• 中国科技论文统计源期刊
  • 中国科技核心期刊
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Volume 44 Issue 9
Sep.  2019
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Clinical analysis of extraperitoneal laparoscopic radical prostatectomy by different surgical approaches

  • Received Date: 2019-03-30
    Accepted Date: 2019-06-17
  • ObjectiveTo investigate the clinical analysis of extraperitoneal laparoscopic radical prostatectomy on local prostate cancer by different surgical approaches.MethodsThe clinical data of 87 patients with local prostate cancer undergoing extraperitoneal laparoscopic radical prostatectomy were retrospectively analyzed.Among them, 28 cases underwent three-port ELRP and 59 cases underwent four-port ELRP.The clinical factors as ages, tPSA, prostate volume, clinical stage, hypertension, operative time, estimated blood loss, pathological scores, positive surgical margin rates, biochemical recurrence and drainage tube keeping days.ResultsAll the patients underwent successful surgery without turn to open surgery.During the three-port group and four-port group, operative time were (90.56±17.87) min and(118.66±22.45) min, the estimated blood loss were(121.45±45.76)mL and (189.87±75.43) mL, prostate volume were (36.75±12.26) mL and (67.47±22.65) mL respectively, with significant statistical difference(P < 0.05).Positive surgical margin were 2 cases and 4 cases, of which underwent the endocrine therapy, with no statistical difference(P>0.05).These was no statistical difference in the other factors(P>0.05).Follow-up 3 to 17 months after surgery, biochemical recurrence in 6 cases, to endocrine control satisfaction.ConclusionsCompared with the four-port ELRP, the three-port ELRP not only has not increased complicaiton, but also is more minimally invasive.It is worthy of clinical application for small and localized prostate cancer.
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  • [1] CENTER MM, JEMAL A, LORTET-TIEULENT J, et al.International variation in prostate cancer incidence and mortality rates[J].Eur Urol, 2012, 61(6):1079. doi: 10.1016/j.eururo.2012.02.054
    [2] Tabayoyong W, Abouassaly R.Prostate Cancer Screening and the Associated Controversy[J].Surg Clin North Am, 2015, 95(5):1023. doi: 10.1016/j.suc.2015.05.001
    [3] VERDIER E, DORÉ B, FROMONT G, et al.Open versus laparoscopic radical prostatectomy:a French center experience[J].Prog Urol, 2014, 24(3):173. doi: 10.1016/j.purol.2013.08.313
    [4] AKAND M, CELIK O, AVCI E, et al.Open, laparoscopic and robot-assisted laparoscopic radical prostatectomy:comparative analysis of operative and pathologic outcomes for three techniques with a single surgeon's experience[J].Eur Rev Med Pharmacal Sci, 2015, 19(4):525.
    [5] 花晨朝, 蔡忠林, 周川, 等.经腹途径与经腹膜外途径机器人辅助腹腔镜下根治性前列腺切除术临床疗效的Meta分析[J].中华男科学杂志, 2017, 23(6):540.
    [6] DI BENEDETTO A, SOARES R, DOVEY Z, et al.Laparoscopic radical prostatectomy for high-risk prostate cancer[J].BJU Int, 2015, 115(5):7860.
    [7] 张骞, 宋海峰, 孟一森.三孔六步法经腹膜外途径腹腔镜下根治性前列腺切除术[J].现代泌尿外科杂志, 2016, 21(10):737. doi: 10.3969/j.issn.1009-8291.2016.10.001
    [8] 刘茁, 孟一森, 虞巍.三孔法与四孔法经腹膜外途径腹腔镜下根治性前列腺切除术的比较[J].中华泌尿外科杂志, 2015, 36(8):595. doi: 10.3760/cma.j.issn.1000-6702.2015.08.009
    [9] 戢金瓯.腹膜外腹腔镜前列腺癌根治术治疗老年局限前列腺癌90例[J].蚌埠医学院学报, 2015, 40(6):770.
    [10] 刘茁, 孟一森, 虞巍, 等.单中心95例三孔法经腹膜外途径腹腔镜下根治性前列腺切除术的学习曲线结果分析[J].中华泌尿外科杂志, 2015, 36(9):680. doi: 10.3760/cma.j.issn.1000-6702.2015.09.014
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Clinical analysis of extraperitoneal laparoscopic radical prostatectomy by different surgical approaches

  • 1. Department of Urology, The First Affiliated Hospital of USTC, Hefei Anhui 230031
  • 2. Department of Urology, West Branch of The First Affiliated Hospital of USTC, Hefei Anhui 230031, China

Abstract: ObjectiveTo investigate the clinical analysis of extraperitoneal laparoscopic radical prostatectomy on local prostate cancer by different surgical approaches.MethodsThe clinical data of 87 patients with local prostate cancer undergoing extraperitoneal laparoscopic radical prostatectomy were retrospectively analyzed.Among them, 28 cases underwent three-port ELRP and 59 cases underwent four-port ELRP.The clinical factors as ages, tPSA, prostate volume, clinical stage, hypertension, operative time, estimated blood loss, pathological scores, positive surgical margin rates, biochemical recurrence and drainage tube keeping days.ResultsAll the patients underwent successful surgery without turn to open surgery.During the three-port group and four-port group, operative time were (90.56±17.87) min and(118.66±22.45) min, the estimated blood loss were(121.45±45.76)mL and (189.87±75.43) mL, prostate volume were (36.75±12.26) mL and (67.47±22.65) mL respectively, with significant statistical difference(P < 0.05).Positive surgical margin were 2 cases and 4 cases, of which underwent the endocrine therapy, with no statistical difference(P>0.05).These was no statistical difference in the other factors(P>0.05).Follow-up 3 to 17 months after surgery, biochemical recurrence in 6 cases, to endocrine control satisfaction.ConclusionsCompared with the four-port ELRP, the three-port ELRP not only has not increased complicaiton, but also is more minimally invasive.It is worthy of clinical application for small and localized prostate cancer.

  • 前列腺癌是常见的泌尿生殖系肿瘤之一,其发病率在男性肿瘤中位居第二位[1],近年来前列腺癌在我国的发病率呈显著上升趋势。根治性前列腺切除术是治疗局限性前列腺癌的首选措施,其手术治疗包括开放根治性前列腺切除术、腹腔镜下根治性前列腺切除术和机器人辅助前列腺癌根治术。本文就三孔法或四孔法ELRP治疗局限性前列腺癌病人效果作一报道。

1.   资料与方法
  • 选择2017年4月至2018年9月87例经ELRP治疗的前列腺癌病人,其中采用三孔法ELRP者28例(三孔组),四孔法ELRP59例(四孔组)。三孔法组年龄59~85岁;四孔法组年龄59~84岁。11例因前列腺特异抗原(PSA)增高或者体检行泌尿系B超检查发现前列腺有结节,采用B超引导下经直肠或经会阴前列腺穿刺活检术,穿刺活检病理明确诊断前列腺癌;3例经尿道前列腺电切术后,病理提示前列腺腺癌。术前:行盆腔MRI平扫加增强扫描检查,排除外周组织器官浸润及盆腔淋巴结转移;行ECT全身骨扫描检查,均未见有骨转移征象;完成血清PSA检查及前列腺体积计算;病人心、肺及肝肾功能无明显手术禁忌。2组病人年龄、总前列腺特异性抗原(tPSA)、临床分期、术前是否合并高血压差异均无统计学意义(P>0.05)(见表 1)。

    分组 n 年龄/岁 tPSA/
    (μg/L)
    前列腺
    体积/mL
    临床分期 高血压
    T1 T2a T2b T2c
    三孔法组 28 71.24±7.14 21.53±9.67 36.75±12.26 4 9 18 5 7
    四孔法组 59 69.61±6.22 23.12±11.81 67.47±22.65 10 15 17 9 10
    t 1.88 0.90 10.76 3.88 0.78
    P >0.05 >0.05 < 0.01 >0.05 >0.05
    △示χ2
  • 采用经腹膜外三孔法或四孔法根治性前列腺切除术。气管内插管全身麻醉,病人仰卧位,头低脚高位,常规消毒铺单,取脐下正中4 cm纵形切口,依次切开皮肤、皮下组织及腹直肌前鞘,血管钳撑开腹直肌至腹直肌后鞘,手指先行分离腹膜外间隙后,以自制气囊扩张膀胱前腹膜外间隙,经脐下套管置入腹腔镜,在腔镜监视下,于右侧腹直肌外侧缘脐下两指处放置10 mm Trocar。左侧腹直肌外侧缘脐下两指处放置5 mm Trocar,四孔法要在右侧髂前上棘内侧两指处放置5 mm Trocar,由助手辅助术中操作。分离Retzius间隙,切开盆内筋膜,切断耻骨前列腺韧带,缝扎背深静脉丛(见图 1)。清除前列腺表面脂肪,辨认膀胱颈和前列腺分界线,离断膀胱颈(见图 2)。分离输精管和精囊,切开Denonvilliers筋膜,分离前列腺直肠间隙,处理前列腺侧韧带,分离并保留神经血管束,离断前列腺尖部尿道(见图 3)。将前列腺暂时置于手术野外,再行膀胱和尿道单针连续吻合(见图 4),满意后,适当扩大脐下切口,取出标本,彻底止血,耻骨后留置引流管,结束手术。观察手术时间、术中出血量、术后Gleason评分、术后导尿管留置时间、手术切缘情况及术后生化复发。

  • 术后随访3个月,包括PSA检查及有无尿道症状等。连续2次血清PSA≥0.2 μg/L定义为前列腺癌生化复发。

  • 采用t检验、χ2检验和Fisher确切概率法。

2.   结果
  • 本组87例均顺利完成经三孔法或四孔法ELRP治疗,无一例中转开放手术。术后Gleason评分、术后尿管留置时间及术后复发方面差异均无统计学意义(P>0.05)。三孔法手术时间、术中出血量、前列腺体积均比四孔法少(或小)(P < 0.01)(见表 2)。三孔法切缘阳性发生率较四孔法高,但差异无统计学差异(P>0.05)(见表 2),术后加用内分泌治疗。1例前列腺体积为87.6 mL经三孔法ELRP治疗病人,术中输血300 mL。术后出现漏尿4例,经牵拉导尿管、延迟拔除尿管的时间后愈合;术后发生尿失禁6例,其中5例经盆底肌锻炼后好转,1例卧床时有排尿控制力,站立时不能完全控制。术后随访3~17月,生化复发6例,予内分泌治疗后控制满意。

    分组 n 手术
    时间/min
    术中
    出血量/mL
    术后
    Gleason
    评分
    切缘
    阳性数
    术后生化
    复发数
    术后尿管
    留置时间/min
    三孔法组 28 90.56±17.87 121.45±45.76 7.25±1.45 2 2 16.55±6.62
    四孔法组 59 118.66±22.45 189.87±75.43 7.56±1.36 4 4 15.76±7.34
    t 6.86 8.67 0.78 0.96
    P < 0.01 < 0.01 >0.05 1.000 1.000 >0.05
    △示Fisher确切概率法
3.   讨论
  • 前列腺癌是影响老年男性健康常见的恶性肿瘤,根治性前列腺切除术是治疗局限性前列腺癌的金标准[2]。本组通过三孔、四孔法ELRP治疗87例局限性前列腺癌,取得良好的临床疗效。对于体积较小的局限性前列腺癌而言,三孔法ELRP更具有明显的微创优势,值得临床推广应用。

    相比于开放手术而言,腹腔镜下前列腺根治性切除术由于其独特的微创优势,已成为治疗局限性前列腺癌的首选方式[3-4]。而经腹膜外入路腹腔镜下手术由于直接通过Retzius间隙抵达耻骨后实施操作,未进入腹腔,不仅有效避开对乙状结肠、直肠以及其血管神经等存在潜在损伤,还减少对膀胱分离、降低膀胱医源性损伤和功能紊乱的发生,故而是治疗局限性前列腺癌更好的方法[5]。由于腹腔镜入腔套管多,不仅增加腹部入孔数量,还增加出血、切口疝及内脏损伤的概率,影响腹部皮肤美观。因而,临床上逐渐尝试减少腹腔镜入孔数量开展前列腺癌的手术治疗,即省去右侧髂前上棘内侧穿刺孔,由传统四孔法改进为三孔法ELRP[6-7]。由于三孔法前列腺癌根治术将传统需要1个主刀和2~3个助手才能完成的手术精简只需1个主刀和1个助手就能完成手术,虽然节约了人力资源,但对术者提出了更高的要求。张骞[7]在传统腹腔镜下根治性前列腺切除术的基础上结合其自身的手术经验与心得,对手术过程进行简化和调整,将其归纳为三孔六步法经腹膜外途径腹腔镜下根治性前列腺切除术,推动其在临床开展。

    由于三孔法ELRP较传统操作套管减少,术者通过对膀胱颈的3点和9点钟的位置为膀胱下动脉前列腺支进行夹闭减少出血,使术野清晰,便于前列腺的切除。前列腺完整切除后,采用倒刺线单针连续缝合进行膀胱颈和尿道吻合,操作简化。刘茁等[8-9]通过比较三孔法与四孔法ELRP近期临床疗效,认为与四孔法相比,三孔法经腹膜外途径腹腔镜下根治性前列腺切除术手术时间、术中出血量、病理切缘等效果相对较好,近期肿瘤控制和术后控尿功能恢复情况相似。本组病例显示,相比于四孔法组而言,三孔法ELRP能明显减少手术操作时间和术中出血量,尤其术中出血量平均减少近60mL,而对术后复发、尿控功能及肿瘤控制却无明显差异。故而,对于有丰富腹腔镜手术经验的医师,经三孔法ELRP治疗局限性前列腺癌安全有效。

    当然,三孔法ELRP除了要求术者具备丰富腔镜技术外,还有一些因素需要考虑,比如临床分期、肿瘤是否局限、前列腺体积、术前PSA以及是否合并高血压等。研究[5, 7-8]表明,腹腔镜下对局限性前列腺癌切除具有明显优势,尤其对于临床分期为T1~T2期、前列腺体积 < 60 g者较为适合。本组病例显示,三孔法组前列腺体积要明显小于四孔法组,而且其中1例经三孔法治疗的体积大前列腺癌术中出血较多,说明对于体积较小的局限性前列腺癌病人而言,三孔法ELRP成为其治疗的首先术式。当然,对于年龄、术前PSA及是否合并高血压病人而言,两组之间未见明显差异,与文献[9-10]报道相一致。考虑三孔法ELRP具有手术操作时间短、出血量少等优势,对于高龄合并高血压的局限性前列腺癌病人而言,也应优先考虑三孔法ELRP来治疗。

    尽管本组87例局限性前列腺癌经三孔法或四孔法ELRP治疗后均取得满意疗效,但入选三孔法ELRP组病人的前列腺体积相对较小,今后仍需进一步扩大病例数进行疗效评估和分析。鉴于三孔法ELRP不仅创伤小, 而且还美观,因而对于体积较小的局限性前列腺癌值得推广和应用。

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