腹腔镜在改良保留盆腔自主神经宫颈癌根治手术中的应用

Application of laparoscopy in the modified nerve plane-sparing radical hysterectomy of cervicalcancer

目的探讨腹腔镜下完成宫颈癌保留神经平面广泛子宫切除术（NPSRH）的可行性，评估腹腔镜NPSRH的安全性和有效性。方法收集134例Ib1期一Ⅱa2期子宫颈癌患者的临床资料，其中33例患者接受腹腔镜NPSRH（腹腔镜组），技术要点为在腹腔镜下以输尿管为关键解剖标志，利用盆腔固有间隙，整体保留输尿管下方的自主神经平面。术中应用Hem-o-lok血管钉闭合神经平面周围血管止血。101例患者接受开腹NPSRH（开腹组），术中无特殊器械应用。比较两组患者的各项临床、病理、手术相关指标和术后近期膀胱功能恢复情况。结果腹腔镜组与开腹组患者的年龄、体质指数、既往手术情况、国际妇产科联盟（FIGO）分期和病理类型比较，差异均无统计学意义（均P〉0．05）。腹腔镜组和开腹组患者的手术时间分别为（303．8±67．5）min和（272．4±57．5）min，差异有统计学意义（P=0．01）；中位失血量分别为177．0ml和474．5m1，输血者比例分别为6．1％和49．5％，中位术后住院天数分别为9．2d和11．0d，差异均有统计学意义（均P〈0．01）。两组患者拔尿管后，初次测残余尿达标者比例和中位导尿天数比较，差异均无统计学意义（均P〉0．05）。结论腹腔镜下完成NPSRH可行，保留神经的效果与开腹NPSRH相当，但明显减少了术中出血情况，促进了患者术后恢复。

Objective The aim of this study was to assess the feasibility and safety of laparoscopic nerve plane-sparing radical hysterectomy （NPSRH） and compare with that of open NPSRH. Methods One hundred and thirty-four patients with FIGO stage I bl-Ⅱ a2 cervical cancer were enrolled in the study. Thirty-three patients underwent laparoscopic NPSRH. During the operation, the pelvic autonomic nerve plane which is directly underneath the ureter was integrally preserved by dissecting the pelvic spaces laparoscopically. The vessels around the nerve plane were controlled by Hem-o-lok polymer dips. One hundred and one patients underwent open NPSRH without special instruments. The clinical, pathological and surgery-related parameters were compared between the two groups. Moreover, postoperative short-term bladder function of these patients was also analyzed. Results There was no significant difference between the laparoscopic group and open group in terms of age, body mass index, previous surgery, FIGO stage, pathologic type, etc. （P 〉 0, 05 ）. The mean duration of surgery in the laparoscopic group was significantly longer [ （303.8 ± 67.5 ） rain vs. （272.4 ± 57.5 ） min] （P 〈 0.01 ）. But, the laparoscopic group had less blood loss [ 177.0 ml vs. 474.5 ml, P 〈 0.01 ] and blood transfusion rate [ 6.1% （2/33 cases） vs. 49.5% （ 50/101 cases ）, P 〈 0. 001 ]. There was no significant difference regarding the proportion of patients who firstly passed the post-void residual urine volume （PVR） test （P 〉0.05）. The median time of catheterization between the two groups were also comparable （ P 〉 0.05 ）. However, the postoperative hospital stay was significantly shorter in the laparoscopic group [ median postoperative hospital stay 9.2 days vs. 11.0 days, P 〈 0. 001 ]. Conclusions Laparoscopic NPSRH is feasible. It seems to be comparable with open NPSRH in terms of preserving pelvic nerve function, but is more favorable in terms of blood lossand postoperative recovery.