腹腔镜根治性前列腺切除术中尿控功能保护的方法和手术技巧

Surgical technique for the protection of urinary continence function in laparoscopic radical prostatectomy (report of 81 cases)

目的探讨腹腔镜根治性前列腺切除术中尿控功能的保护,预防术后尿失禁的手术方法及技巧。方法对2008年10月至2012年6月施行的81例腹腔镜前列腺癌根治术资料进行回顾性研究。81例TNM分期为T1C～T2C的前列腺癌患者行腹腔镜前列腺癌根治术,其中经腹膜外径路15例,经腹腔途径66例。术中注重以下策略:①可靠处理背血管复合体;②尽量保留神经血管束,对部分低危患者施行筋膜内根治性前列腺切除术;③保留足够的功能性尿道;④黏膜对黏膜无张力吻合。所有患者于术后1、3、6和12个月随访尿控情况。结果术后留置导尿管7～23d。所有患者均随访满6个月,77例患者随访满12个月。术后6个月,白天62例(76.5%)患者尿控良好,尿失禁19例;夜间68例(84.0%)患者尿控良好,尿失禁13例。术后12个月,白天70例(90.9%)患者尿控良好,尿失禁7例;夜间74例(96.1%)患者尿控良好,仍有尿失禁3例。筋膜内根治性前列腺切除术5例,术后7～11d拔除导尿管后,仅1例白天有尿失禁,随访至术后3个月,已无一例存在尿失禁。随访期间无一例出现尿道狭窄。结论腹腔镜根治性前列腺切除术后的尿控功能恢复是渐进式的,绝大多数患者在术后12个月恢复尿控能力。术野清晰,努力做到解剖性前列腺切除,保留尽可能多的功能性尿道长度,黏膜对黏膜无张力吻合(避免术后尿道狭窄),将膜部尿道缝合至耻骨后就能获得良好的尿控效果。对低危的前列腺癌患者施行筋膜内根治性前列腺切除术将能获得最佳尿控结果。

Objective To discuss the effect of the surgical technique for the protection of urinary continence in laparoscopic radical prostatectomy （LRP） to prevent the urinary incontinence after LRP. Methods From October 2008 to June 2012, 81 cases of laparoscopic prostate cancer data were retrospectively studied. 81 patients with organ-confined prostate cancer （TNM stage of T1C-T2C） underwent laparoscopic radical prostatectomy with extraperitoneal approach in 15 cases and peritoneal approach in 66 cases. The preventive strategies for urinary incontinence during operation included： 1. to meticulously control the bleeding from the dorsal vein complex; 2. to preserve neurovascular bundles as possible, and to choose intra-fascial LRP for some low-risk patients; 3. to reserve enough length of the functional urethra; 4. to create a mueosa-to-mucosa urethrovesical anastomosis without tension. All patients filled out questionnaires on urinary continence function at 1, 3, 6 and 12 months postoperatively. Results The duration of bladder catheterization was from 7 to 23 days. The follow-up visit of all patients was at leaset 6 months, 77 patients were 12 months along. After a 6-month follow-up, 62 patients （76.5 % ） were diurnally continent, and 19 patients were diurnally incontinent. 68 patients （84.0 % ） were nocturnally continent, and 13 patients still suffered from incontinence during night. One year after surgery, 70 patients （90.9%） were diurnally continent, and 7 patients were diurnally incontinent. 74 patients （96.1%） were nocturnally continent, and 3 patients still suffered from incontinence during night. Only one case of 5 intra-facial patients were diurnally in continent after catheter removal after 7 to 11 days postoperatively. After a 3-month follow up, all patients were continent. No one urethral stricture case was found at 12 months of follow-up. Conclusions The recovery of continence after LRP is slow and incremental. Most patients recover continence function within a year. In order to get a better continent function, it is recommended to keep the operation field clear, to achieve anatomical prostatectomy, to preserve enough length of the functional urethral, to create a mucosa-to-mucosa urethrovesical anastomosis without tension, and to stitch the membranous part of urethra on the tissue behind pubis. For low risk patients, the Intra-fascial LRP provides the best result on postoperative continence.