前列腺增生症术后行前列腺癌根治术的临床观察

目的：总结前列腺增生症术后行耻骨后前列腺癌根治手术的体会。方法：对11例经尿道前列腺电切、2例经耻骨上前列腺切除术后病理检查证实为前列腺癌的患者行耻骨后前列腺癌根治术，患者平均年龄65岁，TNM分期为T1a-b 4例，T1c 8例，T2b 1例。结果：13例平均随访2年，全部无瘤存活，1例发生尿道狭窄，1例发生轻度尿失禁，最大尿流率15～32ml／min，3例恢复性功能。结论：前列腺增生症术后前列腺尖部有一定程度粘连，在耻骨后前列腺癌根治术中，通过仔细解剖，采用保护耻骨前列腺韧带和膜部括约肌的方法，同样可获得满意的尿控效果。     

前列腺癌根治术中保护控尿功能的体会

目的：减少耻骨后前列腺癌根治术患者术后尿失禁发生率。方法：对16例B超前列腺癌患者行保护控尿功能的解剖性耻骨后前列腺癌根治术。结果：16例术后随访3个月-5年，平均13个月。膀胱控尿正常者13例，轻度压力性尿失禁者2例，严重尿失禁者1例。结论：在行耻骨后前列腺癌根治术时，认识尿道括约肌及其支配神经的解剖位置及结构，避免对其损伤可以减少术后尿失禁发生率。     

非气腹腹腔镜下前列腺癌根治术11例报告

目的：探讨非气腹腹腔镜下前列腺癌根治术的可行性及疗效。方法2012年7月～2013年6月,行非气腹腹腔镜下前列腺癌根治术11例。前列腺特异抗原（PSA）（19．6±17．2） ng/ml,前列腺体积33～78 ml,平均41 ml。临床分期cT1期3例,cT2期6例,cT3期2例。取耻骨上正中切口3～5 cm,用手指钝性分离膀胱前间隙。在腹腔镜或示指引导下于双侧麦氏点下2 cm与脐下弧形穿出3个操作通道。应用悬吊器械提拉下腹壁创造操作的空间,30°腹腔镜通过脐部的通道进入,术者通过两侧的通道及下腹部的小切口进入器械操作。手术操作与传统的腹腔镜下前列腺癌根治术相同。结果11例手术顺利,手术时间（227±61） min,术中出血量（360±101） ml,无直肠损伤等严重并发症。术后病理均为前列腺腺癌,无切缘阳性。随访1～11个月,平均4个月,排尿通畅,无尿失禁。 PSA 0～0．21 ng/ml,平均0．11 ng/ml。结论非气腹腹腔镜下前列腺癌根治术微创、安全、有效。     

经腹膜外腹腔镜与经耻骨后前列腺癌根治术的对比研究

目的:探讨经腹膜外腹腔镜前列腺癌根治术与经耻骨后前列腺癌根治术的疗效。方法:回顾分析2011年1月至2014年1月60例行前列腺癌根治术患者的临床资料,根据术式分为腹腔镜组(n=27)与开放组(n=33),腹腔镜组行经腹膜外腹腔镜前列腺癌根治术,开放组行经耻骨后前列腺癌根治术,对比分析两组术中及术后相关数据。结果:60例手术均获成功,腹腔镜组术中出血量及术后住院时间少于开放组(P0.01),腹腔镜组手术时间长于开放组(P0.01),拔管时间、手术并发症及术后随访情况两组差异无统计学意义。结论:经腹膜外腹腔镜前列腺癌根治术具有微创、术后康复快等优点,对肿瘤的控制效果、手术并发症及术后生化复发与控尿方面与经耻骨后前列腺癌根治术无显著差异,是治疗局限性前列腺癌更好的术式。     

耻骨后根治性前列腺癌切除术31例报告

目的：探讨耻骨后根治性前列腺癌切除术手术方法和技巧。方法：回顾性分析我院自2006年1月-2008年5月施行的前列腺癌根治术31例。结果：全部病例术后恢复顺利,3周后拔除导尿管。1例出现压力性尿失禁;3例术后6周出现排尿困难,2例经尿道扩张后缓解,1例因不愿行尿道扩张而自愿要求膀胱造瘘;6例远端或两端切缘阳性予以辅助放疗和内分泌治疗,随访3-27个月无生化复发。结论：耻骨后根治性前列腺癌切除术是治疗早期前列腺癌的有效方法,是腹腔镜前列腺癌根治术的有力保证。     

保留尿控功能在耻骨后前列腺癌根治术的应用

目的:探讨保护耻骨前列腺韧带和保护尿道膜部括约肌群在耻骨后前列腺癌根治术后减少尿失禁的作用.方法:Ⅰ组32例前列腺癌按常规操作行耻骨后前列腺癌根治术,Ⅱ组32例前列腺癌采用保留耻骨前列腺韧带和尿道膜部括约肌群的方法行耻骨后前列腺癌根治术,术后1、3、6、12个月分别随访尿失禁情况.结果:两组年龄和PSA无显著差异,两组前列腺尖端切缘均无肿瘤残留,前列腺侧缘阳性率类似.Ⅱ组术后1、3、6个月尿控效果明显优于I组(P<0.05),但1年随访,Ⅰ组和Ⅱ组尿控效果类似.结论:在耻骨后前列腺癌根治术中保留耻骨前列腺韧带作用和尿道膜部括约肌群有显著提高近期尿控的效果,但1年随访两组尿控率无明显差异.     

改良Pfannenstiel切口在前列腺摘除术中的临床应用分析

目的：探讨改良Pfannenstiel切口在耻骨上经膀胱前列腺摘除术中的疗效和优势.方法：随机对63例BPH患者采用改良Pfannenstiel切口行耻骨上经膀胱前列腺摘除术,观察术后切口的愈合情况、手术平均时间,术后患者的体位、切口的疼痛、切口的张力、生活质量、术后并发症等指标的差异.结果：采用下腹部改良Pfannenstiel切口,完全可以替代直切口,切口暴露好,张力小,感染率明显下降,并发症少,切口小而美观,对合并腹股沟斜疝者无须另取切口,可一次完成.结论：改良Pfannenstiel切口在耻骨上经膀胱前列腺摘除术的治疗中是一种安全有效的方法,它具有操作简单.手术时间短,愈合速度快,出血量少,恢复快的优点,从解剖学上避免了下腹部腹直肌后鞘不完整造成的弊端,降低了切口疝的发生率;有很好的临床应用价值.     

耻骨后前列腺癌根治术减少并发症的探讨(附16例报告)

目的　探讨耻骨后前列腺癌根治术保留耻骨前列腺韧带及耻骨直肠悬带等对术后并发症的影响。　方法　对 16例前列腺癌患者 (平均年龄 67岁 ,B期 14例 ,C期 2例 )实施了耻骨后前列腺根治术 ,术中保留耻骨前列腺韧带及耻骨直肠悬带。　结果　 16例患者手术顺利 ,随访 1～ 4年 ,无长期尿失禁及排尿困难 ,6例保留睾丸者术后 4例恢复了性功能 ,9例患者PSA保持在 0ng/ml,7例PSA <0 .0 5ng/ml,16例均存活。　结论　耻骨后前列腺根治术中保留耻骨前列腺韧带及耻骨直肠悬带有助于减少并发症 ,取得较好的手术效果     

保留神经的腹腔镜前列腺癌根治术

近年来，保留神经的腹腔镜前列腺癌根治术逐渐成为治疗局限性前列腺癌的标准方法。通过对肿瘤控制、尿控能力及勃起功能进行长期评价，显示该技术的治疗效果与解剖性耻骨后前列腺癌根治术相近，而患者术后恢复明显优于经典的开放手术。本文就保留神经的腹腔镜前列腺癌根治术的技术特点以及当前的进展做一简要阐述。     

前列腺癌根治术后的腹腔镜腹股沟疝修补术

目的:探讨前列腺癌根治术后病人腹腔镜腹股沟疝修补术临床应用的安全性、可行性及有效性。方法 :收集我院2013年1月至2015年10月经耻骨后前列腺癌根治术后行腹腔镜腹股沟疝修补术20例,分析手术情况及术后恢复情况。结果:20例均顺利完成腹腔镜腹股沟疝修补术,无手术并发症发生及中转。平均手术时间单侧(55±18)min,双侧(82±25)min。术后中位住院天数2(2~5)d。术后有1例出现血清肿,穿刺后消失。术后随访中位时间12(1~21)个月,无复发。结论:腹腔镜腹股沟疝修补术在前列腺癌根治术后病人中应用安全有效。经耻骨后前列腺癌根治术后不是腹腔镜腹股沟疝修补术的禁忌证。     

An easy and safe approach to separating Denonvilliers' fascia from rectum during radical retropubic prostatectomy

PURPOSE: We describe a simple technique for excising Denonvilliers' fascia during nonnerve sparing radical retropubic prostatectomy. MATERIALS AND METHODS: After incision of the perirectal fascia Denonvilliers' fascia is bluntly mobilized off of the rectum digitally and by using an aortic clamp. RESULTS: This technique was used successfully in 200 consecutive cases of nonnerve sparing radical retropubic prostatectomy since 1994 with no rectal injuries. CONCLUSIONS: This procedure guarantees simple and complete excision of Denonvilliers' fascia, which covers the posterior surface of the prostate during nonnerve sparing radical retropubic prostatectomy.     

Modified Pfannenstiel approach for radical retropubic prostatectomy

Radical retropubic prostatectomy is traditionally performed using a vertical midline incision and occasionally using a transverse Pfannenstiel incision. We describe a technique for performing radical retropubic prostatectomy using a modified Pfannenstiel approach. This involves a Y incision of the rectus sheath, instead of a pure transverse incision, and provides both excellent exposure and better cosmetic results.     

Minilaparotomy radical retropubic prostatectomy for prostate cancer

Radical prostatectomy is still the gold standard for treating patients with clinically localized cancer. A total of 33 consecutive patients underwent minilaparotomy radical prostatectomy by a single surgeon. The minilaparotomy radical retropubic prostatectomy was performed via an eight-centimeter lower midline incision and a Book Walter retractor for surgical assistance. Mean patient age was 65 years (range 47 to 74). Tumor stages were observed as 12.1% of total for T1c, 21.2% for T2a, 45.5% for T2b, 6% for T3a and 15.2% for T3b. Satisfactory continence was achieved in 80% of the patients. 85% of patients revealed a prostate-specific antigen at a serum concentration of less than 0.2 ng/ml. Minilaparotomy radical retropubic prostatectomy compares favorably with standard radical retropubic prostatectomy.     

A centralized comparison of radical perineal and retropubic prostatectomy specimens: is there a difference according to the surgical approach?

PURPOSE: We performed a central review of pathology specimens from radical perineal and radical retropubic prostatectomies performed by a single surgeon. We determined whether differences exist in the 2 approaches in regard to the ability to obtain adequate surgical margins around the tumor and adequate extracapsular tissue around the prostate, and avoid inadvertent capsular incision. MATERIALS AND METHODS: The review included whole mount prostates from 60 patients who underwent radical retropubic prostatectomy and 40 who underwent radical perineal prostatectomy. The pathologist (N. S. G.) was blinded to the surgical approach. All prostatectomies were consecutive and performed by the same surgeon (H. J. K.). To ensure consistency of the pathological measurements patients were excluded from analysis if they had undergone preoperative androgen ablation or a nerve sparing procedure, leaving 45 retropubic and 27 perineal prostatectomy specimens for further evaluation. Pertinent clinical parameters were assessed and a detailed pathological analysis of each specimen was performed. RESULTS: In the retropubic and perineal groups 78% of the tumors were organ confined (stage pT2) with extracapsular extension (stage pT3) in the majority of the remaining patients. There was no significant difference in the positive margin rate for the retropubic and perineal procedures (16% and 22%, p = 0.53) or for Gleason 6 and 7 tumors only in the 2 groups (10% and 17%, respectively, p = 0.47). The capsular incision rate was 4% in each group. The distance of the tumor from the posterolateral margins and the amount of extracapsular tissue excised were equivalent in each group. Subgroups of patients with a prostate of less than 50 gm. and containing only low grade, low stage neoplasms were also analyzed. Subgroup analysis showed no difference in any variable. CONCLUSIONS: Radical perineal prostatectomy is comparable to radical retropubic prostatectomy for obtaining adequate surgical margins, avoiding inadvertent capsular incisions and excising adequate extracapsular tissue around tumor foci. Additional patient accrual and prostate specific antigen followup would further help validate the similar efficacy of the 2 surgical approaches as treatment for prostate cancer.     

Comparison of length of hospital stay between radical retropubic prostatectomy and robotic assisted laparoscopic prostatectomy

PURPOSE: Minimally invasive surgery has been shown to decrease postoperative morbidity and length of stay for a number of surgical procedures. Furthermore, length of stay after open radical prostatectomy has decreased dramatically during the last decade. We examined differences in length of stay between a prospectively evaluated cohort of patients who underwent radical retropubic prostatectomy and robot assisted laparoscopic prostatectomy. MATERIALS AND METHODS: Between January 2003 and March 2006, 1,003 radical prostatectomies were performed at our hospital. Data were collected in prospective fashion and a comparison was made between 374 patients who underwent radical retropubic prostatectomy and 629 who underwent robot assisted laparoscopic prostatectomy. Length of stay, factors influencing length of stay, readmission rates and unscheduled clinic or emergency room visits were evaluated. Patients in the 2 groups were treated using the same clinical care pathway. RESULTS: Overall 94.3% of patients in the radical retropubic prostatectomy group and 97.5% in the robot assisted laparoscopic prostatectomy group were discharged home on or before postoperative day 1. Mean length of stay in the radical retropubic and robot assisted laparoscopic prostatectomy groups was 1.25 (median 1.09) and 1.17 days (median 1.03), which was similar and not statistically different (p=0.27). Readmission rates were similar in robot assisted laparoscopic and radical retropubic prostatectomy patients (7% and 5%, respectively, p=0.12). Unscheduled clinic or emergency room visits were the same in the robot assisted laparoscopic and radical retropubic prostatectomy groups (10%, p=0.95). CONCLUSIONS: Patients who underwent radical retropubic prostatectomy or robot assisted laparoscopic prostatectomy can be treated on the same clinical pathway. A targeted hospital discharge date of postoperative day 1 can be achieved in the majority of patients who underwent radical prostatectomy. Readmission rates or unscheduled hospital visits are necessary in a small percent of patients treated with an early discharge program, of which the majority are caused by ileus.     

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.     

Preperitoneal prosthetic mesh hernioplasty during radical retropubic prostatectomy

PURPOSE: The number of radical retropubic prostatectomies performed in the United States has increased during the last decade. There are 5 to 10% of candidates for radical retropubic prostatectomy who have a detectable inguinal hernia on physical examination. Furthermore, recent data suggest that there is an increased incidence of inguinal hernia after radical retropubic prostatectomy. We evaluated the role of simultaneous inguinal hernioplasty during radical prostatectomy. MATERIALS AND METHODS: During 575 radical prostatectomy procedures from June 1991 to June 1997, 70 hernioplasties were performed in 48 patients. Retrospective chart review was performed for all men who underwent simultaneous hernia repair. Mean patient age was 60.9 years (range 43 to 73). Polypropylene or polyester fiber prostheses were used for mesh hernioplasty. All repairs were performed using a preperitoneal approach during radical retropubic prostatectomy. RESULTS: There were 35 hernioplasties performed without and 35 with mesh. Mean postoperative followup was 24 months (range 6 to 66). Of the hernias 71% were indirect and 29% were direct. No recurrence was detected after mesh hernioplasty, whereas 5 hernias (14%) recurred in the nonmesh group. In this group 2 men (4%) also had de novo hernias on the contralateral side during followup. All recurrent hernias were diagnosed within 1 year of the initial operation. No patient had wound infection, persistent neuralgia or ischemic orchitis. CONCLUSIONS: Simultaneous repair of inguinal hernias during radical retropubic prostatectomy is effective and technically feasible. There is convenient access to the preperitoneal space during radical retropubic prostatectomy and hernia repair adds only 5 to 10 minutes of operative time. Mesh repair appears to offer optimized results compared to the nonmesh technique. Despite the use of prosthetic material, no complications were attributable to its application during these genitourinary procedures.     

Incidence of surgical margin involvement in various forms of radical prostatectomy

The pathologic specimens of 64 patients who underwent radical prostatectomy for clinical Stage A or B carcinoma of the prostate were reviewed retrospectively for surgical margin involvement with cancer. Fourteen of the operations were performed by the radical transperineal method, 30 by the standard radical retropubic approach, and 20 by the nerve-sparing radical retropubic technique. Seventy-eight percent of the radical transperineal group had resection margin involvement, as opposed to 30 percent of the standard radical retropubic cases, and 45 percent of the nerve-sparing radical retropubic cases. The average tumor burden of the transperineal group was larger than that of the other two groups. Resection margin involvement in all groups was associated with a higher Gleason histologic score. No significant difference was noted between the two retropubic groups in terms of resection margin involvement (P = 0.28), suggesting that nerve-sparing radical retropubic prostatectomy does not compromise the surgical goal of radical prostatectomy for carcinoma over that of the standard radical retropubic prostatectomy.     

The role of early adopter bias for new technologies in robot assisted laparoscopic prostatectomy

PURPOSE: We determined the potential influence of an early adopter bias in patients undergoing robot assisted laparoscopic prostatectomy. MATERIALS AND METHODS: We compared baseline demographic, clinical and health related quality of life characteristics of patients undergoing 3 different surgical procedures for clinically localized prostate cancer following the introduction of robot assisted laparoscopic prostatectomy at our institution. Patients included in this analysis were participating in a prospective health related quality of life study using the SF-12(R) and Expanded Prostate Cancer Index Composite validated questionnaires. RESULTS: Of 402 patients 159 (39%) underwent robot assisted laparoscopic, 144 (36%) underwent radical perineal and 99 (25%) underwent radical retropubic prostatectomy. There were no statistically significant associations between procedure type and patient age (p = 0.267), race (p = 0.725), number of medical comorbidities (p = 0.490), income (p = 0.056) and level of education (p = 0.495). Mean prostate specific antigen was 5.9 +/- 3.3, 7.3 +/- 5.5 and 5.7 +/- 5.0 ng/ml for robot assisted laparoscopic, radical perineal and radical retropubic prostatectomy, respectively (p = 0.030). The proportion of robot assisted laparoscopic, radical perineal and radical retropubic prostatectomy patients with a final Gleason score of 4-6 was 55%, 45% and 39%, respectively (p = 0.037). The proportion of robot assisted laparoscopic, radical perineal and radical retropubic prostatectomy patients with stage T2 disease was 91%, 68% and 80%, respectively (p = 0.001). Statistically significant associations of higher income and education with higher baseline health related quality of life scores were seen in the sexual and physical domains (each p <0.01). CONCLUSIONS: We failed to find evidence of an early adopter bias for patients undergoing robot assisted laparoscopic prostatectomy. Nevertheless, observational studies comparing robot assisted laparoscopic prostatectomy to radical perineal and radical retropubic prostatectomy should account carefully for patient baseline characteristics to allow meaningful comparisons of surgical outcomes.