经膀胱入路机器人辅助根治性前列腺切除术的短期疗效分析

Surgical techniques and short-term outcomes of transvesical robot assisted radical prostatectomy

目的 探讨经膀胱入路机器人辅助根治性前列腺切除术(TvRARP)的手术经验,分析术后短期疗效。 方法 回顾性分析我院2018年4—8月收治的10例接受TvRARP患者的临床资料。年龄(58.6±9.4)岁,体重指数(26.5±3.1) kg/m^2,术前tPSA(19.5±4.1)ng/ml,术前Gleason评分中位值6分(6~7分),前列腺体积(33.4±15.8)ml,术前国际勃起功能评分(IIEF-5)中位值12分(10~16分)。术前临床分期cT1c 期8例,cT2a期1 例,cT2b期1例。所有患者术前控尿均正常。TvRARP主要步骤:纵行切开膀胱后,沿尿道内口环形切开,先从后方依次分离两侧输精管和精囊,分离前列腺后表面直至前列腺尖部,随后在侧方分离两侧神经血管束,并在前方分离前列腺前表面直至尖部,最后分离、离断尿道,移除标本,完成膀胱-尿道吻合,关闭膀胱。 结果 10例手术均顺利完成,无中转开放病例,无输血病例,无严重术中、术后并发症发生。手术时间(140.5±35.5)min,术中失血量(65.5±35.5)ml。术后病理提示pT2a期6例、pT2b期3例、pT2c期1例;Gleason评分中位值6分(6~7分);切缘阳性1例。术后7 d拔除导尿管,9例即刻实现控尿,1例术后2周实现控尿。10例随访时间2~4个月,平均3个月。所有患者无肿瘤复发表现(tPSA<0.2 ng/ml)。术后2个月,IIEF-5评分中位值11分(8~13分),与术前比较差异无统计学意义(P>0.05)。 结论 TvRARP是治疗低风险局限性前列腺癌的可选术式,术后即刻控尿较理想,肿瘤控制效果和术后勃起功能恢复情况仍有待长期随访观察。

Objective To introduce the technique and report our initial experience of transvesical robot assisted radical prostatectomy (TvRARP).Methods From April 2018 to August 2018, 10 patients underwent TvRARP performed by a single surgical team were retrospectively reviewed. Preoperative data of patients [aged (58.6±9.4) years, BMI (26.5±3.1) kg/m^2, tPSA (19.5±4.1) ng/ml, biopsy Gleason score 6(6-7), prostate volume (33.4±15.8)ml and IIEF-5 score 12(10-16)] were collected. Preoperative study revealed 8 cases of cT1c, 1 case of cT2a and 1 case of cT2b. All patients were continent preoperatively. During the surgical procedure, the bladder was opened, and a circumferential incision was then made around the internal urethral orifice. Initially, posterior dissection of bilateral vas deferens and seminal vesicles was performed, followed by posterior dissection towards apex. Lateral dissection of neurovascular bundles was performed before anterior dissection towards apex. The exposed urethra was transected and specimen was removed. Vesicourethral anastomosis and closure of bladder was performed in a standard way.Results All 10 cases were successfully performed robotically without conversion, transfusion or other major intraoperative or postoperative complications. Postoperative pathology confirmed 6 cases of pT2a , 3 cases of pT2b and 1 case of pT2c [median Gleason score 6(6-7)]. One case was reported positive surgical margin. Operative time was (140.5±35.5) mins. Estimated blood loss was (65.5±35.5) ml. Urethral catheter was removed at 7 days postoperatively. Nine patients achieved urinary continence (0 pads) immediately after the removal of urinary catheter, while 1 patient returned to full continence at 2 weeks postoperatively. During a mean follow-up of 3 months (2-4 months), no biochemical recurrence was detected (tPSA<0.2 ng/ml). At 2 months postoperatively, IIEF-5 score was 11(8-13) and no statistically difference was made compared with preoperative data (p>0.05).Conclusions Transvesical approach is a valid alternative of RARP in patients bearing localized low-risk prostate cancer. Tumor control and preservation of erectile function remains to be determined by long term follow-up.