腹腔镜下扩大盆腔淋巴结清扫术在高危前列腺癌治疗中的应用

Application of laparoscopic expanded lymphadenectomy in the treatment of high-risk prostate cancer

目的探讨腹腔镜下扩大盆腔淋巴结清扫术(extended pelvic lymphnodedissection,e PLND)在高危前列腺癌治疗中的应用价值。方法回顾性分析2014年10月至2016年5月44例在北京大学第一医院泌尿外科住院并实施腹腔镜下扩大盆腔淋巴结清扫+腹腔镜下前列腺根治性切除术的高危前列腺癌患者的临床资料,统计手术时间、术中出血量、术中清扫各组淋巴结的个数、结合术后病理结果统计阳性淋巴结个数和阳性率及术后并发症。结果 44例手术均顺利完成,无中转开放手术。手术时间60~130 min,术中出血量50~200 ml。术后临床分期:T2c13例,T3 a20例,T3b^T4 11例。术后Gleason评分7分17例,Gleason评分8~10分27例。44例患者中每例患者切除淋巴结个数9~36枚,9例患者提示有阳性淋巴结,检出率20.5%。9例阳性患者中每例切除淋巴结个数13~31枚,共切除淋巴结187枚,检出阳性淋巴结共计18枚,阳性率9.6%;术后发生淋巴漏(淋巴囊肿)9例(20.5%),淋巴水肿5例(11.4%),血管损伤(直肠中动脉)1例(2.3%),神经损伤(闭孔神经)1例(2.3%),下肢深静脉血栓1例(2.3%),轻度肺栓塞1例(2.3%)。结论腹腔镜下扩大盆腔淋巴结清扫+腹腔镜下前列腺根治性切除治疗高危前列腺癌手术安全可行,可以更准确的明确前列腺癌的病理分期;ePLND可能对高危前列腺癌有治疗意义,是高危前列腺癌综合治疗中重要的治疗方法;对于部分中危及全部高危的前列腺癌患者推荐进行扩大盆腔淋巴结清扫术。

Objective To explore the application value of laparoscopic extended pelvic lymphnode dissection （ePLND） in the treatment of high risk prostate cancer. Methods From October 2014 to May 2016, a total of 44 patients with high-risk prostate cancer underwent laparoscopic radical prostatectomy with ePLND. Clinical and pathological data of the patients were retrospectively analyzed. The operation time, estimate blood loss, number of lymph node .removed in each region, number of pathologically positive lymph node and positive rate, and postoperative complications were evaluated. Results All 44 patients underwent successful laparoscopic radical prostatectomy with ePLND without any conversion to open surgery. The operation time was 60 - 130 rain. The estimated blood loss was 500 - 200 ml. The postoperative clinical staging was 13 patients in T2,20 in T3 a, and 11 in T3b - T4. The postoperative Gleason score was 17 patients in 7 and 27 in 8 - 10. The number of lymph node dissected of the 44 patients was 9 ~ 36. There were 9 patients found with positive lymph nodes with a positive rate of 20.5%. The number of lymph nodes dissected of the 9 patients was 13 - 31 with a total number of 187 and positive number of 18 and positive rate of 9.6%. Postoperative lymphatic leakage or lymphoeele occurred in 9 （20. 5% ） patients,lymphedema in 5 cases （11.4%） ,vessel injury （middle rectal artery） in 1 case （2. 3% ） ,nerve injury （obturator nerve） in 1 case （2. 3% ） ,deep vein thrombosis of lower limb in 1 case （2. 3% ） ,and mild pulmonary embolism in 1 case （2. 3% ）. Conclusion Laparoscopic radical prostatectomy with ePLND was safe and feasible in treating high risk prostate cancer, which could determine the pathological staging of prostate cancer more accurately. The ePLND was meaningful and important in comprehensive treatment of high risk prostate cancer. According to the guideline and related literature, radical prostatectomy with ePLND was recommended in intermediate and high risk prostate cancer.