延迟缝扎背深静脉复合体技术在腹腔镜前列腺癌根治术中的应用

Application of delayed ligature of the dorsal vasculature complex during laparoscopic radical prostatectomy

目的 探讨延迟缝扎背深静脉复合体（DLDVC）技术在腹腔镜前列腺癌根治术（LRP）中的临床应用疗效.方法 纳入2011年1月-2015年6月浙江大学金华医院泌尿外科局限性前列腺癌患者75例进行前瞻性研究.患者年龄49~74岁,平均63.7岁;术前前列腺特异性抗原（PSA）平均13.0 μg/L,活检Gleason评分平均6.8分,前列腺体积平均56.8 mL,勃起功能国际问卷-5（IIEF-5）评分均≥15分.TNM临床分期cT1期49例、cT2期 26例.根据住院号的奇偶分为DLDVC组（33例）和标准缝扎背深静脉复合体（SLDVC）组（42例）,两组术前PSA、活检Gleason评分、性功能IIEF-5 评分及年龄比较,差异均无统计学意义（P值均〉0.05）.两组患者均行LRP治疗,其中DLDVC组33例术中采用DLDVC技术,SLDVC组42例术中采用SLDVC技术.观察比较两组围手术期指标、手术切缘阳性率、术后控尿率和IIEF-5 评分.结果 DLDVC组和SLDVC组手术时间[（240±87）min、（220±74）min]、术中失血量[（410±92）mL、（370±79）mL]、术后住院时间[（9.2±1.1）d、（9.4±1.3）d]、术后组织病理学结果、手术切缘阳性率[21.2%（7/33）、16.7%（7/42）]两组间比较差异均无统计学意义（P值均〉0.05）.术后平均随访21（6~53）个月.术后拔除尿管即刻及1、3、6个月控尿率DLDVC组分别为60.6%（20/33）、78.8%（26/33）、87.9%（29/33）和93.9%（31/33）,SLDVC组为23.8%、54.8%、71.4%和90.5%,其中早期（拔尿管即刻及1个月）控尿率DLDVC组高于SLDVC组（P值均〈0.05）,后期（拔尿管3个月及6个月）控尿率两组差异均无统计学意义（P值均〉0.05）.术后3、6、12个月IIEF-5 评分DLDVC组分别为（8.4±7.2）、（9.1±7.3）、（14.4±7.1）分,SLDVC组为（7.3±6.1）、（7.4±6.7）、（11.1±9.3）分;术后12个月恢复到术前水平患者比例两组分别为38.1%（8/21）和16.7%（5/30）,组间比较差异无统计学意义（χ2=2.992, P〉0.05）.结论 LRP中,DLDVC能早期恢复控尿功能,对术后早期性功能的恢复优势不明显,但不影响肿瘤学的手术切缘阳性率.

Objective To describe a technique of delayed ligature of the dorsal vasculature complex （DLDVC） for laparoscopic radical prostatectomy（LRP） and to evaluate its postoperative outcomes.Methods From January 2007 to June 2015,75 patients who underwent laparoscopic radical prostatectomy were retrospectively evaluated in the Jinhua Hospital of Zhejiang University.Their mean age was 63.7 （49-74） years, preoperative prostate specific antigen 13.0 μg /mL, Gleason score 6.8, preoperative prostate volume 56.8 mL, preoperative potency [international index of erectile 5（IIEF-5） score≥15 score].TNM clinical stage： cT1 49 patients, 26 patients cT2.According to the hospital parity, they were randomly divided into DLDVC, SLDVC groups.No differences were found between the two groups in terms of preoperative prostate specific antigen values, Gleason score at biopsy, preoperative good potency （IIEF-5 score）and age（all P values〉0.05）.All patients were undergone LRP, including 33 patients （Group DLDVC） with DLDVC for laparoscopic radical prostatectomy, 42 patients （Group SLDVC） with the technique of standard ligature of the dorsal vasculature complex （SLDVC） for laparoscopic radical prostatectomy.The two groups were compared for perioperative variables, positive surgical margin rate, postoperative urinary continence functional and potency （IIEF-5 score）.Results No differences were found between the two groups in terms of operative times[（240±87）min vs.（220±74）min], blood loss[（410±92）mL vs.（370±79）mL], postoperative stay[（9.2±1.1）d vs.（9.4±1.3）d], histologic status, positive surgical margin [（21.2%（7/33） in group DLDVC vs.16.7%（7/42） in group SLDVC]（all P values〉0.05）.Follow-up was 21（6-53） months.In DLDVC, the continence rate was 60.6%（20/33）, 78.8%（26/33） , 87.9%（29/33） and 93.9%（31/33） at immediately after catheter removal, 1, 3 and 6 months, respectively.In the SLDVC it was 23.8%（10/42）, 54.8%（23/42） , 71.4%（30/42） and 90.5%（38/42） at immediately after catheter removal, 1, 3 and 6 months, respectively.The group DLDVC showed a significantly earlier recovery from incontinence compared with that in the group SLDVC at immediately after catheter removal and 1 month, （all P values〈0.05）.No differences were found between the two groups at 3 and 6 months （all P values〉0.05）.Regarding sexual function, at the postoperative 3, 6, 12 months, median IIEF-score was 8.4±7.2、9.1±7.3、14.4±7.1 in the group DLDVC, respectively, and in the group SLDVC it was 7.3±6.1、7.4±6.7、11.1±9.3 respectively.Baseline IIEF-score was reached by 38.1%（5/30） and 16.7%（5/30） at postoperative 12 months.There were no significant differences between the two groups（χ2=2.992, P〉0.05）.Conclusions This delayed ligature of the DVC after its section can contribute to early recovery of continence.It has little to do with postoperative erectile function recovery and will not affect the positive surgical margin rate of oncology.