腹腔镜下前列腺癌根治术治疗高危前列腺癌的临床效果分析

Clinical outcomes of laparoscopic radical prostatectomy for high risk prostate cancer

目的 探讨腹腔镜下前列腺癌根治术治疗高危前列腺癌的临床效果.方法 回顾性分析2011年1月至2013年6月在南京医科大学第一附属医院泌尿外科行腹腔镜下根治手术治疗的65例高危前列腺癌患者临床资料.患者年龄45- 75岁,平均67岁;前列腺特异抗原（PSA）水平11.2 -65.5 μg/L,平均26.7 μg/L.穿刺Gleason评分3＋3分4例,3＋4分27例,4＋3分11例,4＋4分21例,4＋5分2例.骨扫描检查排除骨转移.患者在全身麻醉下行经腹腔径路腹腔镜下前列腺癌根治术,切除前列腺后行扩大盆腔淋巴结清扫.根据术后病理结果决定术后是否辅助放疗或内分泌治疗.术后门诊随访,1年内每1-2个月检测PSA值,每3个月评价尿控情况;1年后每2-3个月检测血PSA值.结果 手术平均时间（134±21） min,术中平均出血量（300±146） ml.术中膀胱颈重建15例,术后平均7d拔除尿管,平均4d拔除引流管.术后病理检查结果示病理分期为pT225例,pT3a 28例,pT3b 9例,pT4 3例;切缘阳性15例.淋巴结平均清扫19枚（11 -24枚）,淋巴结转移患者11例,阳性淋巴结共19枚.术后拔除尿管后恢复正常排尿43例,术后3个月尿失禁5例,术后12个月尿失禁1例.11例患者术后行辅助内分泌治疗,19例患者行辅助放疗.术后随访12-30个月,平均20个月,5例患者随访期间出现生化复发.结论 腹腔镜下前列腺癌根治术加扩大盆腔淋巴结清扫术治疗高危前列腺癌手术安全可行,手术可提供准确的分期分级情况,是高危前列腺癌综合治疗中重要的治疗方法.

Objective To study the technique and clinical outcomes of laparoscopic radical prostatectomy for high risk prostate cancer.Methods A total of 65 patients with high risk prostate cancer were treated with surgery in the First Affiliated Hospital of Nanjing Medical University from January 2011 to June 2013.The mean age was 67 years （range 45-75 years）.The mean preoperative prostate specific antigen （PSA） level was 26.7 μg/L（range 11.2-65.5 μg/L）.The transrectal biopsy revealed Gleason score of 3 ＋ 3 in 4 patients, Gleason 3 ＋ 4 in 27 patients, Gleason 4 ＋ 3 in 11 patients, Gleason 4 ＋ 4 in 21 patients and Gleason 4 ＋ 5 in 2 patients.The bone metastasis was excluded by scintigraphy examination.The surgical procedures were performed through transperitoneal approach.Extended pelvic lymph nodes dissection was performed after the removal of the prostate.Adjuvant radiotherapy or hormonal therapy was administrated according to the pathological results.Serum PSA was detected every 1 to 2 month and urinary continence was evaluated every 3 month in the first year, and then serum PSA was detected every 2 to 3 month.Results The mean operative time was （134 ± 21）minutes and the median blood loss was （300 ± 146） ml.Bladder neck reconstruction was performed in 15 cases.The drainage was removed on postoperative day 4 and the catheter was removed on day 7.Pathologic results demonstrated pT2 in 25 patients, pT3a in 28 patients, pT3b in 9 patients and pT4 in 3 patients.Positive surgical margin was presented in 15 patients.A median of 19 lymph nodes （range 11-24 nodes） were retrieved during lymphadenectomy and 11 patients had lymph nodes metastasis with a total of 19 positive nodes.Forty-three patients recovered continence after the removal of catheter.Eleven patients received adjuvant hormonal therapy and 19 patients received adjuvant radiation therapy.With the median of 20 months follow-up（range 12-30 months）, 5 patients got biochemical recurrence.Conclusions Laparoscopic radical prostatectomy with extended lymph nodes dissection for high risk prostate cancer is safe and technical feasible.It provides accurate information on tumor stage and grade.It is an important component of multimodality for the treatment of high risk prostate cancer.