腹腔镜前列腺癌根治术中膀胱尿道吻合技术的改进及展望

前列腺癌根治术是治疗早期局限型前列腺癌的首选方法。随着腔镜器械的不断发展及手术技术的持续改进,腹腔镜前列腺癌根治术已成为治疗局限型前列腺癌的标准术式,它除了具有与开放手术一样的治疗效果外,还具有创伤小、恢复快的微创优势,迅速在国内大中型医院广泛开展。膀胱尿道吻合是腹腔镜前列腺癌根治术中最关键的步骤之一,如何减少膀胱尿道吻合的难度,提高手术效率并保证吻合的质量,是国内外泌尿外科专家所一直关注并期待解决的课题。本文总结了近几年国内外腹腔镜前列腺癌根治术中膀胱尿道吻合的技术改进和我们自身手术经验,与广大泌尿外科同行共飨。     

前列腺癌根治术后并发膀胱尿道吻合口狭窄的病因分析

通过分析前列腺癌根治术后并发膀胱尿道吻合口狭窄的诸多病因作一综述。通过PubMed检索平台,广泛检索近20年的英文文献。分析大样本(N100例)临床中心研究数据。所有纳入此综述的文献报告病例均是早期局限的前列腺癌患者。前列腺癌根治术后膀胱尿道吻合口狭窄的病因目前仍无统一定论,期待进一步的临床试验研究明确其病因并以此为依据有效预防此类并发症的发生。     

腹腔镜前列腺癌根治术

目的总结腹腔镜前列腺癌根治术的经验。方法2004年9月～2005年12月,我科对8例早期局限性前列腺癌行经腹腔腹腔镜前列腺癌根治术,游离前列腺直肠间隙达前列腺尖部,游离膀胱前间隙及耻骨后间隙,缝扎阴茎背深静脉后离断膀胱颈部,重建膀胱颈并与尿道吻合。结果8例腹腔镜前列腺癌根治术均获成功,无一例中转开放手术。手术时间270～420min,平均325min;术中出血量300～1600ml,平均580ml,其中1例由于术中损伤阴茎背深静脉大出血1600ml,需要输血4例。标本切缘阳性1例。术后膀胱尿道吻合口尿漏2例;术后2周拔除导尿管,出现尿失禁2例,1例尿失禁在随访6个月后尿控能力恢复,另1例尿失禁仍存在。8例术后随访10～24个月,平均16个月,排尿均通畅,未出现生化复发现象。结论熟悉前列腺的局部解剖、有良好的腹腔镜器械辅助及熟悉掌握各种腹腔镜下操作技术是开展此手术的关键。     

腹腔镜下前列腺癌根治术

近年来腹腔镜前列腺癌根治术(laparoscopic radical prosta-tectomy,LRP)成为治疗早期前列腺癌的又一种规范手术。它在保留开放性手术优点的同时,发挥其创伤小、出血少和视野清晰的特点。1992年Schuessler等报告第1例LRP,但因手术时间长(平均9.4h),与开放手术比较优势不大,故未再继续开展。1998年,法国医师Guillonneau和Vallancien再次开拓该项手术,改进和完善此技术,并将手术的关键技术标准化,使LRP在欧美和亚洲得到推广应用。LRP是泌尿外科腹腔镜手术发展过程中的一次最显著的进步。手术者在腹腔镜清晰的视野下,能更精细地和更有效…     

经腹膜外腹腔镜前列腺癌根治术

自1997年Schuesswler等报道腹腔镜前列腺癌根治术(laparoscopic radical prostatectomy,LRP)以来,LRP由于其微创、良好的手术视野以及患者较快的恢复时间,逐渐得到普及.掌握这项技术有较长的学习过程,如何缩短这一学习过程,是泌尿外科医师关注的重点之一,本文回顾性分析2005年4月至2009年10月应用腹腔镜手术治疗的33例前列腺癌根治性切除术患者的资料,报导如下.     

腹腔镜前列腺癌根治术36例报告

目的探讨腹腔镜前列腺癌根治术(laparoscopic radical prostatectomy,LRP)的可行性和手术技巧。方法2005年3月～2008年12月,行LRP36例。平均年龄64岁(51～73岁),术前病理检查均证实为前列腺癌。T111例,T225例。21例参照Montsouris方法行经腹腔途径LRP,15例行经腹膜外途径LRP。结果平均手术时间265min(155～480min),平均出血量455ml(170～2500ml)。中转开放手术3例,其中2例为阴茎背静脉复合体出血,1例为直肠损伤。术后病理报告切缘阳性2例。术后尿管留置10～30d,平均14d,无真性尿失禁发生。术后漏尿6例,尿道狭窄2例。术后平均随访15.5月(2～44个月),穿刺孔皮下种植转移1例,余35例无复发转移。术后1个月前列腺特异抗原(PSA)0～5.85ng/ml。结论LRP治疗局限性前列腺癌安全有效。熟练掌握盆腔解剖,预先处理阴茎背静脉复合体,熟练掌握膀胱颈重建和镜下吻合技术是成功完成手术的关键。     

机器人辅助腹腔镜前列腺癌根治术

前列腺癌好发于中老年男性,是目前最常见的泌尿系统恶性肿瘤之一.在美国,前列腺癌是发病率仅次于皮肤癌的男性恶性肿瘤,在肿瘤相关死亡原因中排在第二位.随着社会的人口老龄化、生活习惯的改变、前列腺癌检出率的提高,我国前列腺癌的发病率正逐年上升.关于前列腺癌的手术治疗近年有较多进展,其中手术机器人的出现使前列腺癌的微创外科治疗进入了新的时代,现简单阐述如下.     

保留控尿功能的腹腔镜前列腺癌根治术

目的 探讨保护控尿功能的前列腺癌根治术的技术要点.方法 对收治的94例T1b～T2c前列腺癌患者行保留控尿功能的前列腺癌根治术,即腹腔镜下精细解剖前列腺尖部,保护EUS及其控尿神经,膀胱颈后唇成形后与尿道吻合;并同前期42例行常规前列腺癌根治术(LRP)的患者比较,术后30、60和90 d评估患者的控尿状况.控尿标准: 站立或行走时无尿液漏出,或全天使用尿垫不超过1块.结果 术后30、60 d控尿率LRP组为27.7%(13/47)、66.0%(31/47);CSLRP组为55.3%(26/47)、85.1%(40/47),均有统计学差异(χ2＝7.406,4.663,P<0.05).术后90 d两组控尿率为78.7%(37/47)和91.5%(43/47)(χ2＝3.02,P>0.05).结论 利用腹腔镜的优点,保护EUS和膀胱颈后唇成形加强尿道后壁,能明显加快前列腺癌根治术后控尿的恢复时间.     

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。     

经膀胱途径单孔腹腔镜下前列腺癌根治术治疗局限性前列腺癌 8 例报告

目的 探讨经膀胱途径单孔腹腔镜下前列腺癌根治术(transvesical single-site laparoscopic radical prostatectomy,TVSSLRP)的手术技巧和疗效. 方法 选取2010年11月至2011年5月局限性前列腺癌患者8例.年龄37 ～ 65岁,平均58岁.体质指数(body mass index,BMI) 20.0 ～26.0 kg/m2,平均22.5 kg/m2.术前PSA 0.98 ～ 10.04 μg/L,平均7.50 μg/L.国际勃起功能指数(IIEF-5)≥21分7例,＜21分1例.术前穿刺活检病理TNM分期T1c期3例,T2a期5例.Gleason评分2+2分4例,3+2分3例,3+3分1例.D' Amico风险分层均为低风险.全麻下行TVSSLRP,手术由同一名术者完成.使用自制3通道单孔套管建立气膀胱操作通道.远离输尿管开口切开膀胱颈后缘,分离并切断双侧输精管,游离双侧精囊,切开狄氏筋膜,分离前列腺后壁.沿前列腺两侧做环形切口方便暴露前列腺侧韧带,筋膜内层面保留两侧阴茎勃起神经血管束.沿前列腺两侧游离至耻骨后,紧贴前列腺表面切断耻骨前列腺韧带,推开耻骨后血管复合体,分离前列腺尖部,切断尿道.为减少膀胱尿道吻合张力,在膀胱颈两侧和6点处切开膀胱黏膜及黏膜下层,用V-LocTM免打结缝线行膀胱尿道吻合. 结果 本组8例TVSSLRP均顺利完成,无增加辅助通道.手术时间75～ 180 min,平均125 min.术中出血量85 ～450 ml,平均140 ml,无输血患者.术中无手术并发症发生.术后病理检查分期pT2a期3例,pT2b期4例,pT2c期1例;Gleason评分2+2分2例,3+2分4例,3+3分2例;手术切缘均阴性.术后拔除尿管时间9～16d,平均14 d,拔管后控尿均满意,无尿失禁.住院天数13～25 d,平均17d.术后随访12 ～18个月,平均14个月,无尿道狭窄和生化复发发生.术后6个月5例患者勃起功能满意,IIEF-5≥21分. 结论 经膀胱途径单孔腹腔镜下前列腺癌根治术能有效保护阴茎勃起神经和控尿神经,肿瘤根治疗效好.     

New semiautomatic suturing device (Maniceps) for precise vesicourethral anastomosis during radical retropubic prostatectomy

Performing vesicourethral anastomosis following retropubic radical prostatectomy may, under some anatomical conditions, be difficult. We describe the use of a new suturing semiautomatic device for deep surgical operations (Maniceps) to facilitate vesicourethral anastomosis. Maniceps is a pair of forceps both jaws of which have a groove at the tip. A 7 mm straight needle is set on the needle-holder jaw. By closing and reopening the forceps, the needle is moved onto the needle-receiver jaw. The use of Maniceps in vesicourethral anastomosis ensure the procedure is safe, easy and effective.     

经腹腔途径腹腔镜前列腺癌根治术并发症的预防及处理

前列腺癌是西方国家发病率最高的肿瘤,也是男性患者致死率第二位的肿瘤.在中国,前列腺癌的发病率和死亡率也逐年上升.腹腔镜前列腺癌根治术已经成为治疗局限性前列腺癌的标准治疗方案之一.该手术的主要并发症包括:血管损伤、直肠损伤、吻合口瘘、吻合口狭窄、性功能障碍等.本文分享我们在经腹腔途径腹腔镜前列腺癌根治术的经验,探讨该术式相关并发症的预防和处理.     

腹腔镜前列腺癌根治术中两种膀胱尿道吻合方法的比较研究

目的:比较腹腔镜前列腺癌根治术中两种膀胱尿道吻合方法的患者临床资料,探讨单针体外牵拉缝合方法的效果。方法:回顾性分析95例接受经腹膜外腹腔镜前列腺癌根治术患者的临床资料。根据膀胱尿道吻合方法分为两组;双针连续缝合法组(A组,n=52)和单针体外牵拉缝合法组(B组,n=43)。分别比较两组手术时间、膀胱尿道吻合时间;引流管留置时间、导尿管留置时间、并发症以及手术切缘等指标。结果:与A组相比,B组有较短的手术时间(A组179.9min,B组142.8min,P<0.05)、膀胱尿道缝合时间(A组22.0min,B组12.9min,P<0.05);和较低的吻合口漏尿发生率(A组15.4%,B组2.3%,P<0.05)。但在术后尿道狭窄发生率、引流管留置时间、导尿管留置时间以及手术切缘阳性率等方面两组并无明显差异。结论:腹腔镜前列腺癌根治术中采用单针体外牵引缝合法可以缩短膀胱尿道吻合时间以及总手术时间,同时可以减少吻合口漏尿发生率。     

The single-knot method with Lapra-Ty clips is useful for training surgeons in vesicourethral anastomosis during laparoscopic radical prostatectomy

We determined the applicability of the running single-knotted suture with Lapra-Ty clips to locking the vesicourethra at the 6 o’clock position for teaching anastomosis during laparoscopic radical prostatectomy to trainee surgeons. Fifty consecutive patients underwent laparoscopic radical prostatectomy for prostate cancer conducted by five surgeons with no experience of this procedure. Twenty (group 1) and 30 (group 2) of the patients underwent vesicourethral anastomosis using the single-knot running technique without or with Lapra-Ty clips. Surgical data, duration of surgical anastomosis, extravasation rate, time until healing and catheter removal, and occurrence of anastomotic structures were evaluated. The duration of surgical anastomosis was significantly greater without than with the Lapra-Ty clips (56 ± 13 min versus 45 ± 10 min, P < 0.01). The extravasation rate on postoperative cystography was significantly higher without than with the Lapra-Ty clips (30.0% versus 10.0%, P < 0.05). Leakage occurred on the 6 o’clock side of the anastomosis in all of these patients and urinary retention occurred in one patient (5.0%) in group 1. The single-knot method with Lapra-Ty clips in vesicourethral anastomosis during laparoscopic radical prostatectomy is useful, safe, and efficient, especially for surgeons learning the technique.     

Utility of extracorporeal traction with nylon thread for easier vesicourethral anastomosis in laparoscopic prostatectomy

PURPOSE: Vesicourethral anastomosis in laparoscopic prostatectomy is a very difficult procedure. Our purpose in this study was to evaluate a new method using extracorporeal bladder neck traction with nylon thread for vesicourethral anastomosis during laparoscopic radical prostatectomy. MATERIALS AND METHODS: A total of 10 patients underwent laparoscopic radical prostatectomy by this technique, and we evaluated anastomosis time, operative time, and postoperative status of vesicourethral anastomosis. RESULTS: It was possible to shorten both anastomosis time and operative time by this procedure, and to obtain a hermetic anastomosis without higher risk of incontinence, stricture, or leakage. CONCLUSIONS: Extracorporeal bladder neck traction with nylon thread is a very useful procedure to carry out easier vesicourethral anastomosis, especially for a surgeon's initial experience in laparoscopic radical prostatectomy.     

Outcome of precise vesicourethral anastomosis following retropubic radical prostatectomy using a Foley catheter

PURPOSE: In order to evaluate precise anastomosis using a Foley catheter, complications following radical retropubic prostatectomy were examined. METHODS: Twenty-one patients underwent radical retropubic prostatectomy. Precise vesicourethral anastomosis was performed, visualizing the urethral stump by raising up the urogenital diaphragm using a Foley catheter. Complications, such as prolonged urinary extravasation and temporary urinary retention, were checked when the catheter was removed. Incontinence was evaluated both within 6 weeks and more than 6 weeks after operation. Anastomotic and urethral strictures were also checked during follow up. RESULTS: The follow-up period ranged from 4 to 47 months (mean (+/- SD) 22.0 +/- 12.1 months). Eighteen of 21 patients (85.7%) achieved continence after the operation. However, two patients still had stress incontinence and one patient had mild incontinence. Neither prolonged urinary extravasation nor temporally urinary retention were observed. Anastomotic and urethral stricture were not experienced during follow up. CONCLUSIONS: Precise anastomosis using a Foley catheter is technically easy and useful, even for relatively inexperienced urologists, to perform. Patients can often achieve continence following this procedure.     

Knotless “three‐U‐stitches” technique for urethrovesical anastomosis during laparoscopic radical prostatectomy

We describe a new technique for urethrovesical anastomosis that consists of placing three “U” stitches of Monocryl 2‐0 to connect the bladder neck and urethral stump together. The margins are united by a double passage of the suture, without tying any knots. The sutures are tied on the bladder's surface using Lapra‐Ty clips fixed at a certain distance from where to two mucosal margins have been joined. We carried out this technique on 90 patients who underwent laparoscopic extraperitoneal radical prostatectomy. The good joining of the margins, the absence of knots and the minimum trauma to the urethral wall together enable to create an anastomosis that is both “sealed” and “tension free”, allowing a quick “welding” of the margins and an early catheter removal. Regarding urinary continence, 56.6% (51) of patients were continent at catheter removal, 87.6% (78) were continent 3 months later and 98.9% (89) were continent after 6 months. In nine patients (10%), an episode of acute urinary retention occurred within 24 h after the removal of the catheter. We did not encounter any cases of vesicourethral anastomosis stenosis.     

Technical description and outcomes of a continuous anastomosis in open radical prostatectomy

OBJECTIVE

To describe the surgical technique, objective and subjective medium‐term outcomes of a novel continuous vesico‐urethral anastomotic suture in open radical prostatectomy (ORP).

PATIENTS AND METHODS

A continuous anastomosis comprising separate anterior and posterior monofilament 3–0 polydioxanone sutures, with the bladder neck ‘parachuted’ down on to the urethral stump, was used in 39 consecutive patients. A cystogram was taken after ORP in the first 23 patients. The catheter was removed as soon as patients were fully mobile. A validated postal questionnaire to determine continence and its effect on quality of life was sent to all patients ≥3 months after ORP.

RESULTS

The mean follow‐up was 18 months; there were no major complications. There was an insignificant or no leak in 91% of the patients who had a cystogram. Before discharge, 33 patients reported that they were continent, whilst five required a pad(s) for stress incontinence, and one was discharged with a catheter after failing the first catheter removal. Of the 95% who completed the questionnaire, 95% either did not leak urine, or only leaked a small amount; 84% of patients reported that leaking had a minimal effect on everyday life. No patients developed symptomatic urethral or bladder neck stricture/contracture.

CONCLUSIONS

Our technique of continuous anastomotic suturing for ORP is safe, reliable and well tolerated. Further randomized studies are warranted to compare the outcome with the standard interrupted vesico‐urethral anastomosis.     

Novel technique to enhance bladder neck dissection with traction of Foley catheter during extraperitoneal laparoscopic radical prostatectomy

BackgroundLaparoscopic radical prostatectomy (LRP) is a challenging technique that is associated with a steep learning curve. We describe a novel technique to develop bladder neck traction using a Foley catheter during extraperitoneal LRP to enhance bladder neck dissection, thereby improving patient and procedural outcomes.Materials and methodsThe novel technique employed a four-trocar approach to prostatectomy, which involved the introduction of a 1-0 Vicryl suture into the extraperitoneal space using an Endo Close needle to pull up the Foley catheter tip and make the bladder neck prominent. From June 2006 to November 2012, clinicopathological data of 71 patients who underwent four-port extraperitoneal LRP (modified extraperitoneal LRP, Group 1) were assessed and compared with those from 22 patients who underwent transperitoneal LRP (Group 2) retrospectively.ResultsThe two groups were comparable in terms of pathological staging and Gleason score. The operative time was significantly shorter (p < 0.05) and the total blood loss was less in Group 1 patients (p < 0.05). No patient in either group underwent early reintervention for bleeding or blood transfusion. Bilateral or unilateral nerve sparing surgery was performed in 80.3% and 45.5% of Group 1 and Group 2 patients, respectively. The immediate, 1 month, 3 month, 6 month, and 1 year continence rates were, respectively, 19.7%, 38%, 69%, 91.5%, and 100% in Group 1 and 18.2%, 50.0%, 77.3%, 86.4%, and 95.5% in Group 2. In Group 1, 100% of patients were continent 12 months postprocedure. The potency rate was 71.4% in both groups.ConclusionImproved bladder neck enhancement provides a clearer vision during bladder neck dissection. Similar functional results and cancer control rates were also encountered during modified extraperitoneal radical prostatectomy. This novel technique is a feasible method for performing endoscopic radical prostatectomy using four ports instead of five.     

Morbidity of laparoscopic radical prostatectomy: Summary of early multi-institutional experience in Japan

AIM: Laparoscopic radical prostatectomy is being evaluated throughout the world. The aim of the present study is to report early multi-institutional experience of the procedure in Japan. METHODS: A total of 148 men who were diagnosed with clinically localized prostate cancer underwent laparoscopic radical prostatectomy at seven different institutions in Japan. Early complications (within 30 days postoperatively) and postoperative convalescence were reviewed retrospectively. The median age of patients was 68.0 years (range, 51-80). RESULTS: The median operative time was 403 minutes (range, 167-925; average, 427). Blood loss ranged from 50 to 5000 mL (median, 540; average, 856). A total of 66 complications were reported in 55 patients (37.2%). Intraoperative complications were noted in 25 of 148 patients (16.9%): 10 rectal injuries (6.8%); five bladder injuries (3.4%); five cases of subcutaneous emphysema (3.4%); two intestinal injuries (1.4%); one major vessel injury (0.7%); one ureteral injury (0.7%); and one obturator nerve injury (0.7%). Overall, 16 of 148 patients (10.8%) required open conversion or postoperative open surgical repair. The most common postoperative complications were anastomotic leakage (6.8%), wound-related complications (4.7%) and perineal pain (4.7%). The bladder catheter was removed on day 7 or earlier in 73 cases (49.3%). The median time to ambulation was 1 day (mean 1.4, range 1-5). Oral intake was started on postoperative day 1 in 67 patients (45.2%) and on postoperative day 2 in 65 (43.9%). CONCLUSION: Although laparoscopic radical prostatectomy is technically demanding, reduced blood loss and shorter convalescence periods can be expected from the procedure. Surgeons should be aware of the disturbingly high morbidity rate related to early experience. By mastering laparoscopic skills and sharing knowledge, surgeons could reduce the impact of the learning curve required to complete this procedure competently.