筋膜内切除法在腹腔镜下前列腺癌根治术中的应用

目的 探讨筋膜内切除法在腹腔镜下根治性前列腺切除术中的应用.方法 前列腺癌患者23例,平均年龄65岁.术前PSA 4.5～8.6(6.25 ±2.1)ng/ml;临床分期T1 16例、T2 7例;活检组织Gleason评分:5分3例、6分11例、7分9例.有性生活者18例.行腹腔镜下根治性前列腺切除术.不打开盆内筋膜,自前列腺基底部沿前部正中线纵形切开前列腺筋膜,贴前列腺包囊分离前列腺前面、两侧、尖部.保留神经血管束.保护前列腺尖尿道相连处括约肌.结果 23例手术顺利.平均手术时间125(110～170)min.出血量320～1500(550±210)ml,输血3例.平均留置尿管12(9～15)d.术后随访12个月,完全尿控20例(87%).有轻微压力性尿失禁3例(13%).18例术前有性生活的患者能充分勃起完成性交13例(72%).随访期间出现生化复发2例(9%).结论 腹腔镜下筋膜内切除法剥离前列腺对前列腺周围筋膜、附着于筋膜的神经血管束以及尿道外括约肌损伤小.手术方法可行.     

Nerve sparing laparoscopic radical prostatectomy: our technique

PURPOSE: To describe our technique of nerve sparing laparoscopic radical prostatectomy (LRP). We present the oncological and functional results (potency and urinary continence). MATERIAL AND METHODS: LRP has become standard at our institution based on experience with more than 2800 consecutive cases operated on between 1997 and 2005. From May 2003 to March 2005 a total of 677 LRP were performed, 425 consecutive patients candidates for a nerve sparing technique have been operated using the intrafascial approach. The challenge of our technique is to remove the prostate without any thermic and mechanic traumatism, avoiding dissection of outer layer. Oncological data were assessed by pathological examination and post-operative PSA level. Functional results were assessed with a self questionnaire. RESULTS: By pathological stage, 2 pT2a specimens (7.4%), 7 pT2b specimens (21%), 44 pT2c specimens (24%), 63 pT3a specimens (43%), 11 pT3b specimens (46%) were found to have positive surgical margins (SMs). In 86 specimen (59%) positive SMs were focal inframillimetric. Median follow-up was 11 months (range 1-22). The continence rate (no leakage/no pad) was 95% at 6 months, confirmed at 12 months among 202 patients. For 137 patients, potency rate was 58.5% at 12 months. CONCLUSION: Intrafascial LRP provides satisfactory results in regard to recovery of continence and sexual function. Long-term progression and survival outcome are necessary before this procedure should be offered as a replacement for interfascial nerve sparing technique.     

Early experience with extraperitoneal endoscopic radical retropubic prostatectomy

This article reports our early experience using laparoscopic instruments and techniques when performing radical retropubic prostatectomy through an entirely extraperitoneal endoscopic approach. Two patients with localized adenocarcinoma of the prostate underwent endoscopic radical retropubic prostatectomy through an entirely extraperitoneal approach (EERRP). The procedure was evaluated for its efficacy in removing prostate and seminal vesicles and in effecting complete vesicourethral anastomosis. Operative time, blood loss, hospital stay, and pathology were also evaluated. Complete endoscopic removal of the prostate and seminal vesicles was achieved in both patients. Endoscopic reconstruction of the bladder neck with watertight anastamosis was successful in both. Operative time and estimated blood loss improved from 5 h and 45 min and 600 cc, respectively, in patient 1 to 4 h and 400 cc in patient 2. Hospital stay was 2.5 days for both. The early experience for EERRP is encouraging. Further evaluation to standardize technique and determine its efficacy and role in treating prostate cancer is in order. Received: 21 July 1997/Accepted: 11 November 1997     

经腹与经腹膜外腹腔镜下前列腺癌根治术的效果比较

目的 比较经腹与经腹膜外途径腹腔镜下手术治疗前列腺癌的临床效果.方法前列腺癌患者33例行腹腔镜下前列腺癌根治术,其中经腹21例,经腹膜外12例.对2组患者手术时间、术中出血量、术中并发症、肠功能恢复时间、术后住院时间、术后并发症等资料进行比较分析.结果 33例手术均成功.经腹与经腹膜外2组手术时间分别为(299±46)和(309±64)min,出血量分别为(618±448)和(677±469)ml,2组比较差异无统计学意义(P＞0.05).经腹组术中发生大出血3例、膀胱损伤2例、单侧输尿管损伤1例,经腹膜外组术中发生大出血1例、闭孔神经损伤1例、腹膜损伤1例、膀胱三角损伤1例.2组术后留置导尿时间分别为(14.6±3.8)和(12.3±2.9)d,肠功能恢复时间分别为(2.7±0.7)和(2.1±0.5)d,术后住院时间分别为(17.0±3.6)d和(11.2±3.5)d,2组比较差异均有统计学意义(P＜0.05).结论 腹腔镜下前列腺癌根治术经腹膜外比经腹途径具有视野清晰、对腹腔器官影响小、术后恢复快、术后住院短等优点.     

Patient-reported validated functional outcome after extraperitoneal robotic-assisted nerve-sparing radical prostatectomy.

BACKGROUND AND OBJECTIVES: Erectile function after prostate surgery is an important criterion for patients when they are choosing a treatment modality for prostate cancer. Improved visualization, dexterity, and precision afforded by the da Vinci robot allow a precise dissection of the neurovascular bundles. We objectively assessed erectile function after robot-assisted extraperitoneal prostatectomy by using the SHIM (IIEF-5) validated questionnaire. METHODS: Between July 2003 and September 2004, 150 consecutive men underwent da Vinci robot-assisted extraperitoneal radical prostatectomy for clinically localized prostate cancer. The IIEF-5 questionnaire was used to assess postoperative potency in 67 patients who were at least 6 months postsurgery. Erectile function was classified as impotent (<11), moderate dysfunction (11 to 15), mild dysfunction (16 to 21), and potent (22 to 25). All patients used oral pharmacological assistance postprocedure. RESULTS: Sixty-seven patients were available to complete the IIEF-5 questionnaire 6 months to 1 year postprostatectomy. Twelve patients were excluded from the study who abstained from all sexual activity after surgery for emotional or social reasons. Of the 55 patients evaluated, 22 (40%) were impotent, 3 (5.5%) had moderate ED, 12 (21.8%) had mild ED, and 18 (32.7%) were fully potent. The table compares IIEF-5 scores with nerve-sparing status. Of patients who had bilateral nerve sparing, 28/45 (62.2%) had mild or no ED within 6 to 12 months postsurgery, and all expressed satisfaction with their current sexual function or rate of improvement after robotic prostatectomy. CONCLUSION: Robot-assisted extraperitoneal prostatectomy provides comparable outcomes to those of open surgery with regards to erectile function. Assessment of the ultimate maximal erectile function will require continued analysis, as this is likely to further improve beyond 6 to 12 months.     

Patient-reported validated functional outcome after extraperitoneal robotic-assisted nerve-sparing radical prostatectomy.

BACKGROUND AND OBJECTIVES: Erectile function after prostate surgery is an important criterion for patients when they are choosing a treatment modality for prostate cancer. Improved visualization, dexterity, and precision afforded by the da Vinci robot allow a precise dissection of the neurovascular bundles. We objectively assessed erectile function after robot-assisted extraperitoneal prostatectomy by using the SHIM (IIEF-5) validated questionnaire. METHODS: Between July 2003 and September 2004, 150 consecutive men underwent da Vinci robot-assisted extraperitoneal radical prostatectomy for clinically localized prostate cancer. The IIEF-5 questionnaire was used to assess postoperative potency in 67 patients who were at least 6 months postsurgery. Erectile function was classified as impotent (<11), moderate dysfunction (11 to 15), mild dysfunction (16 to 21), and potent (22 to 25). All patients used oral pharmacological assistance postprocedure. RESULTS: Sixty-seven patients were available to complete the IIEF-5 questionnaire 6 months to 1 year postprostatectomy. Twelve patients were excluded from the study who abstained from all sexual activity after surgery for emotional or social reasons. Of the 55 patients evaluated, 22 (40%) were impotent, 3 (5.5%) had moderate erectile dysfunction (ED), 12 (21.8%) had mild ED, and 18 (32.7%) were fully potent. The table compares IIEF-5 scores with nerve-sparing status. Of patients who had bilateral nerve sparing, 28/45 (62.2%) had mild or no ED within 6 to 12 months postsurgery, and all expressed satisfaction with their current sexual function or rate of improvement after robotic prostatectomy. CONCLUSION: Robot-assisted extraperitoneal prostatectomy provides comparable outcomes to those of open surgery with regards to erectile function. Assessment of the ultimate maximal erectile function will require continued analysis, as this is likely to further improve beyond 6 to 12 months.     

经腹膜外腹腔镜下前列腺癌根治术

目的 探讨腹膜外腹腔镜下前列腺癌根治术的手术方法和疗效. 方法 2003年2月至2008年6月对91例前列腺癌患者行腹膜外腹腔镜下前列腺癌根治术,患者均经病理检查确诊,Gleason评分≤8分,盆腔CT、MR和核素全身骨扫描示无盆腔淋巴结、精囊和骨转移,手术经腹膜外顺行径路切除前列腺,标本自脐下切口处取出.术中行盆腔淋巴结活检32例,行保留性神经前列腺癌根治11例. 结果 平均手术时间173(105～270)min,平均出血量315(110～1200)ml.术中直肠损伤2例,术后病理检查切缘阳性11例.术后出现不同程度尿失禁19例.其中术后3个月内恢复尿控18例,真性尿失禁1例.32例行盆腔淋巴结活检者均未发现阳性淋巴结,11例保留性神经患者中术后随访勃起功能良好5例.87例随访3～30个月,无尿道狭窄,术后28个月出现生化复发3例.结论腹膜外腹腔镜下前列腺癌根治术安全有效,手术创伤小、恢复快,与开放前列腺癌根治术效果相近.     

Robot-assisted versus pure laparoscopic radical prostatectomy

The aim of this study is to report the relative advantages and disadvantages of the radical prostatectomy with a laparoscopic (LRP) and a robotic (RALP) approach. A medline search was performed. Published data regarding perioperative parameters, complications, oncological results, functional results were analyzed. Shorter learning curves have been reported with the RALP. Intra-operative and post-operative outcomes appear to be comparable between the two approaches. The average time for LRP is 234 min (151–453) versus 182 min (141–250) for RALP. Estimated blood loss for the LRP averages 482 ml (185–850) versus 234 ml (75–500) for the RALP. Complication rates in single institution studies are similar. Long-term outcomes data on PSA progression is not yet available for LRP or RALP due to their relatively short existence. RALP appears to offer a significant benefit to the laparoscopically naïve surgeon with respect to learning curve when compared to LRP. This, however, comes at an increased cost. Intra-operative and post-operative outcomes appear to be similar. Longer follow-up data is necessary to compare oncological and functional outcomes.     

Rehabilitative therapy for erectile function after nerve-sparing radical prostatectomy

BackgroundTo date, the time course for recovery of erectile function and the effect of rehabilitative treatment after nerve-sparing radical prostatectomy (RP) is still under debate. The aim of this study was to evaluate the effect of low-dose sildenafil for rehabilitation of erectile function after nerve-sparing RP.MethodsIn a prospective, randomised study, 43 sexually active patients underwent a nerve-sparing retropubic RP. Erectometer measurement of nocturnal penile tumescence and rigidity (NPTR) was carried out 7–14 days after surgery. Some patients (23) with preserved nocturnal erections received sildenafil 25 mg/day at night to support recovery of erectile function. A control of 18 patients underwent follow up without phosphodiesterase type 5 (PDE-5) inhibitors. The International Index of Erectile Function (IIEF-5) questionnaire was given 6, 12, 24, 36, 52 and 78 weeks after operation.ResultsA total of 41 out of 43 patients (95%) showed 1–5 erections during the first night after catheter removal. In the daily sildenafil group, the IIEF-5 score decreased from a preoperative mean score of 20.8 to mean scores of 3.6 at 6 weeks, 3.8 at 12 weeks, 5.9 at 24 weeks, 9.6 at 36 weeks, 14.1 at 52 weeks and 19.4 at 78 weeks after prostatectomy. In the control group, the preoperative IIEF-5 mean score of 21.2 decreased to 2.4 at 6 weeks, 3.8 at 12 weeks, 5.3 at 24 weeks, 6.4 at 36 weeks, 9.3 at 52 weeks and 13.4 at 78 weeks. Statistical evaluation showed a significant difference in IIEF-5 score and time to recovery of erectile function between the groups (p<0.001) with potency rates of 92% vs. 68%.ConclusionsIn this study of men, the measurement of NPTR after nerve-sparing RP showed erectile function even during the “first” night after catheter removal. Sildenafil was efficacious when used in a “daily low dose” treatment and led to a significant improvement in recovery of erectile function.     

Categorisation of complications of endoscopic extraperitoneal and laparoscopic transperitoneal radical prostatectomy

The aim of the present review is to focus on the various attempts of categorisation of complications after endoscopic extraperitoneal and laparoscopic transperitoneal radical prostatectomy. Several classifications of complications and adverse events have been proposed in the literature but none is widely accepted or applied so far. We thus present a review of the existing literature and the complications of our series of 900 patients treated with endoscopic extraperitoneal radical prostatectomy (EERPE). We applied the recently revised Clavien classification system to grade EERPE complications.     

腹腔镜下经腹膜外径路行前列腺癌根治术(附7例报告)

目的:探讨腹腔镜下经腹膜外径路行前列腺癌根治术的手术方法和临床效果。方法:7例前列腺癌患者,腹腔镜下经腹膜外径路分离前列腺,切开膀胱颈部,分离前列腺尖部、游离精囊后顺行前列腺切除术,膀胱颈成形后与尿道吻合。结果:平均手术时间为6.7h,术中平均出血量为1385ml。术后24～48h恢复肠道功能,2～3周后拔除尿管,2例出现轻度尿失禁,无术后出血、直肠损伤、尿路狭窄等其他并发症发生。结论:腹腔镜下腹膜外途径前列腺癌根治术创伤小、视野清晰、出血少、康复快,是早期前列腺癌根治术的方法之一。     

Modular surgical training for endoscopic extraperitoneal radical prostatectomy

OBJECTIVE: To develop a modular training scheme which enabled the use of individual steps of laparoscopic radical prostatectomy (RP) for teaching and training surgeons with varied experience, including residents with no experience in open RP, as in extending laparoscopic surgery to more complex operations like RP, the proper training of urologists is crucial. SUBJECTS AND METHODS: The technique of endoscopic extraperitoneal RP (EERP) was divided into 12 individual steps of differing complexity. The levels of difficulty were called "modules" and graded according to their requisite skills from module 1 (lowest level of difficulty) to module 5 (highest level). Based on this modular system we established a training programme whereby the trainee learns the procedure in a mentor-initiated schedule. During each training operation the trainee only performs the modules (steps) of the operation, which correspond with his or her actual skill level. The mentor performs all the other steps, with the trainee assisting. Four trainees with different surgical experience participated in the study. RESULTS: After a phase of assisting and camera holding during EERP, the trainees entered the modular training programme and required 32-43 procedures until they were considered to be competent. An analysis of the first 25-50 procedures done independently by the trainee showed mean operative times of 176-193 min and a transfusion rate of 1.3%. Complications during and after EERP requiring re-intervention were one each of recto-urethral fistula, haemorrhage, symptomatic lymphocele and anastomotic leak. The positive margin rate for pT2 disease was 12.2% and for pT3 tumours 37%. CONCLUSION: The modular concept for teaching EERP is an attractive concept, which overcomes many of the problems involved in complex laparoscopic procedures. Based on a highly standardized technique, this concept offers a short learning curve; it enables training on different sites in cooperation with a high-volume centre, and it makes it possible to start with this complex procedure as a beginner or with no experience in open RP.     

Prediction of functional outcomes after nerve-sparing radical prostatectomy: results of conditional survival analyses

Background

In prostate cancer (PCa) patients treated with radical prostatectomy (RP), the rate of urinary continence (UC) and erectile function (EF) recovery may change significantly depending on the time interval between surgery and patient assessment. This effect, known as conditional survival, has not yet been assessed.

Objective

Evaluate the conditional rates of UC and EF recovery after nerve-sparing RP (NSRP).

Design, setting, and participants

We included 1135 PCa patients treated between January 2000 and June 2011 at a single referral center.

Intervention

All patients underwent NSRP.

Outcome measurements and statistical analysis

The Kaplan-Meier method assessed the time to recovery of UC (defined as an International Consultation on Incontinence Questionnaire score <6) and of EF (defined as an International Index of Erectile Function-Erectile Function score ≥22). Cumulative survival estimates were used to generate conditional recovery rates assessed at a 6-mo interval. Multivariable Cox regression analyses were performed to predict functional outcomes recovery after accounting for confounders.

Results and limitations

UC recovery rates were 89.5%, 94.7%, and 97.0% at 6-, 24-, and 36-mo follow-up, respectively. Corresponding EF recovery rates were 53.6%, 65.0%, and 67.5%, respectively. In patients who were still incontinent at 1, 6, 12, 18, 24, 30, and 36 mo after surgery, UC recovery rates in the following 6-mo period significantly decreased as the time from surgery increased: 74.9%, 58.2%, 41.4%, 14.9%, 24.8%, 24.6%, and 13.3%, respectively. Similarly, in patients still impotent at the same time points, the 6-mo rate of sexual potency recovery was 36.9%, 26.8%, 17.8%, 8.2%, 3.1%, 4.0%, and 0%, respectively. Multivariable analyses confirmed these results. The study is limited by its retrospective design.

Conclusions

In incontinent and/or impotent patients, the period elapsed from surgery represents an important predictor of the recovery of subsequent functional outcomes. The highest increments in UC and EF recovery were observed during the first year after surgery; they were virtually null after 36 mo.     

Initial experience with extraperitoneal endoscopic radical retropubic prostatectomy

Objectives

We report our initial experience using laparoscopic instruments and techniques in the performance of radical retropubic prostatectomy (RRP) through an entirely extraperitoneal endoscopic (EE) approach.

Methods

A 62-year-old man with a Gleason score of 7 and clinical Stage T1c adenocarcinoma of the prostate underwent EERRP. The procedure was evaluated for achievement of removal of the prostate and seminal vesicles and for complete vesicourethral anastomosis. Operative time, blood loss, hospital stay, and pathologic findings were also evaluated.

Results

Complete endoscopic removal of the prostate and seminal vesicles was achieved. Endoscopic reconstruction of the bladder neck with a watertight anastomosis was successful. Operative time was 5 hours and 45 minutes, with an estimated blood loss of 600 cc. Hospital stay was 2.5 days. Final pathologic evaluation was a Gleason score of 7 and Stage T2 disease with negative margins.

Conclusions

The initial experience for EERRP is encouraging. Further evaluation to refine the technique and determine its efficacy and role in treating prostate cancer is in order.     

高龄患者腹腔镜下行前列腺癌根治性切除术围手术期并发症及预后研究

目的 探讨高龄患者行腹腔镜前列腺根治性切除术（LRP）围手术期并发症发生及预后。方法 选取2012年1月至2017年12月在本院收治的116例高龄前列腺癌（PCa）患者（≥75岁）,均行LRP术,分析围手术期发生并发症、手术时间、术中出血量和术后住院时间等情况。围手术期并发症定义为术后30 d内发生的并发症。结果 平均手术时间175.8 min,平均出血量154.7 mL。术后平均住院时间15.9 d。围手术期并发症发生率33.6%（39例）,包括尿漏、尿路感染、肺炎、下肢静脉血栓、肺栓塞等。结论 LRP术仍有较高的并发症发生率,术前应积极治疗基础疾病,术中严格操作,术后采取相应预防措施以防止出现严重并发症,并根据患者情况选择合适的治疗方案。     

Frozen section for the management of intraoperatively detected palpable tumor lesions during nerve-sparing scheduled radical prostatectomy

OBJECTIVES: The intraoperative finding of palpable tumor lesions has been described as a contraindication for nerve-sparing (NS) radical prostatectomy (RP). However, its evaluation is subjective. Especially in patients with a strong demand to regain postoperative erectile function, a surgeon might be reluctant to sacrifice neurovascular bundles (NVBs) based on this information. We investigated the use of frozen section (FS) analysis to monitor the safety and efficiency of NS during RP in patients with intraoperatively identified subcapsular tumor lesions. METHODS: In 83 of 608 patients, who underwent NS-RP, intraoperative FS was performed because of a lesion palpable close to the capsule. A wedge of 4cm in diameter including the lesion was cut off and stained differently for capsule and intraprostatic margin. In case of presence of carcinoma adherent to the capsule, the NVB was resected; otherwise, the NVB remained in situ. RESULTS: Patients with palpable tumor lesions had pT3 tumors in 36% and 61% had Gleason 4 pattern, compared to 18% and 42% for the control group. Carcinoma was found in 93% of the FS specimens. In 42% of the FS samples, tumor had contact with the capsule and 14% of secondary resected NVB specimens demonstrated a carcinoma invasion. In 52% NVBs could be preserved despite an ipsilateral nodule without negatively affecting the margin status. However, the false-negative rate of the FSs was 6%. Conversely, FSs set the intraoperative decision to remove the NVB in 42% of FS patients, resulting in an additional 36% of negative margins. CONCLUSIONS: In patients with intraoperatively detected tumor lesions during a NS planned RP, FS objectively supports the decision of secondary NVB resection as well as preservation.