机器人辅助腹腔镜前列腺癌根治术中神经血管束保留技术的新进展

近年来机器人辅助腹腔镜前列腺癌根治术(RARP)已逐渐成为治疗局限性前列腺癌的一种安全有效措施,但术后性功能障碍一直困扰着患者及泌尿外科医师。本文将从RARP术中保留神经血管束的新技术以及对术后性功能恢复情况作一综述。     

机器人辅助腹腔镜与腹腔镜前列腺癌根治术的疗效比较

目的:分析比较机器人辅助腹腔镜与腹腔镜前列腺癌根治术治疗前列腺癌的效果,并探讨机器人辅助腹腔镜前列腺癌根治术的临床应用价值。方法:将2011年05月~2014年02月收治的38例前列腺癌患者作为机器人辅助腹腔镜手术组,以同期行腹腔镜前列腺癌根治术的32例患者为腹腔镜手术组。观察比较手术时间、术中出血量、术中输血率、术后引流管留置时间、术后住院时间、切缘阳性率、生化复发以及随访尿控及性功能情况。结果:两组均成功完成手术,机器人辅助腹腔镜手术组在术中出血量、术中输血率、术后引流管留置时间、术后住院时间、尿控及性功能保留方面均优于腹腔镜手术组,差异具有显著性(P0.05)。结论:机器人辅助腹腔镜前列腺癌根治术手术并发症少,术后尿控及性功能保留良好,是治疗前列腺癌安全、有效的微创术式。     

机器人前列腺癌根治术中困难盆腔的评估和手术策略

正达芬奇机器人系统因视野清晰、操作精细、缝合精确,在前列腺癌根治术中得到了越来越广泛的应用,目前,机器人辅助腹腔镜前列腺癌根治术(robot-assisted laparoscopic radical prostatectomy,RALP)已成为发达国家前列腺癌根治术的主要术式~([1])。RALP与开放和腹腔镜前列腺癌根治术相比,     

结直肠癌根治术后行机器人辅助腹腔镜前列腺癌根治术：7例经验总结并文献复习

目的:探讨结直肠癌术后前列腺癌患者行机器人辅助腹腔镜前列腺癌根治术的安全性和有效性。方法:回顾性分析2020年10月—2023年10月于北京大学第三医院和上海市第一人民医院由单一术者主刀的结直肠癌术后接受机器人辅助腹腔镜前列腺癌根治术的患者资料,分析其围术期结果、功能学结果和肿瘤学结果。结果:共有7例患者纳入分析,所有患者均在完全机器人辅助下完成手术,无一例患者中转开放。患者的平均手术时间为203 min,平均术中出血量为96 mL。所有患者均未发生直肠损伤等术中并发症。术后6个月所有患者(100%)均恢复自主控尿,但仅有1例(14.3%)患者保留勃起功能。结论:初步结果显示,结直肠癌术后行机器人辅助腹腔镜前列腺癌根治术是安全可行的。患者术后控尿功能恢复良好,然而性功能的保留不尽如人意。     

保留功能性尿道的逆行前列腺根治性切除术

<正>近年来前列腺癌发病率逐年升高,调查发现该病已成为美国男性发病率第一的恶性肿瘤[1]。腹腔镜前列腺癌根治术(laparoscopic radical prostatectomy,LRP)已经在我国大中型医院广泛开展,但LRP难度大、耗时长,术后尿失禁及性功能障碍等并发症较多。开放性耻骨后根治性前列腺切除术(open radical retropubic prostatectomy,ORRP)的应用比例虽然也在下降,但仍是局限性前列腺癌治疗的"金标准",LRP的相关并发症、近期与远期手术     

非手术因素对前列腺癌根治术术后尿控的影响

<正>前列腺癌是老年男性最常见的恶性肿瘤之一,其发病率在我国呈逐年上升的趋势^[1]。前列腺癌根治术在前列腺癌的治疗中一直占有重要地位,尤其是随着腹腔镜及机器人辅助技术的广泛应用,越来越多的前列腺癌患者因前列腺癌根治术而获益。前列腺癌手术“三连胜”指“瘤控、排尿功能恢复及性功能恢复”。瘤控是根治手术的基本面。     

机器人辅助完全后入路筋膜内前列腺癌根治术5例经验总结

目的简要介绍机器人辅助完全后入路筋膜内前列腺癌根治术的初步经验。方法回顾性分析浙江大学医学院附属邵逸夫医院泌尿外科2016年8月至10月间5例机器人辅助完全后入路筋膜内前列腺癌根治术患者的临床资料。结果所有手术均顺利完成,手术时间为124~155分钟,平均(139.8±13.9)分钟;术中出血量30~80ml,平均(52.0±19.2)ml。无切缘阳性患者。术后6周复查PSA均达到根治标准。3例患者术后拔除导尿管后即能完全控尿,未使用尿垫,其余2例在术后1个月内控尿完全恢复。2例患者术后1个月内恢复勃起功能,其余3例随访1个月未见明显性功能恢复。结论机器人辅助完全后入路筋膜内前列腺癌根治术是可行的。患者的肿瘤控制、术后尿控以及性功能恢复均较为满意。有条件的单位可选择合适患者施行。     

机器人辅助前列腺癌根治术和腹腔镜前列腺癌根治术的回顾性比较

目的通过对机器人辅助前列腺癌根治术与腹腔镜前列腺根治术的对比研究,探讨机器人外科手术系统在前列腺癌根治术中的优势及不足。方法收集2015年3月至2016年4月收治的前列腺癌患者54例,作为机器人辅助前列腺癌根治术组,2010年1月至2015年1月收治的前列腺癌患者中的50例,作为腹腔镜前列腺癌根治术组。分析比较手术时间、手术出血、围手术期输血率、术后引流量、留置引流管时间、胃肠功能恢复、住院时间、控尿及手术费用等指标。结果两组均成功完成手术,无中转开放性手术。机器人辅助前列腺癌根治术组在尿控方面优于腹腔镜前列腺癌根治术组(P0.05);在手术出血、围手术期输血率低于腹腔镜前列腺癌根治术组;术后引流量,胃肠道功能恢复及住院时间方面与腹腔镜前列腺癌根治术组差异无统计学意义;在手术时间和手术费用方面多于腹腔镜前列腺癌根治术组。结论机器人辅助前列腺癌根治术术后控尿具有显著优势,术后并发症少,有利于机器人手术辅助系统的推广,但其手术准备时间长,手术费用昂贵是机器人辅助手术发展的瓶颈。     

腹腔镜筋膜内与筋膜外前列腺癌根治术近期疗效比较

目的比较经腹膜外途径腹腔镜筋膜内前列腺癌根治术相对于筋膜外前列腺癌根治术在近期治疗效果方面的优劣,评价其临床价值。方法回顾性分析接受同一术者施行的经腹膜外途径腹腔镜前列腺癌根治术治疗的39例患者的临床资料,其中行腹腔镜筋膜内前列腺癌根治术(筋膜内组)20例,筋膜外前列腺癌根治术(筋膜外组)19例。结果 39例手术均获得成功,两组患者在年龄、血清前列腺特异性抗原(PSA)值、前列腺大小、Gleason评分、手术时间、术中出血量、术后进食、住院总费用、术后并发症及切缘阳性率均无明显差异。筋膜内组患者在术后住院时间、术后3月尿控恢复情况及术后6、12月性功能恢复情况方面明显优于筋膜外组患者,差异有统计学意义(P0.05),而术后6月、12月尿控恢复情况两组患者差异无统计学意义(P0.05)。结论腹腔镜下筋膜内前列腺癌根治术在手术时间、术中出血量、切缘阳性率等方面可取得与筋膜外前列腺癌根治术相当的效果,对于较年轻、肿瘤分期为cT1~cT2术前性功能正常的患者,腹腔镜下筋膜内前列腺癌根治性切除术是一种值得推荐的手术方式。     

前列腺癌根治术后勃起功能障碍的相关问题

前列腺癌根治术后的勃起功能障碍一直是困扰泌尿外科医师的难题,并严重影响患者的生活质量.术中海绵体神经的损伤是造成术后勃起功能障碍的主要原因.随着保留神经血管束或重建海绵体神经的前列腺癌根治术的开展及腹腔镜技术、机器人辅助腹腔镜技术与治疗药物的应用,前列腺癌根治术后勃起功能障碍的发生率已逐渐下降.本文拟就前列腺癌根治术后勃起功能障碍的相关问题进行讨论,以促进前列腺癌根治术后勃起功能障碍防治措施的推广应用.     

他达拉非用于前列腺术后阴茎康复的研究进展

前列腺癌根治性切除术(RP)是治疗绝大多数临床局限性前列腺癌的标准术式,保留神经的NSRRP术式的广泛采用使得RP的疗效得到了显著的提升,但是对RP术后勃起功能的保护仍是泌尿外科的难题。RP术后及早开始阴茎康复可显著改善RP术后勃起功能障碍(ED)对患者的术后生活质量。作为唯一的长效选择性磷酸二酯酶-5抑制剂(PDE5Is),他达拉非在RP术后阴茎康复中的显著疗效在临床试验和基础研究中均得到了证实。本文旨在回顾目前RP术后ED的相关进展,及他达拉非在RP术后阴茎康复中的有效性和安全性证据。     

Prostate operations: long-term effects on sexual and urinary function and quality of life. Comparison with an age-matched control population

The purpose of this study was to investigate the effects of radical prostatectomy (RP) for prostate cancer, transurethral resection of the prostate (TURP) for benign prostate hyperplasia (BPH), and the alterations induced by ageing on quality of life, urinary and sexual function, and bother. We evaluated 283 patients who filled in and returned the questionnaire used. A total of 105 were treated with RP and were selected prostate cancer patients with localised disease without recurrences. An additional 98 underwent TURP for BPH and a third group consisted of 80 apparently healthy men. The general quality of life was estimated by the Rand 36-Item Health Survey 1.0. Urinary function was estimated by the AUA Symptom Index and the UCLA Prostate Cancer Index (urinary function and bother scale). Sexual function and bother, were explored using the Brief Male Sexual Function Inventory for Urology. Patient outcome 2 years post treatment was compared to the pre-treatment status and to that of the matched control population. General quality of life was not affected by RP or TURP, with the exception of an increase in the emotional/well being domain in RP patients to control group levels. After RP there was more bother reported for the urinary function than urinary malfunction itself, while TURP, as expected, restored urinary function and bother to normal population norms. Elderly males had urinary function and bother similar to the operated patients. Estimating sexual function on RP patients, erectile dysfunction (ED) predominates, leading to decreased sexual life. TURP marginally affects sexual life, mainly due to the loss of ejaculation, while in men from the control group, sexual function, although affected, was still present.     

Update on erectile dysfunction in prostate cancer patients

PURPOSE OF REVIEW: Evolution in the management of prostate cancer includes increased attention being paid to patient quality of life after treatment, specifically with issues related to sexual function. Erectile dysfunction is one of the major concerns of patients undergoing treatment for prostate cancer. There are several recognized factors that determine the postoperative incidence of erectile difficulties, including patient age, degree of cavernosal nerve sparing during surgery, cancer stage, and associated vascular comorbidities. Early initiation of rehabilitation protocols after radical prostatectomy has been advocated to promote the speed and degree of recovery of erectile function. The aim of this communication is to review recent initiatives in erectile dysfunction restoration after prostate cancer therapy. RECENT FINDINGS: In recognition of the neurogenic basis of erectile dysfunction after radical prostatectomy, new strategies have been devised to initiate the rehabilitation process. Type 5 phosphodiesterase inhibitors, vacuum erection devices, and intracavernosal and intraurethral application of vasoactive agents have all been reported in a positive light in recent studies. Developments in cavernous nerve graft interposition procedures, perioperative neuroprotection measures, and postoperative neurotrophic treatments aim to preserve prostate cancer patients' qualities of life. SUMMARY: Data generated from a number of clinical investigations document that pharmacologic rehabilitation programs provide a higher rate of recovery of erectile function following radical prostatectomy. Both intracavernosal and intraurethral applications of vasoactive agents and vacuum devices can speed the recovery period for return of erectile function. Various neuroprotective and neurotrophic approaches are thought to provide integral roles for the maintenance of sexual function in men undergoing prostate cancer therapy.     

Disease-specific quality of life among patients with localized prostate cancer: an Australian perspective

OBJECTIVES: To examine differences in sexual, urinary and bowel function, and bother, in patients with prostate cancer after treatment with radical prostatectomy (RP) or external beam radiation (EBRT), compared to a convenience sample of men with no diagnosis of prostate cancer, as little is known about the disease-specific health-related quality of life (HRQoL) of men in Australia after treatment for clinically localized prostate cancer. PATIENTS AND METHODS: The study was a retrospective cross-sectional survey of 95 controls, 82 men with localized prostate cancer treated with RP and 39 with EBRT at > or = 2 years before data were collected. Disease-specific HRQoL was assessed using the University of California Los Angeles Prostate Cancer Index, a validated measure that includes six subscales addressing sexual, urinary and bowel symptoms, and level of bother associated with the symptoms. Univariate analyses were conducted to ascertain differences in disease-specific HRQoL among the three groups. To minimize the influence of other factors, age and comorbid medical conditions were included as covariates. RESULTS: Men treated with RP had more sexual and urinary symptoms (both P < 0.001) than those treated with EBRT, and more sexual bother (P < 0.001). Men treated with EBRT reported significantly worse bowel function (P = 0.02) and more bother (P < 0.001) with these symptoms than those who had RP. CONCLUSIONS: Except for bowel dysfunction and the bother associated with these symptoms, disease-specific HRQoL was generally worse after RP than EBRT.     

Preferences for sexual information resources in patients treated for early-stage prostate cancer with either radical prostatectomy or brachytherapy

OBJECTIVE: To identify the preferences for sexual information resources of patients before and after definitive treatment for early-stage prostate cancer with either radical prostatectomy (RP) or brachytherapy. PATIENTS AND METHODS: Two hundred patients (mean age 64 years) treated with either RP or brachytherapy were recruited from radiation oncology (100) and urology (100) outpatient clinics. Patients completed a survey questionnaire to identify the types of information used, preferred sources of information, knowledge of treatments for erectile dysfunction (ED), effect of sexual function on the treatment decision, and the International Index of Erectile Function (IIEF) to assess their current level of sexual function. RESULTS: Urologists were identified as the main source of sexual information. Written information, Internet access and videos were identified as preferred sources of information before and after treatment. The effects of treatment on sexual function had no apparent significant influence on the men's definitive treatment choice. Compared with patients in the brachytherapy group, patients in the RP group reported having significantly higher levels of sexual desire (P < 0.001) after treatment, but otherwise the erectile domains of the groups were remarkably similar. Two-thirds of patients wanted more information on the effects of treatment on sexual function, and on available treatments for ED. CONCLUSIONS: These results support the need for physicians to offer patients access to information on the effect of treatment for early-stage prostate cancer on erectile function before and after treatment.     

Health-related quality of life after radical prostatectomy in Japanese men with localized prostate cancer

PURPOSE: We evaluated retrospectively health-related quality of life (HRQOL) after radical prostatectomy (RP) in Japanese men with localized prostate cancer. METHODS: The study was based on self-reported HRQOL of 280 patients. Patients were divided into seven groups: time 0 (T0), baseline before operation; T1, 1-3 months after RP; T2, 4-6 months after RP; T3, 7-12 months after RP; T4, 13-24 months after RP; T5, 25-36 months after RP; and T6, more than 36 months after RP. We measured the general and disease-specific HRQOL using the RAND 36-item Health Survey 1.0 (SF-36) and the University of California, Los Angeles Prostate Cancer Index (UCLA PCI). RESULTS: The general HRQOL of the postoperative groups was assessed by SF-36. The postoperative groups showed almost the same or higher scores than those of the baseline group. Urinary function scores decreased substantially after surgery. In contrast, there was no difference in urinary bother between the baseline and postoperative groups. Sexual function deteriorated substantially in all postoperative groups. Similarly, the sexual bother score significantly deteriorated after RP. The sexual bother score of men aged 65-years or younger was significantly worse than that of their counterparts in the T1-2 groups. CONCLUSION: Despite reports of problems with sexual activity and urinary continence, general HRQOL was mostly unaffected by RP. Although there was a substantial decrease in urinary function, recovery from urinary bother was rapid. Since the deterioration of sexual function was marked through the postoperative period, careful attention should be paid to this issue during preoperative counseling, especially for younger patients.     

Current Status of Salvage Robot-Assisted Laparoscopic Prostatectomy for Radiorecurrent Prostate Cancer

Radiation therapy (RT) is one of the treatment options for prostate cancer (PCa). Transperineal low-dose rate brachytherapy (BT) is another safe and effective technique for low-risk PCa. Recurrence after RT for localized PCa can be defined by a PSA value of 2 ng/mL above the nadir after RT, and biochemical recurrence (BCR) rate after RT is 40-60 %. In case of radiorecurrent PCa, treatment options include salvage radical prostatectomy (RP), cryotherapy, high-intensity focused ultrasound (HIFU), and salvage BT. Only salvage RP has cancer control results for over 10-year follow-up in a substantial portion of patients (30-40 %). However, salvage RP is technically demanding, and experienced surgeons are needed; in fact, RT-induced cystitis, fibrosis, and tissue plane obliteration can lead to significant complications, such as rectal injuries, anastomotic stricture, and urinary incontinence. This review describes indications, oncologic and functional outcomes, surgical techniques, and complications of salvage robot-assisted RP.     

Patient-reported quality of life after radical prostatectomy for prostate cancer

BACKGROUND: Increasingly, quality of life (QOL) assessments are receiving greater attention in the management of malignancies, including prostate cancer. We evaluated the impact of radical prostatectomy on patient QOL 12 months or longer after surgery. PATIENTS AND METHODS: We evaluated the impact of radical prostatectomy on QOL in 60 patients with prostate cancer. The patients comprised two groups: the first group (n = 32) was evaluated 12 months or longer after radical prostatectomy; the second group (n = 28) was evaluated while awaiting radical prostatectomy. General health-related QOL was measured with the European Organization for Research and Treatment of Cancer Prostate Cancer QOL Questionnaire. Sexual function was assessed with the Sapporo Medical University Sexual Function Questionnaire. A newly developed instrument assessing urinary function was prepared only for the postoperative group. RESULTS: No differences between the two groups were seen in comparisons of general health-related QOL subscales. Men who underwent surgery reported significant deterioration in sexual function (decreased quality of erection, decreased sexual activity and decreased satisfaction with sex life) than those awaiting surgery. Of the 32 postoperative patients, 26 (81%) did not use pads at all, five (16%) used one or fewer pads per day due to occasional spotting and only one patient (3%) used two to four pads per day to deal with urine dripping. Twenty-six postoperative patients (81%) stated that, given the choice, they would undergo radical prostatectomy again. CONCLUSIONS: General health-related QOL does not appear to be compromised following radical prostatectomy. Patients are willing to accept some morbidity for a perceived survival benefit. Although minimal urinary dysfunction was reported, most patients were dissatisfied with postoperative sexual function. In preoperative counselling, greater emphasis should be placed on the risk of postoperative impotence.     

Sexual function with localized prostate cancer: active surveillance vs radical therapy

Study Type – Outcomes (cohort sample) Level of Evidence 2b What's known on the subject? and What does the study add? The study compares the sexual function of men with low‐risk prostate cancer who chose active surveillance (expectant management) with similar men who received radiation therapy or radical prostatectomy. The first group appeared to be sexually active more frequently and had less erectile dysfunction. The study was non‐randomized. No other studies exist on the effect of active surveillance on sexual function vs other treatment methods.

OBJECTIVE

• ? To compare sexual function of men with localized prostate cancer (PCa) on active surveillance (AS) with similar patients who received radical therapy.

PATIENTS AND METHODS

• ? Two groups of men with screening‐detected localized PCa were compared. The first were men on AS within the prospective protocol‐based Prostate Cancer Research International: Active Surveillance study. The second were men participating in the European Randomized Study of Screening for Prostate Cancer study who had received radical prostatectomy (RP) or radiation therapy (RT).
• ? Questionnaires were completed at two different timepoints after diagnosis or treatment (6 and 12–18 months). These contained 10 items on sexual function, the mental and physical component summary from the Short‐Form 12‐item health survey, the Center for Epidemiologic Studies Depression scale depression measure and the State Trait Anxiety Inventory general anxiety measure.
• ? Sexual function was compared between groups, and determinants were analysed in multivariable analysis, adjusting for baseline differences.

RESULTS

• ? A total of 65–68% of men on AS, 35–36% of those who underwent RP, 36–37% of those who underwent RT and 36% of men in the RP and RT groups combined (combined Tx) were sexually active.
• ? A total of 20–30% of men in the AS group, 86–91% of men in the RP group, 56–60% of men in the RT group and 71–76% of men in the combined Tx group were sexually inactive as a result of erectile dysfunction.
• ? A total of 44–51% of men in the AS group, 96% of men in the RP group, 73–76% of men in the RT group and 84–85% of men in the combined Tx group who were sexually active had problems getting or keeping an erection.
• ? In multivariable analysis these differences were significant, except for AS vs RT.

CONCLUSIONS

• ? Men with localized PCa on AS were more often sexually active than similar men who received radical therapy, especially RP. If not sexually active, this was less often attributable to erectile dysfunction for those on AS. If sexually active, this was less often associated with problems getting or keeping an erection for those on AS.
• ? The study was non‐randomized; the latest advances in RP and RT might impact results.