机器人辅助腹腔镜下根治性前列腺切除术保留耻骨后间隙技术与阿芙罗狄蒂面纱保留神经技术的比较研究

A comparative study of Retzius-sparing technique with veil of Aphrodite technique nerve sparing robotic-assisted laparoscopic radical prostatectomy

目的比较保留耻骨后间隙机器人辅助腹腔镜下根治性前列腺切除术（robotic—assistedLaparoscopicradicalprostatectomy，RALP）与经典的阿芙罗狄蒂面纱保留神经RALP的疗效。方法回顾性分析2015年1月至2016年12月收治的39例行保留耻骨后间隙RALP（后入路组）和阿芙罗狄蒂面纱保留神经RALP（前入路组）患者的临床资料。后入路组19例，平均年龄（66．3±5．9）岁，平均体重指数（25．5±3．1）kg／m^2，术前tPSA平均（16．4±5．0）．g／ml，术前Gleason评分中位值6分（5—7分），前列腺体积平均（32．7±7．4）ml，术前国际勃起功能间卷表-5（international index of erectilefunction-5，IIEF-5）评分中位值14分（5—18分）。前入路组20例，平均年龄（64．6±7．3）岁，体重指数平均（25．5±2．0）kg／in。，术前tPSA平均（18．5±1I．0）．g／ml，术前Gleason评分中位值7分（5～8分），前列腺体积平均（31．4±10．8）ml，术前IIEF．5评分中位值15分（6—19分）。两组患者的上述指标比较差异均无统计学意义（均P〉0．05）。术前临床分期后入路组cT1c期8例、cT2a期3例、ck期2例、cT2c期6例，前入路组cT1c期1例、cT2a期6例、cT2b期5例、cL期8例。所有患者术前尿控均正常。两组患者均采用经腹腔入路RALP。比较两组患者手术时间、术中出血量、术后住院时间、术后病理分期、术后Gleason评分、尿控恢复时间、术后IIEF-5评分。结果39例手术均顺利完成，无中转开放手术，无输血病例，无严重术中、术后并发症发生。术后后入路组病理分期pT2a期5例、pT2b期8例、pT2。期6例；前入路组病理分期pT2a期7例、pT2b期5例、pT2c期8例，两组间差异均无统计学意义（均P〉0．05）。后入路组手术时间（106．5±26．4）rain，术中失血量（48．9±20．2）ml；前入路组手术时间（93．2±20．8）min，术中失血量（42．5±16．8）ml；两组患者上述指标比较差异均无统计学意义（均P〉0．05）。后入路组术后7d拔除导尿管，其中18例即刻实现尿控（无需使用尿垫），1例术后2周实现尿控；前入路组术后3周拔除导尿管，完全恢复尿控时间为（6．8±3．6）周，两组差异有统计学意义（P〈0．001）。两组患者随访时间3～12个月，平均6个月，所有患者均无肿瘤生化复发（tPSA〈0．2ng／ml）。术后第3个月，IIEF-5评分中位值后入路组为14分（4～16分），前入路组为14分（4～18分），两组差异无统计学意义（P〉0．05）；两组IIEF一5评分与术前比较差异均无统计学意义（均P〉0．05）。结论保留耻骨后间隙RALP和阿芙罗狄蒂面纱保留神经RALP是治疗局限性前列腺癌的有效手段。保留耻骨后间隙RALP较阿芙罗狄蒂面纱保留神经RALP在术后尿控恢复方面具有显著优势。

Objective To introduce the technique and report our initial experience of Retziussparing robotic-assisted laparoseopie radical prostateetomy （RALP） and compare perioperative outcomes with the standard yell of Aphrodite technique （Veil technique）. Methods nineteen Retzius-sparing RALP and 20 Veil nerve sparing RALP with posterior reconstruction for Tic to Tec prostate cancer performed by a single surgical team between 2015 January and 2016 December were retrospectively reviewed. Preoperative data of patients in Retzius-sparing group [ patient age （66. 3 ±5.9） years, BMI （25.5 ±3.1 ） kg/m2, tPSA （16. 4 ±5.0） ng/ml, biopsy Gleason score 6（5 -7） , prostate volume （32. 7 ±7.4） ml and IIEF-5 score 14（5 - 18） ] and Vell group~ patient age （64. 6 ±7. 3） years, BMI （25.5 ±. O） kg/m2, tPSA （ 18.5 ±11. O） ng/ml, biopsy Gleason score 7（5 -8）, prostate volume （31.4 ± 10. 8）ml and IIEF-5 score 15（6 - 19 ） J. No significant difference was found between the two group in the above parameters （all P 〉 0. 05 ）. All patients were continent preoperatively. Retzius-sparing RALP and Veil nerve sparing RALP were performed via transperitoneal RALP. Operative time, estimated blood loss, postoperative hospital stay, postoperative staging, postoperative Gleason score, return of urinary continence and postoperative IIEF-5 score of the two groups were statistically analyzed. Results All 39 cases were successfully performed robotically without conversion, transfusion or other major intraoperative and postoperative complications. Postoperative pathology confirmed pT2~ 5 cases, pT2b 8 cases and pT2c 6 cases in Retzius-sparing group and pT2a 7 cases, pT2b 5 cases and pT2c 8 cases in Veil group （ all P 〉 0. 05 ）. For Retzius group, operative time was （106. 5 ±26. 4） min and estimated blood loss was （48.9 ±20. 2） ml; for Veil group, operative time was （93.2 ±20. 8） rain and estimated blood loss was （42. 5 ± 16. 8） ml. No significant difference was found in the above parameters （ all P 〉 0. 05 ） . Urethral catheter was removed at postoperative 7-day （Retzius-sparing group） and 21-day （Veil group）, respectively. 18 patients in Retzius-sparing group achieved urinary continence （0 pads ） immediately after the removal of urinary catheter, while 1 patient returned to full continence in 2 weeks postoperatively. Patients in Veil group returned to continence （6. 8 ± 3.6） weeks postoperatively （P 〈0. 001）. At 3-month follow up, IIEF-5 score was 14（4 - 16） in Retzius- sparing group and 14 （4- 18） in Veil group; no significant changes was noted in preoperative and postoperative IIEF-5 score in both groups, or in postoperative IIEF-5 scores in the two groups （P 〉 0. 05 ）. No sign of tumor recurrence was appreciated for all cases （tPSA 〈 0. 2 ng/ml） during follow-up of 6 months （3 to 12 months）. Conclusions Retzius-sparing RALP and the Veil nerve sparing RALP were both effective for the surgical treatment of localized prostate cancer. Our data revealed no statistical difference in perioperative outcomes between the two approaches, however, the Retzius-sparing technique seemed to yield a better outcome regarding early return to urinary continence postoperatively.