基于病理大切片改进腹腔镜下保留神经的根治性前列腺切除术

Whole Mount Section Pathology Improves Nerve- sparing Techniques in Laparoscopic Radical Prostatectomy

目的腹腔镜下保留神经的根治性前列腺切除术是一项复杂的手术操作,需要较长的学习曲线才能做到控瘤、控尿、保神经的三大目标。病理大切片是确保肿瘤完整切除和神经血管束保留的"金标准",将其引入手术学习的过程可能有助于缩短学习曲线。本研究探讨手术→病理→手术的反馈模式能否改进腹腔镜下保留神经前列腺癌根治术的学习模式。方法笔者提出基于病理大切片的手术学习模式:利用前列腺大切片病理技术准确评判手术切缘和神经保留程度,基于病理信息对照手术录像分析手术过程中解剖层次,建立视觉-解剖-操作的规律并不断改进。本文回顾性分析2015年1月至12月间进行的20例腹腔镜下保留神经的根治性前列腺切除术。比较这些患者临床病理信息、手术时长,术中出血量以及术后性功能和尿控功能。结果相比于前期手术病例(A组),后10例患者(B组)的控瘤、控尿、保神经成功率均显著提升。B组患者的平均手术时间缩短至94.6分钟,平均术中出血量减少至153ml,切缘阳性率也显著降低,术后3个月的性功能量表显示性功能和尿控的满意度的EPIC-CP,平均评分达到8.6分。结论基于病理大切片的手术学习模式可以缩短腹腔镜下保留神经前列腺癌根治术的学习曲线。

Objective Nerve - sparing laparoscopic radical prostatectomy is a complicated surgery. In order to achieve complete tumor control, low incontinence rate and best nerve sparing, steep learning curve is necessa-ry. Whole mount section pathology’ as a ＂ gold standard＂ in assessment of tumor removal and nerve vascular bundle sparing, helps to shorten the learning curve. T he aim of this study was to evaluate the significance of the ＂operation - pathology - operation＂ feedback cycle in improving nerve - sparing techniques in laparoscopic radical prostatectomy. Methods We proposed a learning system using whole mount section pathology to judge thesurgical margin and the extent of nerve sparing. Oncological data and operation videos were used to analyze anat-omy structures, to establish a Mvisual - anatomy - operation＂ learning system. Our study retrospectively ana-lyzed 20 cases who received nerve - sparing laparoscopic radical prostatectomy between Jan 2015 to Dec 2015. The clinical and pathological variables, operating time, blood loss, sexual function and continence rates were compared. Results Comparing to earlier cases （ group A ）,the later 10 cases （ group B ） had satisfactory results in tumor control, sexual function and continence rates. T he average operation time reduced to 94.6 minutes, the estimated blood loss reduced to 153 ml, and the positive surgical margins also significantly decreased. T he aver-age Expanded Prostate Cancer Index Composite for Clinical Practice （ EPIC - CP ） scored about 8.6 at 3 months postoperatively. Conclusions The learning system based on whole mount section pathology can shorten the learn-ing curve of nerve - sparing techniques in laparoscopic radical prostatectomy.