经耻骨后膀胱入路机器人辅助腹腔镜前列腺癌根治术初步体会

前列腺癌根治术是泌尿外科最复杂的手术之一,由于疾病本身的多样性,手术治疗的方法也是多种多样的。目前较为常用的方法主要有以下几种:前入路、后入路、侧入路,经膀胱入路作为一种新的手术入路也在逐渐开展和运用[1]。2008年,Desai等[2]在2例尸体模型中完成了经膀胱入路机器人辅助腹腔镜前列腺癌根治术,开创了经膀胱入路行根治性前列腺切除的先河,其中1例为单孔腹腔镜,另1例为多孔腹腔镜,并发现单孔腹腔镜存在操作器械碰撞的问题。     

经膀胱前入路和经膀胱后入路机器人辅助前列腺癌根治术早期效果比较

目的:探讨不同入路机器人辅助前列腺癌根治术的早期效果。方法:回顾性分析2018年3月至2020年3月北京协和医院泌尿外科同一术者完成的44例机器人辅助前列腺癌根治术的病例资料,患者平均年龄65.9岁（范围：46~81岁）。手术经膀胱前入路完成24例（前入路组）,经膀胱后入路完成20例（后入路组）。采用 t检...     

国产单孔蛇形臂机器人手术系统在前列腺癌根治术中的初步应用

目的探讨国产单孔蛇形臂机器人手术系统用于前列腺癌根治术的安全性和可行性。 方法2021年10月至2022年4月,海军军医大学第一附属医院、南京医科大学第二附属医院、浙江大学医学院附属第一医院采用国产单孔蛇形臂机器人手术系统完成前列腺癌根治术17例,记录患者一般情况、肿瘤学指标、手术入路、手术时间、操作时间、术中出血量、辅助孔数量、围术期并发症、病理结果、术后一个月PSA及尿控情况等指标。 结果患者平均年龄（70±7）岁,平均BMI （24.8±2.7） kg/m²,术前平均PSA 11.9（6.6） ng/ml,Gleason评分6分者7例,7分者10例。17例手术均顺利完成,其中经腹腔入路10例,经腹膜外入路7例。5例手术为纯单孔术式,12例手术增加一枚12 mm辅助通道。平均手术时间（210±63）min,主刀医师上机操作时间（172±52）min,术中出血量（115±92）ml,围手术期无输血、肠道损伤、漏尿、发热、切口愈合不良等并发症。术后病理提示Gleason评分6分者4例,7分者12例,9分者1例;T₂期14例,T₃期3例;切缘阳性者4例（23.5%）。术后1个月平均PSA 0.01（0.074） ng/ml,12例患者尿控满意（71%）。 结论采用国产单孔蛇形臂机器人手术系统可安全、有效的开展经腹腔和经腹膜外的前列腺癌根治术。     

经腹膜外途径行单孔机器人辅助腹腔镜前列腺癌根治术的临床应用(附36例报告)

目的:总结经腹膜外途径行单孔机器人辅助腹腔镜前列腺根治术的临床经验。方法:2021年6月至12月共为36例前列腺癌患者经腹膜外入路行单孔机器人辅助腹腔镜前列腺癌根治术。Gleason评分均≤7分,cTNM分期T_2c期2例,余34例均为T_2c期以下。20例患者行标准的筋膜外切除技术(第1组),10例患者行常规筋膜内切除技术(第2组),6例采用最大保留周围结构的筋膜内切除技术(第3组)。结果:患者均顺利完成手术。第1组手术时间平均(75.5±15.5)min,第2组(105.6±18.8)min,第3组(85.6±16.8)min;术中出血量第1组平均(39.75±12.82)mL,第2组(82.5±12.08)mL,第3组(144.17±13.2)mL。术后6周复查总前列腺特异性抗原,均降至0.05 ng/mL以下。在尿控恢复方面,即刻尿控第1组为30%(6/20),第2组为70%(7/10),第3组为83.3%(5/6)。第2组、第3组在性功能恢复方面优于第1组。结论:经腹膜外入路行单孔机器人辅助前列腺癌根治术可成为中低危局限性前列腺癌的常规...     

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。     

腹腔镜前列腺癌根治术(附八例报告)

目的：总结腹腔镜前列腺癌根治术的体会。方法：8例均为pT1b-pT2期前列腺癌患者。腹腔镜下采用“5孔7步法“，经腹分别行膀胱后入路和前入路分离前列腺、切开膀胱颈、前列腺两侧分离、前列腺尖部切除、膀胱尿道吻合。结果：8例患者手术时间5-11h，平均7.3h。出血量200-1000ml，平均620ml。术后患者恢复良好，3周后拔除尿管排尿通畅，随访3-18个月无尿失禁等并发症发生。结论：腹腔镜前列腺癌根治术有良好的解剖影像，利于术中操作，减少术中出血，更好地保护重要解剖结构，术后恢复迅速。     

机器人辅助腹腔镜经腹腔与腹膜外单孔前列腺癌根治术围手术期护理的对比研究

目的:回顾性分析机器人辅助腹腔镜经腹腔与经腹膜外单孔前列腺癌根治术治疗前列腺癌的围手术期护理的疗效,探讨后者的护理优势。方法:回顾性分析四川省人民医院机器人微创中心2019年7月—2020年6月接受机器人辅助腹腔镜前列腺癌根治术的患者142例,其中行机器人辅助腹腔镜经腹腔前列腺癌根治术82例,行机器人辅助腹腔镜经腹膜外单孔前列腺癌根治术60例,所有手术均为同一术者完成。术后随访比较两组患者的手术切口护理情况、引流管拔除时间、疼痛评分、术后住院天数、术后排气时间、尿管留置时间、控尿训练的效果、切口愈合情况及美观度、术后随访患者满意度。结果:142例手术均在机器人辅助腹腔镜下顺利完成,无中转开放。经腹腔组与经腹膜外单孔两组手术切口护理切口感染3例(3.7%)、1例(1.7%),差异无统计学意义(P>0.05);引流管拔除时间分别为4.8(3~13)d和2.8(1~10)d,差异有统计学意义(P<0.05);术后疼痛评分分别为2.1(1~9)分和1.9(1~8)分,差异无统计学意义(P>0.05);术后住院天数分别为9.3(8.0~16.0)d和8.4(7.0~13.0)d,差异无统计学意义(P>0.05);术后排气时间分别为1.3(0.65~3.0)d和3.4(2.0~7.0)d,差异有统计学意义(P<0.05);术后尿管留置时间分别为9.0(7.0~21.0)d和6.0(4.0~8.0)d,差异有统计学意义(P<0.05);两组术后即刻、3个月、6个月尿控例数分别为8例(9.8%)、51例(62.2%)、62例(75.6%)和17例(28.3%)、43例(71.7%)、54例(90.0%),差异有统计学意义(P<0.05);两组总切口长度分别为12.1(10.4~13.4)cm和5.6(5.0~6.0)cm,差异有统计学意义(P<0.05);术后满意度分别为90%和100%,差异有统计学意义(P<0.05)。结论:机器人辅助腹腔镜腹膜外单孔前列腺癌根治术围手术期护理具有恢复时间更短、尿控缓解率更高、切口美观整洁、术后满意度更高的优势,更有利于术后护理工作的开展。     

免气腹单孔腹腔镜宫颈癌根治术护理配合

目的总结免气腹经脐单孔腹腔镜下宫颈癌根治术的手术配合经验,为手术护理提供参考。方法对32例免气腹经脐单孔腹腔镜下宫颈癌根治术患者,巡回护士根据手术特点做好术前访视、体位、眼睛及皮肤护理,器械护士熟悉手术步骤,密切配合,严格无菌、无瘤操作等。结果 32例均顺利完成手术,麻醉复苏顺利,返回病房后住院4～7 d出院。结论熟练掌握无气腹单孔腹腔镜手术特点和患者情况,严格操作规程,有利于术者操作及手术顺利完成。     

经膀胱单孔腹腔镜前列腺癌根治术：附2例报告

目的报道2例经膀胱单孔腹腔镜前列腺癌根治术的初步经验。方法选择2例前列腺癌（T1b,PSA〈10ng/ml）病例完成经膀胱单孔腹腔镜前列腺癌根治术。自制＂两环一套＂单孔四通道装置经穿刺入膀胱,建立单孔操作通道。手术程序包括环形切开膀胱颈,在前列腺包膜外游离并切除精囊、输精管、前列腺侧韧带,保留神经血管束,离断前列腺尖部,切断尿道,行尿道膀胱吻合。结果 2例手术均经膀胱单孔腹腔镜下完成。前列腺体积分别为53ml,24ml,手术时间分别3h和2.5h。失血量分别为150ml和80ml,术后7d拔除膀胱造瘘管,9d拔除尿管。拔管后患者完全控尿。结论经膀胱单孔腹腔镜前列腺癌根治术在技术上是可行的,该术式更适用于早期前列腺癌病例。     

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。     

经腹膜外机器人单孔腹腔镜根治性前列腺切除术的初步应用

经腹膜外机器人单孔腹腔镜根治性前列腺切除术的研究国内鲜有报道。本研究对9例局限性前列腺癌患者采用经腹膜外机器人单孔腹腔镜根治性前列腺切除术,手术均顺利完成,无额外增加辅助孔。手术时间及出血量可控,住院时间短。术后短期随访肿瘤控制及功能恢复效果满意,该术式安全可行,但远期疗效需进一步观察。     

腹膜外入路经脐单孔腹腔镜前列腺癌根治术围手术期护理：附11例报告

目的报道使用自制多通道套管经脐切口行单孔腹腔镜前列腺根治性切除术护理体会。方法2009年8月至2010年3月,对11例局限性前列腺癌患者行单孔腹腔镜下前列腺根治性切除术,配合围手术期的各项处理。观察术后手术切口护理、管道护理、疼痛评估、控尿训练的效果。结果11例手术均顺利完成,1例术后膀胱尿道吻合口漏,2例淋巴漏,1例泌尿系感染,经保守治疗治愈。患者术后第3天平均疼痛评分为1．5／10（0．5）。5例尿失禁观察6个月恢复完全控尿。结论做好围术期护理,特别是术前心理护理、肠道准备和术后管道护理,控尿训练对确保手术的成功,提高患者的自理能力和生存质量起着重要的作用。     

Cirugía robótica multicuadrante concomitante para prostatectomía radical y nefrectomía parcial izquierda. Dos procedimientos mediante un solo abordaje

IntroductionTo present the first case of a concomitant robotic radical prostatectomy and a left robotic partial nephrectomy performed by a single-port approach using the SP® da Vinci surgical system (Intuitive Surgical, Sunnyvale CA, EE.UU.).Patient and methodsA 66-year-old male diagnosed with localized prostate cancer and a left kidney renal mass incidentally found on computed tomography (CT) scan during prostate cancer evaluation. Procedures were performed using a single supra-umbilical 3 cm incision, plus one additional laparoscopic port, utilizing a standard Gelpoint® (Applied Medical, Rancho Santa Margarita, CA, EE.UU.) and replicating the technique previously described for single-port transperitoneal radical prostatectomy and partial nephrectomy with the use of the SP® robotic platform.ResultsTotal operative time was 256 minutes (min) with a console time of 108 min for radical prostatectomy, and 101 min for the partial nephrectomy respectively, including a warm ischemia time of 26 min. Estimated blood loss was 250 cc. Blood transfusion was not needed. Final pathology for prostate was adenocarcinoma Gleason 7 (4 + 3) and for the kidney lesion was renal cell carcinoma. After two months of follow-up, PSA was undetectable and no complications or recurrence were detected.ConclusionsThe single-port approach has advantages as easier surgical planning and transition for combined and multi-quadrants surgeries: faster recovery, minimal postoperative pain and need for opioids, and excellent cosmetic outcome. We suggest that combined procedures should be performed only in high volume institutions by surgeons with vast experience in robotic surgery in selected patients.     

单孔腹腔镜前列腺癌根治术：附5例报告

目的报道经脐部单孔多通道腹腔镜前列腺癌根治术手术的初步经验。方法 2010年6月至2010年11月,对5例TNM分期为T1b～T2的前列腺癌患者行经腹途径单孔腹腔镜前列腺癌根治术,所有患者既往无盆腔手术史。经脐部切口,长约4cm,置入单孔多通道设备（Quadport）,在此切口之外无附加任何其他操作通道。结果 5例手术均获得成功,无一例中转开放或传统腹腔镜手术。手术时间185～370min,平均303min。术中出血量220～650ml,平均431ml,无一例患者需输血。术后留置尿管时间12～21d,平均17d。无直肠损伤等并发症。术后住院时间12～25d,平均19d。所有病例术后病理均报告前列腺包膜完整,肿瘤切缘均为阴性。所有5例患者术后随访2～15周,控尿恢复良好,每天使用尿片约0～2片。结论单孔腹腔镜前列腺癌根治术是安全有效的治疗方法。     

Laparoscopic and robot assisted radical prostatectomy: establishment of a structured program and preliminary analysis of outcomes

PURPOSE: The technique of laparoscopic radical prostatectomy is difficult to master and is associated with a steep learning curve. We hypothesized that a structured approach to establishing a laparoscopic prostatectomy program would diminish complications during the learning process and that robotic technology would be useful in learning the operation. MATERIALS AND METHODS: A structured laparoscopic radical prostatectomy program was introduced at the Vattikuti Urology Institute on October 23, 2000. One of 2 surgeons with a combined experience of more than 500 laparoscopic radical prostatectomies performed or supervised the first prostatectomies, training a third surgeon with extensive "open" surgical skills but no laparoscopic experience. The "trained" surgeon then started performing the operation independently with robotic assistance. The results of this approach were analyzed at the end of 12 months. RESULTS: We performed 48 laparoscopic radical prostatectomies and 50 robot assisted prostatectomies within the 12-month period. The preoperative and intraoperative demographical variables were comparable in both groups as were the operative times, changes in hemoglobin concentrations, durations of hospitalization, positive margin rates and overall complication rates. All measured parameters were comparable to the "best-in-class" values for laparoscopic radical prostatectomy reported in the literature. CONCLUSIONS: A structured approach minimizes complications during the establishment of laparoscopic radical prostatectomy program. Robotic assistance helps skilled "open" surgeons learn the technique of laparoscopic radical prostatectomy.     

Robotic radical prostatectomy in the community setting--the learning curve and beyond: initial 200 cases

PURPOSE: The introduction of robotic assistance has the potential to improve surgical outcomes and reduce the steep learning curve associated with conventional laparoscopic radical prostatectomy. We report on our experience with robotic radical prostatectomy in the community setting. MATERIALS AND METHODS: A total of 200 patients underwent robotic radical prostatectomy during 18 months. Prospective data collection included a quality of life (Expanded Prostate Cancer Index Composite) questionnaire, basic demographics, prostate specific antigen (PSA), clinical stage and Gleason grade. Operative outcome measures included operative time, estimated blood loss and complications. Postoperative outcome measures included hospital stay, catheter time, pathology, PSA and return of continence. RESULTS: Average operative time was 141 minutes with an estimated blood loss of 75 cc. The intraoperative complication rate was 1% with no mortality, reexploration or transfusion. Of the patients 95% were discharged home on postoperative day 1 (1 to 3) with hematocrit averaging 34.5 (range 25 to 45). The average difference in preoperative and postoperative hematocrit was 3 points (range -2 to 15). Average catheter time was 7.2 days (range 5 to 15). The positive margin rate was 10.5% for the entire series, 5.7% for T2 tumors, 28.5% (T3a), 20% (T3b) and 33% (T4a). Of the patients 95% had undetectable PSA (less than 0.1 ng/ml) at average followup of 9.7 months. Continence at 1, 3, 6, 9 and 12 months was 47%, 78%, 89%, 92% and 98%, respectively. CONCLUSIONS: Our initial experience with robotic radical prostatectomy is promising. The learning curve was approximately 20 to 25 cases. With a structured methodical approach we were able to implement robotics safely and effectively into our community practice with minimal patient morbidity, and good oncological and functional outcomes.     

A direct comparison of robotic assisted versus pure laparoscopic radical prostatectomy: a single institution experience

PURPOSE: We compared a single institution experience with radical prostatectomy using a pure laparoscopic technique vs a robotically assisted technique with regard to preoperative, intraoperative or postoperative parameters. MATERIALS AND METHODS: From May 2003 to May 2005 we reviewed 133 consecutive patients who underwent extraperitoneal robot assisted radical prostatectomy and compared them to 133 match-paired patients treated with a pure extraperitoneal laparoscopic approach. The patients were matched for age, body mass index, previous abdominopelvic surgery, American Society of Anesthesiologists score, prostate specific antigen, pathological stage and Gleason score. Preoperative, perioperative and postoperative data, including complications and oncological results, were analyzed between the 2 groups. RESULTS: The 2 groups were statistically similar with respect to age, body mass index, prostate specific antigen, Gleason score and clinical stage. No statistical differences were observed regarding operative time, estimated blood loss, hospital stay or bladder catheterization between the 2 groups. The transfusion rate was 3% and 9.8% for laparoscopic radical prostatectomy and robotic assisted laparoscopic prostatectomy, respectively (p = 0.03). Conversion from robotic assisted laparoscopic prostatectomy to laparoscopic radical prostatectomy was necessary in 4 cases. None of the laparoscopic radical prostatectomy cases required conversion to an open technique. The percentage of major complications was 6.0% vs 6.8%, respectively (p = 0.80). The overall positive margin rate was 15.8% vs 19.5% for laparoscopic radical prostatectomy and robotic assisted laparoscopic prostatectomy, respectively (p = 0.43). CONCLUSIONS: We demonstrated that the laparoscopic extraperitoneal radical prostatectomy is equivalent to the robotic assisted laparoscopic prostatectomy in the hands of skilled laparoscopic urological surgeons at our institution with respect to operative time, operative blood loss, hospital stay, length of bladder catheterization and positive margin rate.     

腹膜外入路经脐单孔腹腔镜下前列腺癌根治术11例报告

目的 探讨使用自制多通道套管经脐切口行单孔腹腔镜下前列腺根治性切除术的方法及初步疗效.方法 2009年8月至2010年3月,对11例局限性前列腺癌患者行单孔腹腔镜下前列腺根治性切除术.经脐3 cm切口,腹膜前置入自制多通道套管,行单孔腹腔镜下双侧闭孔淋巴结清扫、前列腺根治性切除、膀胱尿道吻合术.膀胱尿道吻合采用活结套结连续缝合法完成.结果 1例增加1个套管,其余10例手术均顺利完成,无中转常规腹腔镜手术或开放手术.平均手术时间256(195～315)min,平均出血量90(20～180)ml,平均术后住院时间15.4(13～24)d,术后12 d拔除尿管.无术中并发症.术后1例出现膀胱尿道吻合口漏、2例出现淋巴漏、1例出现泌尿系感染,均经保守治疗治愈.病理报告11例手术标本切缘均阴性,清扫淋巴结阴性.患者平均随访7(3～11)个月,无肿瘤生化复发.结论 单孔腹腔镜下前列腺根治性切除术技术上可行,具有美观、微创、并发症少的特点,具有良好的短期功能和肿瘤控制效果,中长期疗效需进一步随诊观察.

Abstract：

Objective To present our initial experience in laparoscopic radical prostatectomy performed through an umbilical incision using a home-made multichannel port. Methods From August 2009 to March 2010, we performed single-port laparoscopic radical prostatectomy in 11 patients with localized prostate cancer. A home-made multichannel port was inserted extraperitoneally through a 3-cm umbilical incision. The single port extraperitoneal procedures included obturator fossa lymphadenectomy, radical prostatectomy and urethro-vesical anastomosis, while the urethro-vesical anastomosis was performed by a slip-knot running suture technique. Data were collected and analyzed prospectively. Results All cases were completed successfully, without conversion to a standard laparoscopic approach or open surgery except adding an additional port in one case. The average operative time was 256 minutes (range195-315), and the mean blood loss was 90 ml (range 20- 180), without any blood transfusion. The postoperative hospital stay was 15.4 days (range13- 24), and the Foley catheter was removed 12 days after surgery. No intraoperative complications occurred. One patient developed a vesico-rethralanastomosis leakage, 2 had lymphatic leakage and 1 had urinary tract infection,all of the cases were managed successfully with conservative treatment. Histopathological results showed negative surgical margine and negative lymph node dissection. All patients had no biochemical relapse after an average follow-up of 7 months. Conclusions Single-port laparoscopic radical prosta tectomy is feasible, cosmetic and minimally invasive with a low complication rate and good short-term outcome. Additional investigation is needed to evaluate the long-term safety and oncologic adequacy of this new approach.     

新型国产腔镜机器人在前列腺根治术中的医护配合探讨

目的 探讨“图迈TM”机器人实施前列腺根治切除术的手术护理配合方法。方法通过对19例国产腹腔内窥镜手术系统-“图迈TM”机器人前列腺切除术的手术配合和临床效果进行分析,提出手术室护士术中配合的具体要点,建立“图迈TM”机器人手术配合流程。结果 入组患者均顺利完成手术,无中转开放手术或更改为普通腹腔镜手术。本组患者平均术前准备时间（34±4）min,平均出血量（98±4）ml,平均手术时间（214±62）min,均未发生24 h内二次手术,并且均未出现因用物准备不充足,手术配合不熟练,手术衔接过程不流畅等问题造成手术时间延长的现象。医护配合满意度和患者满意度分别为95%和96%,本组患者在术后均未出现Clavien-Dindo≥Ⅲ级或与护理相关的并发症,患者排尿功能均有改善,平均肛门排气时间（2.3±0.6）d,平均疼痛评分（5.3±1.1）分,平均住院时间（4.7±3.5）d。结论 在新型国产机器人辅助前列腺根治术中,护理团队充分的术前准备和体位管理、流程化的配合与优化的头部空间管理有利于手术配合,保障了手术的顺利进行和患者的安全,值得广泛推荐运用。