保留耻骨膀胱复合体技术在腹腔镜根治性前列腺切除术中的应用

Application of pubovesical complex preserving technique during laparoscopic radical prostatectomy

目的探讨腹腔镜根治性前列腺切除术中完全保留耻骨膀胱复合体技术的应用及其疗效。方法回顾性分析2011年1月至2017年5月收治的168例局限性前列腺癌患者的病例资料。年龄46～74岁，平均62.8岁。术前前列腺特异性抗原（PSA）平均11.3 ng/ml。术前活检Gleason评分平均6.7分。术前均行经直肠超声检查：前列腺体积平均46.5 ml。患者术前均有较好的勃起功能，国际勃起功能指数-5（IIEF-5）≥15分。TNM临床分期：cT1期123例，cT2期45例。168例均行腹腔镜根治性前列腺切除术（LRP），其中59例采用完全保留耻骨膀胱复合体技术（A组），术中不切开盆筋膜及缝扎背深静脉复合体（DVC），完全保留所有围绕前列腺周围的耻骨前列腺韧带、逼尿肌围、DVC及神经血管束（NVB）。46例（B组）采用传统筋膜内保留神经技术，63例（C组）采用筋膜间保留神经技术。3组的年龄、临床分期、PSA水平、活检Gleason评分和术前IIEF-5差异均无统计学意义（P〉0.05）。比较3组的围手术期指标、手术切缘阳性（PSM）率、术后尿控率、术后IIEF-5和生化复发率。术后控尿定义为每天使用尿垫≤1片。用Kaplan-Meier法和log-rank检验分析3组的生化复发率。结果3组手术均顺利完成，手术时间、术中失血量、尿管留置时间、术后住院时间、术后病理检查结果比较差异均无统计学意义（P〉0.05）。A、B、C组的PSM率分别为8.5%（5/59）、13.0%（6/46）和11.1%（7/63），差异无统计学意义（P〉0.05）。A组术后拔除尿管即刻，以及术后1、3、6个月控尿率分别为71%（42/59），86%（51/59），92%（54/59）和100%（59/59）；B组分别为63%（29/46），80%（37/46），89%（41/46）和96%（44/46）；C组分别为24%（15/63），54%（34/63），79%（50/63）和86%（54/63）。A组（χ2＝27.47，P〈0.001；χ2＝15.20，P〈0.01）和B组（χ2＝17.00，P〈0.01；χ2＝8.20，P〈0.05）术后早期（即刻和1个月）控尿率均显著高于C组；A组与B组比较差异无统计学意义（P〉0.05）。3组术后3、6个月控尿率比较差异无统计学意义（P〉0.05）。术后1、3、6个月IIEF-5评分A组分别为10、11、16分，B组分别为8、9、13分，C组分别为7、8、12分，3组比较差异无统计学意义（P〉0.05）。术后6个月勃起功能恢复至术前状态的比例，A、B、C组分别为53%（31/59）、35%（16/46）、21%（13/63）。A组与C组比较差异有统计学意义（χ2＝13.45，P〈0.01），与B组比较差异无统计学意义（χ2＝3.30，P〉0.05）。168例术后随访6～69个月，平均31.6个月。A、B、C组的3年无生化复发率分别79.3%、76.3%和76.4%，差异无统计学意义（χ2＝0.405，P〉0.05）。结论行LRP时采用完全保留耻骨膀胱复合体技术能显著提高患者早期控尿功能恢复率，使性功能较快恢复至术前水平；对经过选择的前列腺癌患者，不增加PSM率。

ObjectiveTo describe a novel pubovesical complex preserving technique for laparoscopic radical prostatectomy and to evaluate its postoperative outcomes.MethodsFrom January 2011 to May 2017, 168 patients who underwent laparoscopic radical prostatectomy were enrolled and analyzed retrospectively. Their mean age were 62.8 （46-74） years, preoperative PSA 11.3ng/ml, Gleason score 6.7, preoperative prostate volume 46.5 ml. They all got preoperative potency （IIEF-5 score ≥15 score）. TNM clinical stage： cT1 123 cases, 45 cases cT2. There were 59 patients with pubovesical complex preserving technique for laparoscopic radical prostatectomy（group A）： without pelvic fascia cut and deep vein complex suture. The preservation of the periprostatic anatomy was kept by preserving the pubovesical complex, including detrusor apron with pubovesical ligaments, DVC and NVB. There were 46 patients with conventional intrafascial laparoscopic radical prostatectomy（group B） and 63 patients with interfascial laparoscopic radical prostatectomy（group C）. No differences were found between the three groups in terms of preoperative age, clinical staging, prostate-specific antigen （PSA） values, Gleason score at biopsy and preoperative good potency （IIEF-5 score）（P〉0.05）. Continence was defined as zero to one security pad per day. The three groups were compared for perioperative variables, PSM（positive surgical margin, PSM）rate, postoperative urinary continence functional and potency （IIEF-5 score）. Biochemical recurrence-free survival was by Kaplan-Meier and log-rank.ResultsNo differences were found in the three groups in terms of operative times, blood loss, catheterization time and postoperative stay and histologic status （PSM was similar to that of the groups （8.5% in group A, 13.0% in group B vs. 11.1% in group C）. Urinary incontinence： group A, the continence rate was 71%, 82%, 92% and 100% at 1, 3 and 6 months after catheter removal, respectively; group B, the continence rate was 63%, 80%, 89% and 96% respectively; group C, it was 24%, 54%, 79% and 86% respectively. The group A showed a significantly earlier recovery from incontinence compared with that in the group C at immediately after catheter removal and 1 month after catheter remove（χ2=27.47, P〈0.001; χ2=15.20, P〈0.01）. The group B showed a significantly earlier recovery from incontinence compared with that in the group C at immediately after catheter removal and 1 month, （χ2=17.00, P〈0.01; χ2=8.20, P〈0.05）. No differences were found between the A and B groups at immediately after catheter removal and 1 month, （P〉0.05）. Regarding sexual function, at the postoperative 1, 3, 6 months, median IIEF-score was 10, 11, 16 in the group A, respectively, 8, 9, 13 in the group B respectively, and 7, 8, 12 in the group C respectively. No differences were found in the three groups in potency （IIEF-5 score）. Baseline IIEF-score was reached by 53%, 35% and 21% at postoperative 6 months. There were significant differences between the A and the C groups.（χ2=13.45, P〈0.01）. There were no significant differences between the A and the B groups. （χ2=3.30, P〉0.05）. Follow-up was 31.6（6-69） months. Biochemical recurrence-free survival at 3 years was 79.3%, 76.3% and 76.4% by A, B and C group, respectively.ConclusionsThe pubovesical complex preserving technique for laparoscopic radical prostatectomy provides early recovery from incontinence, faster recovery of sexual function preoperative levels.