减少根治性耻骨后前列腺切除术失血的新方案

为减少根治性耻骨后前列腺切除术(RRP)失血,2001年起改进此手术围手术期处理方案,包括:①减少术中输液量,特别是在麻醉开始至取出前列腺标本期间;②硬膜外(T_(12)～L_2)置管(PDK),给予丁吡卡因麻醉;③Tren- delenburg体位25～35°。1998年至     

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。     

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。     

耻骨后根治性前列腺切除术在前列腺手术与未曾手术患者的应用

<正>根治性前列腺切除术(radical retropubic prostatectomy,RRP)是治疗局限性前列腺癌(prostaticcancer,PCa)最有效的方法[1]。我们把2003年1月至2008年6月因前列腺增生手术后发现PCa而行RRP的20例编为A组,将同期前列腺未曾手术过的连续20例PCa行RRP的编为B组,对A、B两组进行比较,以评价前列腺术后RRP的手术难度和疗效。     

前列腺根治性切除术后腹股沟疝

前列腺癌（prostate cancer,PCa）是男性泌尿生殖系统最常见的恶性肿瘤之一。前列腺根治性切除术（radical prostatectomy,RP）是治疗局限性前列腺癌的常用方法,可分为开放性耻骨后、腹腔镜、机器人辅助腹腔镜等方法。腹股沟疝是RP术后常见并发症。随着近些年RP由传统的开放式向微创方向的转变,使其术后腹股沟疝的临床特点发生了较大变化。本文就RP术后腹股沟疝的临床研究进展作一综述。     

开放性耻骨后顺行根治性前列腺切除术（附光盘）

与逆行方式相比,耻骨后顺行根治性前列腺切除术可降低切缘阳性的发生率,本文简要介绍耻骨后顺行根治性前列腺切除术的操作要点、技巧以及作者所探索的一些技术改进。     

根治性前列腺切除术

根治性前列腺切除术周志耀作者单位：２１０００８南京大学医学院鼓楼医院泌尿外科虽然患局限性前列腺癌的病人，治疗效果目前仍不容乐观，但现在尚无其他治疗肿瘤原发病灶及远处转移肿瘤的方法，疗效可超过前列腺根治性切除术。根治性前列腺切除术的手术病人选择，应由以...     

耻骨上前列腺切除术后出血防治措施及体会

我院自1996年8月～1999年4月，对76例经耻骨上摘除前列腺患者，采取电凝止血、早期冲洗、长效止痛法，有效减少术后出血。病人痛苦小、恢复快，现报告如下。     

根治性耻骨后前列腺切除术切缘阳性患者的PSA复发率

根治性耻骨后前列腺切除术后切缘阳性患者的治疗存在争议。目前可供选择的治疗方式包括观察、放疗和早期激素治疗。作出合理的治疗选择应基于对切缘阳性患者不采取治疗时复发风险的评估。作者回顾研究1383例迈阿密大学医学院由同一位医师完成的根治性耻骨后前列腺切除术患者病历资料。所有标本均由同一位病理医师完成病理检查。共有936例患者符合纳入标准。平均随访45．8个月（最少12个月），总的PSA生化复发率为11．5％（108／936）。     

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…     

Reducing blood loss in open radical retropubic prostatectomy with prophylactic periprostatic sutures

Study Type – Therapy (case series)
Level of Evidence 4

OBJECTIVE

To determine whether the placement of small‐calibre, rapidly absorbed prophylactic periprostatic sutures before the mobilization of the prostate could reduce blood loss during open retropubic radical prostatectomy (RRP).

PATIENTS AND METHODS

In 2007, during open RRP, we began placing prophylactic haemostatic sutures of 4‐0 and 3‐0 plain catgut in the anterior portions of the distal neurovascular bundles (NVBs) and lateral to the proximal NVBs and prostate pedicles before initiating the nerve‐sparing dissection and mobilizing the prostate gland. To evaluate whether this reduced intraoperative blood loss, we compared estimated blood loss (EBL), non‐autologous transfusion rates, and postoperative haemoglobin (Hb) levels between 100 consecutive patients treated immediately before and 100 consecutive patients treated immediately after the adoption of the prophylactic periprostatic suture technique.

RESULTS

Before the use of prophylactic haemostatic sutures, the mean intraoperative blood loss was 1285 mL, and one patient (1%) received an intraoperative non‐autologous transfusion. After the adoption of prophylactic sutures, the mean EBL was 700 mL (P < 0.001), and there were no transfusions. The mean Hb concentration the morning after RRP was 10.9 g/dL before and 11.8 g/dL after the initiation of prophylactic haemostatic sutures (P < 0.001).

CONCLUSION

Prophylactic periprostatic haemostatic sutures significantly reduce intraoperative blood loss during open RRP.     

Open retropubic radical prostatectomy

Radical prostatectomy (RP) is a common treatment choice for localized prostate cancer. While there is increasing utilisation of robotic assisted RP in some centres, open RP (ORP) remains well established and commonly performed in many parts of the world. The goals of modern ORP are to remove the prostate en-bloc with negative surgical margins, while minimising blood loss and preserving urinary continence and erectile function. We present a technical review of ORP incorporating contemporary techniques for control of the deep venous complex, additional haemostatic measures, nerve-sparing and vesicourethral reconstruction.     

Estimated blood loss as a predictor of PSA recurrence after radical prostatectomy: results from the SEARCH database

Study Type – Diagnosis (exploratory cohort)
Level of Evidence 2b

OBJECTIVE

To clarify the relationship between estimated blood loss (EBL) and biochemical recurrence, assessed by prostate‐specific antigen (PSA) level, as blood loss is a long‐standing concern associated with radical prostatectomy (RP), and no studies to date have examined the association between blood loss and cancer control.

PATIENTS AND METHODS

In all, 1077 patients were identified in the Shared Equal‐Access Regional Cancer Hospital database who underwent retropubic RP (between 1998 and 2008) and had EBL and follow‐up data available. We examined the relationship between EBL and recurrence using multivariate Cox regression analyses.

RESULTS

Increased EBL was correlated with PSA recurrence in a multivariate‐adjusted model (P = 0.01). When analysed by 500‐mL EBL categories, those with an EBL of <1500 mL had a similar risk of recurrence. However, the risk of PSA recurrence tended to increase for an EBL of 1500–3499 mL, before decreasing again for patients with an EBL of ≥3500 mL. Men with an EBL of 2500–3499 mL had more than twice the risk of recurrence than men with an EBL of <1500 mL (P = 0.02). EBL was not associated with adverse tumour stage, grade or margin status.

CONCLUSIONS

There was a significant correlation between EBL at the time of RP and biochemical recurrence. We hypothesized that this association might be due to transfusion‐related immunosuppression, excessive blood obscuring the operative field, EBL being a marker of aggressive disease, or EBL being a marker of poor surgical technique. However, our data did not completely fit any one of these hypotheses, and thus the ultimate cause for the increased risk of recurrence remains unclear and requires further study.     

Endoscope-assisted minilaparotomic radical retropubic prostatectomy

OBJECTIVE: To assess the clinical efficacy of endoscope-assisted minilaparotomic radical retropubic prostatectomy (EAM-RRP) compared with conventional radical retropubic prostatectomy (cRRP). METHODS: From September 2001 to December 2003, 30 patients with localized prostate cancer were treated by EAM-RRP. The surgical manipulation was performed through the wound with thoracoscopic assistance, using standard surgical instruments. In all cases, 800 mL of blood was collected from the patient for autotransfusion. For both EAM-RRP and cRRP, the internal iliac and obturator lymph nodes were dissected before the prostate removal. Clinical indicators such as operation time, blood loss, and duration of postoperative urine incontinence were analysed in the two groups. RESULTS: The postoperative period before ambulation and the duration of postoperative urine incontinence were significantly shorter after EAM-RRP than after cRRP, while no significant difference was found in operation time, blood loss, and duration of urethral catheterization. None of the cases required allotransfusion. CONCLUSION: EAM-RRP, which had a shorter postoperative period before ambulation and continence, is considered a safe and useful technique for radical prostatectomy.     

New perioperative management reduces bleeding in radical retropubic prostatectomy

OBJECTIVE: To describe the effect of modifications to radical retropubic prostatectomy (RRP, known to be associated with severe bleeding) on blood loss in a retrospective analysis comparing RRPs by one experienced surgeon before and after the changes. PATIENTS AND METHODS: The new method comprised reducing the intravenously applied volume, using a peridural catheter and maintaining a 25-30 degrees Trendelenburg position. The difference in haemoglobin before and after RRP was analysed before the changes (group 1) and after (group 2). If transfusions were required the haemoglobin value was corrected, whereby 1 mL of erythrocyte concentrate increased the patient's haemoglobin by 0.03 g/L. RESULTS: Assessment was possible in 201 of 234 patients, 110 from group 1 and 91 from group 2. The mean transfusion-corrected difference in haemoglobin was 53 g/L in group 1 (20% transfusion rate) and 35.2 g/L in group 2 (1.09% transfusion rate; P > 0.001). The median intravenous volume applied was 5.96 L in group 1 and 3.49 L in group 2 (P < 0.001). The complication rate did not differ between the groups. CONCLUSION: This new method minimizes the intraoperative blood loss during RRP; transfusions are only necessary in rare cases and the complication rate remained unaltered.     

Efficacy of preoperative donation of autologous blood in patients undergoing radical retropubic prostatectomy

BACKGROUND: Radical retropubic prostatectomy (RRP) has resulted in substantial blood loss and the frequent need for homologous blood transfusion. In this study, the efficacy of autologous blood transfusion, from medical and financial perspectives, was evaluated in patients undergoing RRP. METHODS: Between 1994 and 2000, 80 patients with localized prostate cancer underwent RRP in our institute. Based on informed consent, preoperative donation of autologous blood (PDA) was performed in 65 out of 80 patienets. Four or six units were donated during the first 3 years; however, donation units were reduced to a maximum of 4 units since 1997 onwards. The discard rate of donated blood and frequency of homologous transfusion were examined. Changes of hematocrit (Ht) and hemoglobin (Hb) levels through donation and surgery and important factors that may affect postoperative levels of Ht and Hb were evaluated in 56 patients receiving 4-unit donations. RESULTS: Overall, 2 or 4 units of donated blood were discarded in four patients and homologous transfusion was required in two patients. In 56 patients receiving 4-unit donation, the mean Ht level at predonation was 43.3%. Following donation, this decreased to 35.7%. The administration of recombinant human erythropoietin (rHuEpo) relieved declining Ht levels following donation, but changes in Ht levels after surgery were minor. Important factors related to postoperative decline of Ht and Hb levels were operative time and blood loss. CONCLUSIONS: The program of 4-unit PDA can be performed safely without rHuEpo injection, and it is useful to reduce the risk of requiring homologous transfusion. However, more efficient programs to relieve patient burden and to reduce medical cost are needed.     

Bladder neck contracture after radical retropubic prostatectomy

OBJECTIVE: To examine the incidence, management and outcome of vesico-urethral anastomotic strictures after bladder-neck sparing radical retropubic prostatectomy (RRP). PATIENTS AND METHODS: We assessed the incidence, management and outcome of anastomotic strictures in 510 consecutive patients (mean age 61 years, range 45-76) who had open RRP by one surgeon between 1994 and 2003. RESULTS: The mean (range) follow-up was 30 (2-89) months; 48 patients (9.4%) developed an anastomotic stricture. Dilatation of the stricture was an effective treatment, with few patients requiring further treatment. CONCLUSION: Stricture of the vesico-urethral anastomosis after bladder-neck sparing RRP is relatively frequent but can usually be successfully managed with one graduated dilatation under light sedation.