腹腔镜前列腺癌根治术术中实时盆底括约肌肌电监测的可行性研究

Feasibility of real-time pelvic sphincterial electromyographic monitoring during laparoscopic radical prostatectomy

目的 通过在腹腔镜前列腺癌根治术中实时用NIM-Response TM肌电监测仪监测盆底括约肌电活动,了解控尿神经的分布,以便术中保护控尿神经,提高术后控尿效果;并对比手术前后患者控尿情况,评价实时监测技术在保护控尿神经方面的效果及意义。方法 80例前列腺癌患者临床分期为T2a～T3a纳入研究。将这些术前控尿正常的患者随机分成2组,每组40例。其中A组(神经监测组)利用NIM-Response TM肌电监测仪对以上患者腹腔镜前列腺癌根治术中盆底括约肌电活动进行术中实时监测。所有患者均采用气管全麻,避免术中使用肌松药。接地电极接于上臂,探测电极置于肛门括约肌及尿道括约肌。术中在前列腺邻近结构处以神经刺激探针以最高5mA电流刺激和探测证实控尿神经在膀胱颈、前列腺、尿道周围行程及功能状态,通过避免电切电凝破坏控尿神经邻近结构达到保护其免受损伤的目的。B组(非神经监测组)行常规腹腔镜前列腺癌根治术。对比术前、术后拔尿管后24h、术后3个月和术后6个月患者控尿情况,包括尿动力学检查、尿垫试验、膀胱镜检查。结果 术后两组拔尿管后24h完全控尿率有显著差异(65.0%vs37.5%,P<0.05)、术后3个月和术后6个月控尿率则无差异(80.0%vs75.0%,P>0.05和92.5%vs90.0%,P>0.05)。术后30d尿动力学检查证实80例患者前列腺部尿道控制带阻力消失,尿道闭合压正常存在,括约肌肌电正常存在。膀胱镜见40例患者尿道括约肌结构存在,镜下括约肌收缩功能良好。结论 腹腔镜前列腺癌根治术中采用盆底括约肌电活动实时监测,对控尿神经的解剖及功能分布有较强的准确性,可加快术后控尿功能恢复。

Objective To evaluate whether real-time pelvic sphincterial electromyographic （PSE） monitoring during laparoscopic radical prostatectomy contributes to postoperative continence recovery. Methods Eighty patients with stage T2a-T3a prostate cancer （PC） were enrolled. All patients had preopera- tive full continence and were randomly divided into two groups （n=40 per group）. Patients in the PSE group underwent real-time PSE monitoring during laparoscopic radical prostatectomy and those in control group received laparoscopic radical prostatectomy alone. NIM-Response 1.0 eleetromyographic monitor system （Medtronic ENT Medtronic USA, Inc.） was used for the dissection, explosion and protection of the peripro- static nerve during the surgery. Follow up was done at outpatient clinic or by telephone to evaluate the uri- nary continence status on the day of catheter removal, 3rd month and 6th month postoperatively. Cys- tourethroscopy and urodynamic examination were performed on the 30th day after surgery. Results Surgery was successfully performed in all patients. There were no significant differences between two groups in baseline variables （P〉0.05）. In the PSE group, PSE showed the innervation of urethral sphincter was like a network, and thus continence sparing techniques were used in the laparoscopy radical prostatectomy. Signif- icant difference in full continence rate was found on the day of catheter removal （65.0% vs 37.5%, P〈0.05,respectively）, but absent on 3rd month and 6th month after surgery （80.0% vs 75.0% and 92.5% vs 90.0%）. On the 30th day after surgery, urodynamic examination and eystourethroscopy demonstrated urethral closure and urethral sphincter, respectively, in both groups. Conclusion Our findings demonstrate that real-time PSE monitoring during laparoscopic radical prostatectomy is beneficial for the early continence recovery after radical prostatectomy.