解剖性保留控尿肌群技术在腹腔镜根治性前列腺切除术中的临床应用价值

目的 探讨腹腔镜前列腺癌根治术（LRP）中解剖性保留控尿肌群技术对术后早期控尿功能恢复的影响,及其肿瘤学安全性。方法 回顾性队列研究。纳入2016年1月—2020年6月浙江大学医学院附属金华医院泌尿外科采用LRP治疗的前列腺癌患者共292例,将其中采用解剖性保留控尿肌群技术的83例纳入观察组;对另外209例接受经典前列腺癌根治术的患者与观察组患者进行1∶1倾向性评分匹配,选择其中83例纳入对照组。全组共166例,年龄45~75（64.0±7.3）岁,BMI 21~31（24.4±2.4）kg/m²。对比分析2组患者手术时间、术中出血量、术后病理TNM分期、Gleason评分、术后留置导尿时间、手术并发症和手术切缘阳性（PSM）率;采用Kaplan-Meier法评估患者3年、5年无生化复发（BCR）累积生存率;根据术后每天使用的尿垫数量进行控尿功能分级评估,分别于拔除导尿管后的当天（第1个24 h）、1周及1、3、6、12个月时,观察并对比2组患者控尿功能恢复情况。结果 2组患者年龄、临床分期、危险分级、膀胱颈和神经保留与否等临床基线特征比较,差异均无统计学意义（P值均>0.05）。全组166例均在腹腔镜下完成手术,术后恢复良好,无围手术期死亡病例。2组患者手术时间、术中出血量、术后病理TNM分期、术后Gleason评分、术后留置导尿时间和手术并发症比较,差异均无统计学意义（P值均>0.05）。观察组PSM率为10.84％（9/83）,低于对照组的13.25%（11/83）,但差异无统计学意义（χ²=0.23, P=0.633）。2组患者术后随访12~71个月,平均33.73个月。随访期间无死亡病例。观察组3年、5年无BCR累积生存率分别为90.2％和73.2%,对照组分别为91.4%和77.8%,2组差异无统计学意义（χ²=0.38, P=0.535）。在拔除导尿管后当天、1周及1、3、6个月,观察组完全控尿率分别为39.76%（33/83）、53.01%（44/83）、66.27%（55/83）、90.36%（75/83）和97.95%（81/83）,对照组为16.87%（14/83）、21.96%（18/83）、38.55%（32/83）、53.01%（44/83）和68.67%（57/83）;观察组控尿功能分级均优于对照组,差异均有统计学意义（Z=-4.24、-4.09、-3.78、-5.61、-4.99,P值均<0.001）;拔管后12个月,2组完全控尿率分别为98.80%（82/83）和93.98%（78/83）,控尿功能分级比较差异无统计学意义（Z=-1.67,P=0.094）。术后3个月,观察组控尿（完全+社交）率达100％（83/83）,高于对照组的73.49%（61/83）,差异有统计学意义（χ²=25.36, P<0.001）。结论 LRP中解剖性保留控尿肌群技术的应用有助于患者术后早期恢复控尿功能,且不影响手术的肿瘤学安全性。

Application of anatomical preservation muscle group technique in laparoscopic radical prostatectomy

Objective This work aimed to investigate the effect of anatomical-sparing continence muscle group technique on the oncological safety and postoperative urinary continence function of laparoscopic radical prostatectomy (LRP). Methods A retrospective cohort study was adopted. A total of 292 patients with prostate cancer underwent LRP surgery in the Department of Urology of Jinhua Hospital Affiliated to Zhejiang University School of Medicine from January 2016 to June 2020. Among them, 83 patients who underwent anatomical urinary muscle group preservation technique during LRP surgery were included in the observation group. Another 209 patients who underwent classical LRP were matched with the observation group by 1∶1 propensity score matching, and 83 of them were selected as the control group. A total of 166 patients were enrolled with an average age of 45-75 (64.0±7.3) years and a BMI of 21-31 (24.4±2.4) kg/m². Operation time, intraoperative bleeding, postoperative pathological TNM staging, Gleason score, postoperative indwelling catheterization time, surgical complications, and positive surgical margin (PSM) rate were compared between the two groups. Kaplan-Meier method was used to evaluate the cumulative 3- and 5-year survival rates without biochemical recurrence (BCR). Continence recovery was graded according to the number of pads used per day after surgery. The recovery of urinary continence function was observed and compared at 24 hours, 1 week, 1 month, 3 months, 6 months, and 12 months after catheter removal. Results The two groups had no significant differences in age, clinical stage, risk classification, and bladder neck and nerve preservation (all P values >0.05). All patients in the two groups underwent laparoscopic surgery and recovered well. No perioperative death was recorded. No significant differences in operation time, intraoperative bleeding, postoperative TNM staging, Gleason score, indwelling catheterization time, and surgical complications were found between the two groups (all P values >0.05). The PSM rates were 10.84% (9/83) and 13.25% (11/83) in the observation and control groups, respectively, and the difference was not statistically significant (χ²=0.23, P=0.633). No deaths occurred during follow-up for the average of 33.73 (12-71) months. The 3- and 5-year BCR-free rates were 90.2% and 73.2% in the observation group and 91.4% and 77.8% in the control group, respectively, and had no statistical significance (χ²=0.38, P=0.535). The rates of complete continence at 24 hours, 1 week, 1 month, 3 months, and 6 months after catheter removal were 39.76% (33/83), 53.01% (44/83), 66.27% (55/83), 90.36% (75/83), and 97.95% (81/83) in the observation group, respectively, which were significantly better than those in the control group (16.87% 14/83], 21.96% 18/83], 38.55% 32/83], 53.01% 44/83], and 68.67% 57/83], the classification of urinary continence function in the observation group were better than that in the control group, and the differences were statistically significant (Z=-4.24, -4.09, -3.78, -5.61, -4.99, all P values < 0.001). The continence rates in the observation and control groups at 12 months after catheter removal were 98.80% (82/83) and 93.98% (78/83), respectively, there was no significant difference in the classification of urinary continence function between the two groups (Z=-1.67,P=0.094). The continence rates (complete urine control and social urine control) in the observation and control groups at 3 months after catheter removal were 100% (83/83) and 73.49% (61/83), respectively, and had no significant difference (χ²=25.36, P<0.001). Conclusion The application of anatomical-sparing continence muscle group technique does not affect the oncological safety of LRP but helps patients restore urinary continence function in the early postoperative period, including patients with localized prostate cancer other than the lateral side.