高危及局部晚期前列腺癌新辅助治疗后行腹腔镜下前列腺癌根治术的临床体会

Clinical experience of laparoscopic radical prostatectomy in high-risk and local advanced prostate cancer after neoadjuvant therapy

目的：探讨高危及局部晚期前列腺癌在3个月内分泌新辅助治疗后，行腹腔镜下前列腺癌根治术的临床经验和短期疗效。方法患者年龄55～81岁，所有患者术前行超声引导下的前列腺12点系统穿刺，发现79例前列腺癌患者。根据患者术前血前列腺特异性抗原（PSA）、Gleason评分和磁共振检查，发现其中36例为局限性前列腺癌（A组），43例为高危和局部晚期前列腺癌（B组）。A组穿刺后4～6周行腹腔镜下前列腺根治术，B组先行3个月左右的新辅助内分泌治疗（全雄激素阻断），再行腹腔镜下前列腺癌根治术。结果 A组患者穿刺前PSA 3.6～15.8 ng/ml，平均9.3 ng/ml。B组患者前列腺穿刺前PSA 12.6～45.2 n g/ml，平均23.6 n g/ml。经3个月新辅助内分泌治疗后PSA下降至0.02～3.6 ng/ml，平均1.2 n g/ml。手术时间A组65～180 min，平均136 min；B组70～210 min，平均152 min。术中出血A组30～400 ml，无术中输血；B组50～600 ml，其中2例患者输血红细胞400 ml。两组患者皆无直肠和周围脏器损伤等严重并发症出现。术后病理标本A组发现前列腺切缘阳性2例，无膀胱颈部、精囊和局部淋巴阳性；B组发现前列腺切缘、膀胱颈部和精囊阳性6例，局部淋巴阳性4例。术后1个月复查PSA，A组0.001～0.03 ng/ml，B组0.01～0.45 ng/ml。术后对于其中病理切缘、膀胱颈部、精囊和局部淋巴结阳性以及术后生化复发，皆给予辅助内分泌治疗。患者随访6～20个月，其中A组3例生化复发，1例局部复发，无骨转移和远处转移；B组12例出现生化复发，4例局部复发，2例出现骨转移和远处转移。结论新辅助内分泌治疗后能够明显缩小前列腺肿瘤体积，通过临床降期使高危及局部晚期患者获得手术机会。与局限性前列腺癌相比，并未明显增加手术难度和并发症。新辅助内分泌治疗配合腹腔镜下前列腺癌根治术，为高危及局部晚期前列腺癌患者提供了新的治疗手段。但该方法仍有较高的肿瘤复发和转移发生，与传统的单纯内分泌治疗相比，是否能够改善前列腺癌患者的长期预后，尚有待长期随访结果的观察。

Objective To investigate the clinical experiences and short-term therapeutic effects of laparoscopic radical prostatectomy （LRP） for high-risk and local advanced prostate cancer after a three-month neo-adjuvant endocrine therapy. Methods With age ranging from 55 to 81, all patients were screened by ultrasound guided 12 cores prostate biopsy, among which 79 cases were diagnosed as prostate cancer. According to the prostate specific antigen （PSA） in blood before operation, Gleason scores and magnetic resonance imaging （MRI）, 36 cases were diagnosed as localized prostate cancer （group A）, and 43 cases were diagnosed as high-risk and local advanced prostate cancer （group B）. Group A was subjected to LRP four to six weeks after biopsy, while group B received three-month neo-adjuvant endocrine therapy （maximal androgen blockade） and LRP in sequence. Results The PSA of group A was 3.6-15.8 ng/ml （mean： 9.3 ng/ml）. After three-month neo-adjuvant endocrine therapy, PSA of group B reduced from 12.6-45.2 ng/ml （mean：23.6 ng/ml） before biopsy to 0.02-3.6 ng/ml （mean：1.2 ng/ml）. The operation time of group A was 65-180 minutes （mean：136 minutes）, and that of group B was 70 to 120 minutes （mean：152 minutes）. The intraoperative blood loss of group A was 30-400 ml without blood infusion, while that of group B was 50-600 ml, with 2 patients received red blood cells infusion of 400 ml. No severe complications occurred in both groups, such as rectal injuries, peripheral organs injuries and so on. Postoperative pathology found 2 positive surgical margins in group A, without positive case in bladder neck, seminal vesicle and regional lymph nodes. Group B was found 6 positive cases in prostate resection margin, bladder neck and seminal vesicle, and 4 positive regional lymph nodes. One month after LRP, PSA of group A and group B were 0.001-0.03 ng/ml and 0.01-0.45 ng/ml, respectively. Patients with positive pathologic results in prostate resection margin, bladder neck, seminal vesicle and regional lymph nodes received adjuvant endocrine therapy immediately, as well as those with biochemical recurrence in the follow-ups. After a follow-up duration of 6 to 20 months, 3 cases were found with biochemical recurrence, one case with regional recurrence in group A, without bone metastasis and distant metastasis. In group B, 12 cases were found with biochemical recurrence, 4 cases with regional recurrence and 2 cases with bone metastasis and distant metastasis. Conclusion Neo-adjuvant endocrine therapy can reduce the volume of prostate cancer significantly, allow high-risk and local advanced patients to operation by reducing clinical stage, without increasing operative difficulty and complications obviously, compared to localized prostate cancer. Neo-adjuvant endocrine therapy in combination with LRP provides a new therapeutic approach for patients with high risk and local advanced prostate cancer. However, relative high rates of cancer recurrence and metastasis still exist. Compared with traditional hormone therapy, whether this approach can improve long-term prognosis of patients with prostate cancer still awaits investigation into the results of long-term follow-ups.