察两组病人术后排尿功能与性功能状况.结果 术后排尿功能障碍发生率,腹腔镜组和开腹组分别为18.57％、21.82％,两组比较差异无统计学意义（P＞0.05）.术后勃起功能障碍发生率,腹腔镜组和开腹组分别为47.14％、43.64％,射精功能障碍发生率分别为34.29％ 、32.13％,两组比较差异无统计学意义（P＞0.05）.结论 腹腔镜辅助保留盆腔自主神经的直肠癌根治术是安全、有效的.     

腹腔镜直肠癌根治术保留盆腔植物神经效果分析

目的：探讨在腹腔镜直肠癌根治手术中保留盆腔植物神经（PANP）对男性局部复发率、生存率和术后生活质量的影响。方法：不同时期的2组腹腔镜直肠癌根治手术病人,其中非保留盆腔植物神经组34例,保留组88例,回顾性分析比较2组患者的局部复发率、5年存活率及术后排尿功能和性功能。结果：两组均顺利完成手术。其中保留植物神经组82例获得随访,未保留组28例获得随访。局部复发率保留植物神经组为73％（6／82）,未保留组为7．1％（18／28）;5年存活率保留植物神经组为8412％（69／82）,未保留组为82．1％（23／28）,2组差异无统计学意义（P〉O．05）。排尿功能障碍保留植物神经组为28．1％（23／82）,未保留组为60．7％（17,28）;勃起功能障碍保留植物神经组为24．4％（20,82）,未保留组为67．9％（19／28）;射精功能障碍保留植物神经组24．4％（20／82）,未保留组71,4％,（20／28）,两组比差异均有统计学意义（PcO．05）。结论：腹腔镜直肠癌根治术中保留植物神经功能,对局部复发率和5年存活率无明显影响,但可明显提高患者的生存质量。     

Residual urine volume after total mesorectal excision: an indicator of pelvic autonomic nerve preservation? Results of a case‐control study

OBJECTIVE: The rate of bladder dysfunctions after total mesorectal excision (TME) for rectal cancer can be decreased by bilateral pelvic autonomic nerve preservation (PANP). However, it is not clear yet, how often partial nerve impairment may lead to bladder dysfunction. It was the aim of a case-control study, to examine the residual urine volume in patients before and after TME with and without complete PANP, in order to clarify, whether this parameter allows conclusions on the quality of PANP. PATIENTS AND METHODS: Regarding bladder function, a case group (n = 26) without complete PANP was compared with a control group (n = 26) with complete identification and nerve preservation according to standadized intra-operative documentation. Twenty-six match pairs were established, identical regarding gender, wall infiltration depth, tumour site, operation procedure and operation extent. Rates of neoadjuvant therapy, R0-classification, anastomotic leakage, wound and urinary tract infection were equally distributed for both the case- and control group (P > 0.05). Residual urine volume was pre- and post-operatively determined by sonography. RESULTS: Pre-operatively, residual urine volumes differed neither between the pairs nor between both groups with and without nerve preservation. In the case group with incomplete PANP there was a difference between pre- and post-operative residual urine volume (median; quartil: 2.5 ml; 0.0-32.5 ml vs 130 ml; 0.0-317 ml; P = 0.001). In the control group there was no difference (median; quartile: 0.0 ml; 0.0-20 ml vs 15.5 ml; 0.0-62.0 ml; P = 0.07). The difference between the postoperatively measured volumes of the case and control group were significant (P = 0.001). With residual urine volume = 100 ml, the risk of incomplete PANP was 14 times higher (odds ratio). CONCLUSIONS: Residual urine volume is an indicator of the completeness of PANP during TME. It should be determined pre- and post-operatively, and besides the recording of the neurogenic bladder, serve as a quality control.     

直肠切除术中保留盆腔内脏神经的解剖学基础及要点

目的了解盆腔内脏神经的走行及与盆腔筋膜的关系,寻找安全的操作平面,减少直肠癌手术中对内脏神经的损伤。方法通过解剖12例人骨盆标本,观察盆腔内脏神经的走向分布及与筋膜间隙的关系。结果腹下神经全程走行于骶前筋膜内,下腹下丛走行于盆壁层筋膜内,并于直肠2点及10点处（截石位）在多个平面交叉穿入Denonvilliers筋膜汇入泌尿生殖血管束,Denonvilliers筋膜内存在横行的神经交通支。结论直肠后方及侧方的手术操作平面在直肠固有筋膜与骶前筋膜之间靠近直肠固有筋膜一侧,在直肠前方的手术操作应注意保护直肠2点及10点位置的泌尿生殖神经血管束及Denonvillers筋膜内的神经交通支。     

腹腔镜与开腹直肠癌根治术保留盆腔自主神经对男性排尿及性功能影响的对比研究

目的:探讨腹腔镜直肠癌根治术保留盆腔自主神经对男性患者术后排尿及性功能的影响.方法:回顾分析2007～2010年为96例男性直肠癌患者施行腹腔镜手术的临床资料,总结其对患者术后排尿及性功能的影响,并与114例开腹手术对比.结果:腹腔镜组术后排尿功能障碍率10.42%,勃起功能障碍率13.54%,射精功能障碍率19.79...     

Online signal processing of internal anal sphincter activity during pelvic autonomic nerve stimulation: a new method to improve the reliability of intra‐operative neuromonitoring signals

Aim Intra‐operative neuromonitoring is increasingly applied in several surgical disciplines and has been introduced to facilitate pelvic autonomic nerve preservation. Nevertheless, it has been considered a questionable tool for the minimization of risk, as the results are variable and might be misleading. The aim of the present experimental study was to develop an intra‐operative neuromonitoring system with improved reliability for monitoring pelvic autonomic nerve function. Method Fifteen pigs underwent low anterior rectal resection with pelvic autonomic nerve preservation. Intra‐operative neuromonitoring was performed under autonomic nerve stimulation with observation of electromyographic signals of the internal anal sphincter and bladder manometry. As the internal anal sphincter frequency spectrum during stimulation was found to be mainly in the range of 5–20 Hz, intra‐operative neuromonitoring signals were postoperatively processed by implementation of matching band pass filters. Results In 10 preliminary experiments, signal processing was performed offline in the postoperative analysis. Of 163 stimulations intra‐operatively assessed by the surgeon as positive responses, 135 (83%) were confirmed after signal processing. In the following five consecutive experiments intra‐operative online signal processing was realized and demonstrated reliable intra‐operative neuromonitoring signals of internal anal sphincter activity with significant increase during pelvic autonomic nerve stimulation [0.5 μV (interquartile range = 0.3–0.7) vs 4.8 μV (interquartile range = 2.5–7.5) ;P < 0.001]. Conclusion Online signal processing of internal anal sphincter activity aids reliable identification of pelvic autonomic nerves with potential for improvement of intra‐operative neuromonitoring in pelvic surgery.     

腹腔镜下直肠癌D3根治术中保留盆腔自主神经的临床研究

目的 ：探讨腹腔镜保留自主神经的直肠癌D3根治术的手术安全性和可行性。方法 ：选择2009年1月—2009年12月在我院手术治疗的Dukes B期和Dukes C期的中低位直肠癌34例,将患者分为开腹组和腹腔镜组,分别进行保留自主神经的开腹直肠癌D3根治术和腹腔镜直肠癌D3根治术。结果：腹腔镜组平均手术时间为286 min,稍长于开腹组,而平均总出血量为155 mL,略少于开腹组;腹腔镜组与开腹组平均检出淋巴结分别为22.2枚和24.125枚,无统计学差异;两组术后排尿及性功能障碍发生率无显著差异。结论：腹腔镜保留自主神经的直肠癌D3根治术能够达到开腹手术的效果,安全可行。     

保留盆腔自主神经在男性腹腔镜直肠癌根治术中的临床效果

目的:探讨腹腔镜直肠癌根治术中应用全直肠系膜切除术(total mesorectal excision,TME)及保留盆腔自主神经(pelvic autonomic nerve preservation,PANP)对特定分期直肠癌的可行性、治疗效果及对盆腔自主神经所支配的(男性)患者术后排尿、勃起、射精功能的影响。方法:选择2012年1月至2015年12月手术治疗的117例直肠癌男性患者,分为腹腔镜TME+PANP组(腹腔镜组)与开腹TME+PANP组(开腹组),对比分析术中、术后各项临床指标及术后1年内排尿、性功能各项指标。结果:腹腔镜组术后3个月储尿、排尿、勃起、射精功能均优于开腹组;而远期(术后1年)疗效两组差异无统计学意义。结论:对于T_3N_2M_0期及以下的直肠癌患者,保留盆腔自主神经的腹腔镜直肠癌根治术安全、可行,最大限度地维持了男性患者的排尿功能及性功能。     

保留自主神经的直肠癌根治术对排尿功能的影响

目的：讨论保留自主神经的直肠癌根治术对排尿功能的影响。方法：回顾性分析全直肠系膜切除术结合盆腔自主神经保护（TME＋PANP组）和全直肠系膜切除术（TME组）术前7 d、术后14 d尿流动力学变化,评估对排尿功能的影响,其主要指标有：最大尿流率、最大尿流率时排尿压、膀胱容积、残余尿量。结果：TME＋PANP组：最大尿流率：术前（19.7±6.6）mL/s,术后（14.2±6.0）mL/s,差异有统计学意义（P〈0.05）;最大尿流率时的排尿压：术前（35.3±20.3）cm H2O,术后（33.1±18.6）cm H2O,差异无统计学意义（P〉0.05）;膀胱剩余容积：术前（358±35）mL,术后（342±39）mL,差异无统计学意义（P〉0.05）;残余尿量：术前（9.4±5.7）mL,术后（11.1±8.4）mL,差异无统计学意义（P〉0.05）。TME组：最大尿流率：术前（17.8±6.2）mL/s,术后（12.5±5.4）mL/s,差异有统计学意义（P〈0.05）;最大尿流率时的排尿压：术前（32.8±18.2）cm H2O,术后（25.4±17.5）cm H2O,差异有统计学意义（P〈0.05）;膀胱剩余容积：术前（354±38）mL,术后（297±40）mL,差异有统计学意义（P〈0.05）;平均残余尿量：术前（9.8±6.1）mL,术后（10.2±7.9）mL,差异无统计学意义（P〉0.05）。TME＋PANP组与TME组术后比较：术后最大尿流率、最大尿流率时排尿压、膀胱剩余容积,TME＋PANP组均大于TME组,且差异有统计学意义（P〈0.05）。结论：保留盆腔自主神经的直肠癌根治术可以较好地改善排尿功能。     

腹腔镜直肠癌根治术中保护盆腔植物神经的体会

目的:探讨腹腔镜直肠癌根治术中显露及保护盆腔植物神经对患者术后性功能和排尿功能的影响。方法:回顾分析2005年5月至2008年3月我院为11例男性直肠癌患者施行腹腔镜全直肠系膜切除术(total mesorectal excision,TME)的基础上保留盆腔植物神经(pelvic autonomic nervepreservation,PANP),降低术后排尿及性功能障碍发生率的临床资料。结果:患者术后勃起功能障碍发生率9.09%,射精功能障碍发生率18.18%,近期排尿障碍发生率9.09%。结论:腹腔镜TME基础上行PANP与传统开腹TME基础上行PANP相比,术中能更清晰地显露盆腔植物神经并予以保护,减少了术后排尿和性功能障碍的发生。     

实时神经监测在腹腔镜直肠癌全直肠系膜切除术中盆腔自主神经丛保护的应用

目的 探讨实时神经监测在腹腔镜直肠癌全直肠系膜切除术中盆腔自主神经丛保护的应用。方法 选取2017年1月至2020年12月非急诊收治的直肠癌患者,共11例。所有患者均进行腹腔镜直肠癌全直肠系膜切除术,术中使用实时神经监测进行盆腔自主神经丛保护,术后评估排尿、肛管直肠功能,并分析两者相关性。结果 所有患者均成功进行术中实时神经监测,神经监测电生理结果均为阳性,术后第6月进行功能评估,均未发生排尿、肛管直肠功能不全,两者相关性良好（r=1.0）。结论 实时神经监测在腹腔镜直肠癌全直肠系膜切除术中盆腔自主神经丛保护的应用安全、有效,结果阳性提示术后排尿、肛管直肠功能完好。     

保留盆腔植物神经对老年男性患者术后性功能及排尿功能的影响

目的:探讨保留盆腔植物神经的直肠癌手术对老年男性患者性功能及排尿功能的影响。方法:1999~2005年因直肠癌手术的170例老年男性患者分为PANP组(含规范的TME手术方法)和非PANP(TME规范情况不详),对两组术后性功能、排尿功能和局部复发率进行回顾性总结、比较。结果:PANP组性功能与排尿功能明显优于非PANP组,但统计学无显著差异(P<0.05)。而PANP组局部复发率低于非PANP组(P>0.05)。结论:老年直肠癌患者应重视性功能和排尿功能的保护。     

男性直肠癌直肠系膜切除术中保留盆腔自主神经对排尿及性功能影响的研究

目的 探讨男性直肠癌直肠系膜切除术(TME)保留盆腔自主神经(PANP)对排尿功能及性功能的影响.方法 男性直肠癌患者240例,分为PANP组120例,行TME术并保留盆腔自主神经;对照组120例,不保留盆腔自主神经.统计学比较2组患者术后排尿功能及性功能、3年生存率和局部复发率. 结果PANP组术后排尿功能障碍发生率为30.8%、术后勃起功能障碍发生率为28.3%、术后射精功能障碍发生率为34.2%,对照组分别为55.0%、60.0%、62.5%,2组比较差异均有统计学意义(P<0.05);PANP组术后3年局部复发率和生存率分别为9.4%、75.0%,对照组为9.0%、65.0%,2组比较差异无统计学意义(P>0.05).结论 男性直肠癌TME术中PANP可以明显改善患者的排尿功能和性功能,提高患者的术后生活质量,且不影响治疗效果.     

直肠癌根治术保留自主神经56例临床体会

目的探讨直肠癌根治术保留自主神经对男性患者排尿及性功能、女性患者排尿功能的影响。方法对56例接受保留自主神经的直肠癌根治术的直肠癌患者临床资料进行回顾性分析。结果术后男性患者排尿及性功能、女性患者排尿功能均恢复较好;局部复发率无明显增高。结论保留自主神经的直肠癌根治术,可较好地保存排尿及性功能,肿瘤局部复发率无增加。     

腹腔镜全直肠系膜切除术中保留盆腔自主神经对术后男性患者性功能的影响

目的:对比腹腔镜及开腹全直肠系膜切除术中保留盆腔自主神经对男性患者术后性功能的影响。方法:回顾分析2011年6月至2015年6月92例直肠癌根治术(均行Dixon术)患者的临床资料,其中45例行腹腔镜下保留盆腔自主神经的全直肠系膜切除术(腹腔镜组),47例开腹行保留盆腔自主神经的全直肠系膜切除术(开腹组),对比两组患者术后勃起功能障碍、射精功能障碍发生率及术后1年盆腔局部复发情况。结果:术后1、3、6个月,开腹组勃起功能障碍、射精功能障碍发生率明显高于腹腔镜组,差异有统计学意义(P0.05);术后12个月后,两组差异无统计学意义(P0.05)。1年后两组患者盆腔局部复发率差异无统计学意义(P0.05)。结论:腹腔镜全直肠系膜切除术中保留盆腔自主神经在达到与开腹手术相同的根治效果的基础上,术后早期(6个月内)患者性功能恢复效果更好,且于术后12个月达到与开腹手术相同的保护患者性功能的效果,明显改善了男性患者的术后生活质量,具有较高的临床应用价值。     

腹腔镜D3淋巴结清扫联合保留盆腔自主神经的直肠癌根治术对男性患者排尿功能的影响

Objective To investigate the influence of laparoscopic D3 lymphadenectomy combined with pelvic autonomic nerve preservation on the urinary function of male patients with rectal cancer. Methods From August 2006 to August 2007, 119 male patients with rectal cancer who had been admitted to Southwest Hospital were assigned to open surgery group (n=59) and laparoscopic group (n=60) according to the random number table. Three months after the operation, the urinary function of patients was assessed by urodynamics investigation and international prostate symptom score (IPSS). Differences in measurement data were compared with paired t test. Results There was no significant difference in IPSS between laparoscopic group (10.9±2.9) and open surgery group (11.5±3.1) (t=-1. 309, P>0.05). The maximum flow rate, voided volume, residual urine volume, detrusor contraction pressure and maximum urethral pressure were 15.2 ml/s, 150.1 ml, 6.1 ml, 43.3 cm H2O (1 cm H2O=0.098 kPa) and 77.5 cm H2O in laparoscopic group, and 15.0 ml/s, 140.9 ml, 6.4 ml, 45.6 cm H2O and 72.3 cm H2O in open surgery group, with no statistical difference between the 2 groups (t=1.22, -2.12, -1.73, -1.35, -1.64, P>0.05). Conclusions Laparosceopic D3 lymphadenectomy combined with pelvic autonomic nerve preservation is relatively safe in preserving urinary function, and its efficacy is comparable to that of open surgery.     

腹腔镜D3淋巴结清扫联合保留盆腔自主神经的直肠癌根治术对男性患者排尿功能的影响

Objective To investigate the influence of laparoscopic D3 lymphadenectomy combined with pelvic autonomic nerve preservation on the urinary function of male patients with rectal cancer. Methods From August 2006 to August 2007, 119 male patients with rectal cancer who had been admitted to Southwest Hospital were assigned to open surgery group (n=59) and laparoscopic group (n=60) according to the random number table. Three months after the operation, the urinary function of patients was assessed by urodynamics investigation and international prostate symptom score (IPSS). Differences in measurement data were compared with paired t test. Results There was no significant difference in IPSS between laparoscopic group (10.9±2.9) and open surgery group (11.5±3.1) (t=-1. 309, P>0.05). The maximum flow rate, voided volume, residual urine volume, detrusor contraction pressure and maximum urethral pressure were 15.2 ml/s, 150.1 ml, 6.1 ml, 43.3 cm H2O (1 cm H2O=0.098 kPa) and 77.5 cm H2O in laparoscopic group, and 15.0 ml/s, 140.9 ml, 6.4 ml, 45.6 cm H2O and 72.3 cm H2O in open surgery group, with no statistical difference between the 2 groups (t=1.22, -2.12, -1.73, -1.35, -1.64, P>0.05). Conclusions Laparosceopic D3 lymphadenectomy combined with pelvic autonomic nerve preservation is relatively safe in preserving urinary function, and its efficacy is comparable to that of open surgery.     

腹腔镜D3淋巴结清扫联合保留盆腔自主神经的直肠癌根治术对男性患者排尿功能的影响

Objective To investigate the influence of laparoscopic D3 lymphadenectomy combined with pelvic autonomic nerve preservation on the urinary function of male patients with rectal cancer. Methods From August 2006 to August 2007, 119 male patients with rectal cancer who had been admitted to Southwest Hospital were assigned to open surgery group (n=59) and laparoscopic group (n=60) according to the random number table. Three months after the operation, the urinary function of patients was assessed by urodynamics investigation and international prostate symptom score (IPSS). Differences in measurement data were compared with paired t test. Results There was no significant difference in IPSS between laparoscopic group (10.9±2.9) and open surgery group (11.5±3.1) (t=-1. 309, P>0.05). The maximum flow rate, voided volume, residual urine volume, detrusor contraction pressure and maximum urethral pressure were 15.2 ml/s, 150.1 ml, 6.1 ml, 43.3 cm H2O (1 cm H2O=0.098 kPa) and 77.5 cm H2O in laparoscopic group, and 15.0 ml/s, 140.9 ml, 6.4 ml, 45.6 cm H2O and 72.3 cm H2O in open surgery group, with no statistical difference between the 2 groups (t=1.22, -2.12, -1.73, -1.35, -1.64, P>0.05). Conclusions Laparosceopic D3 lymphadenectomy combined with pelvic autonomic nerve preservation is relatively safe in preserving urinary function, and its efficacy is comparable to that of open surgery.     

腹腔镜D3淋巴结清扫联合保留盆腔自主神经的直肠癌根治术对男性患者排尿功能的影响

Objective To investigate the influence of laparoscopic D3 lymphadenectomy combined with pelvic autonomic nerve preservation on the urinary function of male patients with rectal cancer. Methods From August 2006 to August 2007, 119 male patients with rectal cancer who had been admitted to Southwest Hospital were assigned to open surgery group (n=59) and laparoscopic group (n=60) according to the random number table. Three months after the operation, the urinary function of patients was assessed by urodynamics investigation and international prostate symptom score (IPSS). Differences in measurement data were compared with paired t test. Results There was no significant difference in IPSS between laparoscopic group (10.9±2.9) and open surgery group (11.5±3.1) (t=-1. 309, P>0.05). The maximum flow rate, voided volume, residual urine volume, detrusor contraction pressure and maximum urethral pressure were 15.2 ml/s, 150.1 ml, 6.1 ml, 43.3 cm H2O (1 cm H2O=0.098 kPa) and 77.5 cm H2O in laparoscopic group, and 15.0 ml/s, 140.9 ml, 6.4 ml, 45.6 cm H2O and 72.3 cm H2O in open surgery group, with no statistical difference between the 2 groups (t=1.22, -2.12, -1.73, -1.35, -1.64, P>0.05). Conclusions Laparosceopic D3 lymphadenectomy combined with pelvic autonomic nerve preservation is relatively safe in preserving urinary function, and its efficacy is comparable to that of open surgery.