腹腔镜根治性前列腺切除术后控尿功能及学习曲线

Postoperative urinary continence and learning curve after laparoscopic radical prostatectomy

目的:评价腹腔镜根治性前列腺切除术后的控尿功能,探讨达到稳定控尿的学习曲线。方法:2006年5月至2011年5月于北京大学第三医院行腹腔镜下根治性前列腺切除术的临床局限性前列腺癌患者200例,其中由一名术者施行且随访资料完整的共160例纳入本研究。患者的平均年龄(71.9±5.5)岁(56～85岁),术前无尿失禁。11例为经尿道前列腺电切术后,其余149例于经直肠超声引导下前列腺穿刺活检明确诊断,无肿瘤远处转移。回顾患者的临床资料、手术数据,并对术后控尿情况进行随访。控尿定义为不使用尿垫、日常活动不漏尿或偶尔少许漏尿。根据手术先后顺序平均分成4组,比较组间控尿是否存在差异。结果:手术均在腹腔镜下成功完成,无中转开放。平均手术时间(230±57)min(110～493 min),中位出血量200 mL(30～1 200 mL),输血率7.5%,术后住院时间(11.8±7.9)d(5～60 d)。术后病理分期:T2a期32例(20%)、T2b期27例(16.9%)、T2c期64例(40%)、T3a期24例(15%)、T3b期9例(5.6%)、T4期4例(2.5%)。切缘阳性率32.5%。随访时间均在12个月及以上,总体控尿率:1个月14.4%、3个月48.8%、6个月77.5%、12个月86.3%,截止最后一次随访,仍然有21例(13.1%)存在不同程度的尿失禁,与后期相比,前40例控尿较差(P<0.05)。结论:腹腔镜根治性前列腺切除术后控尿良好,与开放手术的报道类似。手术经验的积累可以改善术后的控尿功能,对于有一定腹腔镜操作经验的术者来说,达到一个比较稳定的控尿水平需要在40～50例之后。

Objective：To evaluate urinary continence outcomes after laparoscopic radical prostatectomy （LRP）, and explore the learning curve for continence. Methods： Between May 2006 and May 2011, 200 consecutive patients with clinically localized Third Hospital, of whom 160 were performed by a prostate cancer underwent LRP in Peking University single surgeon and followed up successfully. The average age was （71.9 ±5.5） years （their age range： 56 to 85 years）. All the patients were continent before operation. Of these patients, 11 had undergone previous transurethral resection of the prostate （TURP） and the other 149 were diagnosed by transrectal prostate biopsy. No metastasis was found before surgery. The data about the patients and the operations were recorded. The time from operation till urinary continence was obtained and accessed by interviews. Continence was defined as the use of no pad and no urinary leakage or loss of a few drops occasionally. The patients were divided into 4 equal groups in the 40 consecutive series to determine whether continence was statistically different in group A （ 1 - 40） as compared with the other groups. Results： All the operations were performed laparoscopically without any conversion to open surgery. The mean operative duration was （230 ±57） min （ranging from 110 to 493 min）, the median estimated blood loss was 200 mL （ranging from 30 to 1 200 mL）, 12 patients （7.5%） received blood transfusions intraoperatively, and the average hospital stay after surgery was （11.8 ± 7.9） d （ranging from 5 to 60 days）. The distribution of pathologic stages was as follows： T2a 20%, T2b 16.9%, T2c 40%, T3a 15%, T3b 5.6% and T4 2.5%. The overall positive surgical margin （PSM） rate was 32.5%. The overall continence rates （no pad） were 14.4% after 1 month, 48.8% after 3 months, 77.5% after 6 months and 86.3% after 12 months. At the end of the follow-up, 21 patients （ 13.1% ） were still incontinent. There was a significant difference in continence between the early （Group A） and later groups （P 〈0.05 ）. Conclusion： Continence results after LRP were encouraging, which were comparable to the results in previously published open series. Continence could be improved with increasing surgical experience, and it takes 40 - 50 cases to reach a plateau for surgeons who have some experiences of laparoscopic operations.