盆底神经解剖定位及实时电生理监测技术在机器人辅助腹腔镜根治性前列腺切除术中的应用探索(附11例报告)

Anatomical localization and real-time neuro-electrophysiological monitoring of pelvic organ nerves during robot-assisted laparoscopic radical prostatectomy(report of 11 cases)

目的:观察神经电生理监测系统在机器人辅助腹腔镜根治性前列腺切除术中进行盆底神经解剖性定位、全程功能监测和功能保护的应用情况,探讨术中保护盆腔神经及神经监测的应用前景。方法:选取2021年1月-2021年4月在中国人民解放军总医院第一医学中心确诊为前列腺癌,并接受根治性前列腺切除术的患者11例,患者术前勃起、尿控及排便功能均正常。术中进行盆底神经电生理监测:先进行盆底神经解剖性分离定位(上腹下丛、腹下神经、盆丛及其各分支),予以电刺激后记录监测时间点效应器官(阴茎海绵体肌、尿道内外括约肌、肛门括约肌)的全程神经电生理波形图,同时记录手术时间、术中失血量、术后尿管拔除时间、即刻及远期尿控情况、术后恢复排气时间、术后恢复排便时间、术后勃起功能评分、尿控及肛门失禁评分等指标。结果:11例手术均顺利完成。术中保留神经方式:5例使用双侧筋膜外技术,4例使用双侧筋膜内技术,1例使用左侧筋膜间,右侧筋膜外技术,1例使用左侧筋膜内,右侧筋膜间技术。患者年龄(61.90±4.70)岁,BMI(26.09±3.91)kg/m^(2),手术时间(193.20±42.97)min,平均术中出血量(109.10±43.69)mL,术后拔除尿管时间(14.82±1.78)d。4例双侧筋膜内患者术后即刻尿控良好,尿失禁评分(ICIQ-SF评分)≤4分,其中3例术后6个月复查IIEF-5与勃起硬度评分明显下降,剩余1例在术中切除前列腺前后予以电刺激诱发,均出现阳性肌电图波形且振幅无明显变化。该患者术后勃起,尿控及排便功能恢复良好。结论:在根治性前列腺切除术中行盆底神经解剖性定位,并应用神经电生理监测安全可行;术中实时监测到的肌电图波形与患者术后功能恢复情况具有一定相关性,为预测患者术后功能保留及恢复提供了一种具有临床应用前景的方法。

objective:To explore the clinical significance of anatomical localization and real-time neuro-electrophysiological monitoring of pelvic organ nerves to preservation of pelvic organ nerves in robot-assisted laparoscopic radical prostatectomy(RALP).Methods:A total of 11 patients with prostate cancer who were treated at the PLA General Hospital from January 2021 to July 2021 with normal erectile function,urinary function,anorectal function before operation were selected to undergo neuro-electrophysiological monitoring of pelvic organ nerves during RALP.During the operation,the pelvic organ nerves(superior hypogastric plexus,hypogastric nerve,pelvic plexus and their branches)were dissected and stimulated.After electrical stimulation,the changes of the electrophysiological waveforms of the effector organs(the Corpus cavernosum,urethral sphincter and ani sphincter)were recorded.Meanwhile,the operation duration,blood lost during operation,the time of the uric catheter removal,the situation of immediate and long-term continence,the time of recovery of ventilation and defecation,the scores of postoperative erectile function,urinary function,anorectal function after the operation were recorded.Results:All 11 patients underwent surgery successfully.For nerves preservation,5 patients underwent bilateral extrafascial technique,1 patient was given left interfascial right extrafascial technique,and 4 patients were subjected to bilateral intrafascial technique,1 case received left intrafascial and right interfascial technique.The average age was(61.90±4.70)years,the average body mass index(BMI)was(26.09±3.91)kg/m^(2),the average operation duration was(193.20±42.97)min,the average intraoperative blood loss was(109.10±43.69)mL,and the postoperative time of uric catheter removal was(14.82±1.78)days.Four patients with bilateral intrafascial surgery recovered immediate continence well and their incontinence score(ICIQ-SF score)≤4.The IIEF-5 and EHS scores in 3 of these patients decreased significantly 6 months after surgery,and the rest one had good recovery of erectile,urinary continence and anorectal function whose electrophysiological waveforms had significant change after stimulation during operation.Conclusions:Anatomical localization and real-time neuro-electrophysiological monitoring of pelvic organ nerves during RALP is safe and feasible with the nerve electric monitoring system.The electromyography waveform of real-time nerve monitoring during operation is correlated with the recovery of erectile function,urinary function,anorectal function,which provides a promising method for predicting the preservation and recovery of these functions after operation.