3种机器人辅助腹腔镜根治性前列腺切除术手术入路对比研究:前入路、后入路及经膀胱入路

Comparative study among three approaches for RARP:veil of Aphrodite nerve-sparing technique,Retzius-sparing and transvesical RARP

目的:比较前入路、后入路及经膀胱入路机器人辅助腹腔镜根治性前列腺切除术(RARP)围手术期指标及手术效果。方法:回顾性分析2015年12月~2018年8月收治的43例前入路RARP(前入路组)、26例后入路RARP(后入路组)和10例经膀胱入路RARP(经膀胱入路组)患者的临床资料。比较三组患者临床资料、围手术期指标(手术时间、术中出血、术后病理分期、术后Gleason评分、切缘阳性率)及手术效果[尿控恢复时间、术后国际勃起功能问卷表-5(IIEF-5)]。结果:前入路组平均年龄(69.7±7.3)岁,平均BMI(22.9±3.1)kg/m2,平均术前tPSA(34.5±21.3)ng/ml,术前Gleason评分中位值8(6~9)分,平均前列腺体积(38.2±16.6)ml,术前IIEF-5评分中位值12(6~19)分。后入路组平均年龄(62.3±10.9)岁,平均BMI(27.2±6.3)kg/m2,平均术前tPSA(15.8±7.2)ng/ml,术前Gleason评分中位值7(6~8)分,平均前列腺体积(44.7±10.8)ml,IIEF-5评分中位值13(6~20)分。经膀胱入路组平均年龄(58.6±9.4)岁,平均BMI(26.5±3.1)kg/m2,平均术前tPSA(19.5±4.1)ng/ml,术前Gleason评分中位值6(6~7)分,平均前列腺体积(33.4±15.8)ml,术前IIEF-5评分中位值16(10~21)分。临床分期前入路组:cT1c期18例,cT2a期3例,cT2b期3例,cT2c期17例,cT3a期1例,cT3b期1例;后入路组:cT1c期17例,cT2a期3例,cT2b期4例,cT2c期2例;经膀胱入路组:cT1c期8例,cT2a期1例,cT2b期1例。所有患者术前尿控均正常。79例手术均顺利完成,无中转开放病例,无输血病例,无严重术中、术后并发症发生。术后病理结合术前检查示前入路组:pT2b期9例,pT2c期16例,pT3a期3例,pT3b期12例,pT4期3例,Gleason评分中位值8(6~9)分;后入路组:pT2a期13例,pT2b期9例,pT2c期2例,pT3a期2例,Gleason评分中位值7(6~8)分;经膀胱入路组:pT2a期6例,pT2b期3例,pT2c期1例,Gleason评分中位值6(6~7)分。前入路组切缘阳性11例(25.6%),后入路组切缘阳性6例(23.1%),经膀胱入路组切缘阳性1例(20.0%),三组比较差异无统计学意义(P>0.05)。前入路组手术时间(115.5±20.5)min,后入路组手术时间(126.5±33.5)min,经膀胱入路组手术时间(140.5±15.5)min。前入路组术中失血量(80±20.5)ml,后入路组术中失血量(44.5±9.5)ml,经膀胱入路组术中失血量(65.5±35.5)ml。前入路组术后3周拔除尿管,其余两组患者术后7d拔除导尿管,前入路组完全恢复尿控时间(6.5±3.5)周,后入路组22例即刻实现尿控(尿控定义为无需使用尿垫),4例术后2周实现尿控;经膀胱入路组患者9例即刻实现尿控,1例术后2周实现尿控;后入路组与经膀胱入路组比较差异无统计学意义(P>0.05),前入路组与后入路组、前入路组与经膀胱入路组比较差异均有统计学意义(P<0.05)。三组患者随访时间3~35个月,平均12个月,所有患者尚无肿瘤复发表现(tPSA<0.2ng/ml)。术后第3个月,IIEF-5评分中位值前入路组为10(4~12)分,后入路组为10(4~13)分,经膀胱入路组为11(5~14)分,三组比较差异无统计学意义(P>0.05);三组IIEF-5评分与术前比较差异均无统计学意义(P>0.05)。结论:经膀胱入路RARP有待成为治疗局限性低风险前列腺癌的可选术式。经膀胱入路与后入路患者术后即刻尿控率较高,均优于前入路,术后肿瘤控制效果和勃起功能仍有待于进一步随访。

Objective:To compare the perioperative data and surgical outcomes among veil of Aphrodite nerve-sparing RARP(Veil RARP),Retzius-sparing RARP(RsRARP)and transvesical RARP(TvRARP).Method:A total of 79prostate cancer patients who underwent Veil RARP(n=43),RsRARP(n=26)and TvRARP(n=10)from December,2015to August,2018were retrospectively reviewed.Perioperative data and surgical outcomes(operative time,estimated blood loss,postoperative staging,postoperative Gleason score,return of urinary continence and postoperative IIEF-5score)of Veil RARP,RsRARP and TvRARP group were comparatively analyzed.Result:Preoperative data of patients in Veil RARP group[patients’age(69.7±7.3)years old,BMI(22.9±3.1)kg/m2,tPSA(34.5±21.3)ng/ml,biopsy Gleason score 8(6-9),prostate volume(38.2±16.6)ml and IIEF-5score 12(6-19)],RsRARP group[patients’age(62.3±10.9)years old,BMI(27.2±6.3)kg/m2,tPSA(15.8±7.2)ng/ml,biopsy Gleason score 7(6-8),prostate volume(44.7±10.8)ml and IIEF-5score 13(6-20)]and TvRARP group[patients’age(58.6±9.4)years old,BMI(26.5±3.1)kg/m2,tPSA(19.5±4.1)ng/ml,biopsy Gleason score 6(6-7),prostate volume(33.4±15.8)ml and IIEF-5score 16(10-21)]were collected.Veil RARP group included 18cases of cT1c,3cases of cT2a,3cases of cT2b,17cases of cT2c,1case cT3aand 1case cT3b.RsRARP group included 17cases of cT1c,3cases of cT2a,4cases of cT2b,and2cases of cT2c.TvRARP group included 8cases of cT1c,1case of cT2aand 1case of cT2b.All patients maintained urinary continence preoperatively.All 79cases were successfully performed robotically without conversion,transfusion or other major intraoperative and postoperative complications.Postoperative pathology confirmed 9pT2bcases,16pT2ccases,3pT3acases,12pT3bcases and 3cases pT4in Veil RARP group[Gleason score 8(6-9)],13pT2acases,9pT2bcases,2pT2ccases and 2pT3ain RsRARP group[Gleason score 7(6-8)],and 6pT2acases,3pT2bcases and 1pT2ccase in TvRARP group[Gleason score 6(6-7),all P>0.05].Positive surgical margin was found in 11cases in Veil RARP group,6cases in RsRARP and 1case in TvRARP(25.6%,23.1%and 20.0%,respectively P>0.05).Operative time was(115.5±20.5)min,(126.5±33.5)min and(140.5±15.5)min respectively.Estimated blood loss was(80±20.5)ml,(44.5±9.5)ml and(65.5±35.5)ml,respectively.Significant difference was found when RsRARP group compared with other two groups(P<0.05).In Veil RARP group,the urethral catheter was removed 3weeks after surgery.In both RsRARP and TvRARP group,the urethral catheter was removed at postoperative 7days.Twenty-two patients in RsRARP group and 9patients in TvRARP group achieved urinary continence(0pad)immediately after the removal of urinary catheter,while 4patients in RsRARP group and 1patient in TvRARP group returned to full continence in 2weeks postoperatively(P>0.05).Patients in Veil RARP group returned urinary continence(6.5±3.5)weeks postoperatively,which was significantly longer than RsRARP and TvRARP group(P<0.05).During a mean follow up period of 12(3-35)months,no sign of recurrence was noted(tPSA<0.2ng/ml).At 3-month postoperatively,IIEF-5score was 10(4-12)in veil of nerve sparing group,10(4-13)in RsRARP group and 11(5-14)in TvRARP group(P>0.05).No significant difference was noted when compared with respective preoperative IIEF-5score(P>0.05).Conclusion:The transvesical approach to perform RARP seems to be a possible alternative for patients bearing localized low-risk prostate cancer.The rate of immediate urinary continence was higher in both TvRARP group and RsRARP group than that in veil RARP group.Tumor control and preservation of erectile function remain to be determined in the long term follow-up.