保留Retzius间隙机器人辅助腹腔镜根治性前列腺切除术：经膀胱入路与后入路的技术比较和临床效果

目的 比较经膀胱入路与后入路保留Retzius间隙机器人辅助腹腔镜根治性前列腺切除术（RARP）两种手术方法的技术特点及临床疗效。方法 回顾性分析2016年12月至2018年12月收治的35例分别行后入路保留Retzius间隙RARP或经膀胱入路保留Retzius间隙RARP的前列腺癌患者临床资料。后入路RARP组22例，术前总前列腺特异抗原（tPSA）（16.9±7.5）ng/mL，Gleason评分7分（5~8分），前列腺体积（42.3±11.2）mL，国际勃起功能指数-5（IIEF-5）评分14分（9~20分），临床分期cT1c期9例、cT2a期4例、cT2b期3例、cT2c期6例；经膀胱入路RARP组13例，术前tPSA（18.6±8.7）ng/mL，Gleason评分6分（5~7分），前列腺体积（35.4±9.6）mL，IIEF-5评分15分（10~21分），临床分期cT1c期8例、cT2a期2例、cT2b期2例、cT2c期1例。所有患者术前尿控均正常。两组患者均采用经腹腔途径完成手术。分析比较两种手术方法的手术时间、术中出血量、术后病理分期、术后Gleason评分、尿控恢复时间、术后IIEF-5评分的差异。结果 35例手术均顺利完成，无术中转开放手术者，无输血病例，无严重术中、术后并发症发生。后入路RARP组手术时间（123.4±31.7）min、术中出血量（48.2±12.8）mL，经膀胱入路RARP组手术时间（135.3±25.6）min、术中出血量（65.2±19.8）mL，两组间差异均无统计学意义（P均>0.05）。术后病理结果提示后入路RARP组病理分期pT2a期6例、pT2b期6例、pT2c期8例、pT3a期2例，术后Gleason评分7分（5~8分），经膀胱入路RARP组病理分期pT2a期8例、pT2b期3例、pT2c期2例，术后Gleason评分6分（5~7分），两组间差异均无统计学意义（P均>0.05）。后入路RARP组切缘阳性5例（22.7%），经膀胱入路组RARP切缘阳性3例（23.1%），两组间差异无统计学意义（P>0.05）。两组患者均于术后7 d拔除导尿管，后入路RARP组18例即刻实现尿控（无需使用尿垫），4例术后2周实现尿控；经膀胱入路RARP组患者12例即刻实现尿控，1例术后2周实现尿控，两组间差异无统计学意义（P>0.05）。术后2个月，后入路RARP组IIEF-5评分为11分（4~13分），经膀胱入路RARP组为12分（5~14分），两组间差异无统计学意义（P>0.05）；两组IIEF-5评分与术前比较差异均无统计学意义（P均>0.05）。两组患者随访3~24个月，均未见肿瘤生化复发表现（tPSA均<0.2 ng/mL）。结论 经膀胱入路保留Retzius间隙RARP治疗体积较小的局限性前列腺癌手术效果与后入路保留Retzius间隙RARP技术相当，具有较好的术后即刻尿控效果，但性功能恢复需要进一步随访。经膀胱入路保留Retzius间隙RARP技术可行，未来有望成为治疗局限性低风险前列腺癌手术方式之一。

Retzius-sparing robot-assisted laparoscopic radical prostatectomy via transvesical and posterior approaches: a comparative study of the techniques and clinical outcomes

Objective To compare the surgical techniques and clinical outcomes between transvesical and posterior approaches for Retzius-sparing robot-assisted laparoscopic radical prostatectomy (RARP). Methods The clinical data of 35 patients with prostate tumors receiving Retzius-sparing RARP between Dec. 2016 and Dec. 2018 were retrospectively analyzed. Twenty-two cases underwent Retzius-sparing RARP via posterior approach (pRARP), and the preoperative data (total prostate-specific antigen [tPSA] [16.9±7.5] ng/mL, Gleason score 7 [5-8], prostate volume [42.3±11.2] mL and international index of erectile function-5 [IIEF-5] score 14 [9-20]) were documented, with nine cases at cT1c stage, four at cT2a, three at cT2b and six at cT2c. There were 13 cases in transvesical RARP (TvRARP) group, and the preoperative data (tPSA [18.6±8.7] ng/mL, Gleason score 6 [5-7], prostate volume [35.4±9.6] mL and IIEF-5 score 15 [10-21]) were also recorded, with eight cases at cT1c stage, two at cT2a, two at cT2b and one at cT2c. All patients had urinary continence preoperatively. Both pRARP and TvRARP were performed transperitoneally. The operation time, intraoperative blood loss, postoperative staging, postoperative Gleason score, recovery of urinary continence and postoperative IIEF-5 score were compared between the two groups. Results The operations were successfully completed in all the 35 cases without conversion to open surgery, blood transfusion or other major surgical complications. The operation time were (123.4±31.7) min and (135.3±25.6) min, and the estimated blood loss were (48.2±12.8) mL and (65.2±19.8) mL in pRARP and TvRARP groups, respectively, without significant differences (both P>0.05). Postoperative pathology confirmed six pT2a cases, six pT2b cases, eight pT2c cases and two pT3a cases in pRARP group, with Gleason score being 7 (5-8); and eight pT2a cases, three pT2b cases and two pT2c cases in TvRARP group, with Gleason score being 6 (5-7) (both P>0.05). Positive surgical margins were found in five cases (22.7%) in pRARP group and three cases (23.1%) in TvRARP group (P>0.05). Urethral catheter was removed at postoperative 7-day in both groups. Eighteen patients in pRARP group and 12 patients in TvRARP group achieved urinary continence (without pads) immediately after the removal of urinary catheter, while four patients in pRARP group and one patient in TvRARP group achieved urinary continence 2 weeks postoperatively (P>0.05). IIEF-5 score was 11 (4-13) in pRARP group and 12 (5-14) in TvRARP group 2 months postoperatively (P>0.05). There was no significant difference in IIEF-5 scores before and after operation in the two groups (both P>0.05). During a follow-up of 3-24 months, no biochemical recurrence was noted (tPSA<0.2 ng/mL). Conclusion The clinical outcomes of Retzius-sparing TvRARP for small localized prostate cancer are similar to those of Retzius-sparing pRARP, with satisfactory immediate postoperative urinary continence. Though the preservation of erectile function requires further follow-up, Retzius-sparing TvRARP is technically feasible and might be a valid alternative for localized low-risk prostate cancer.