C.R.P.C.四步法腹腔镜根治性前列腺切除术的安全性和疗效分析

The application and outcomes of C. R.P.C. four-step radical prostatectomy under extraperitoneal laparoscopy

目的探讨经腹膜外途径C.R.P.C.四步法腹腔镜根治性前列腺切除术治疗局限性前列腺癌的安全性和疗效。方法回顾性分析2015年4月至2017年12月同济医院收治的102例前列腺癌患者的病例资料。年龄(67±5)岁。术前总PSA值(45.32±18.33)ng/ml。前列腺体积(42±12)cm^3。102例均行磁共振检查和前列腺穿刺活检确诊为前列腺癌,临床分期cT1c^cT3b期。102例均在全麻下行经腹膜外途径腹腔镜根治性前列腺切除术。术中采用C.R.P.C.四步法,即控制背深静脉复合体(control dorsal deep venous complex,C);识别前列腺膀胱交界面、精囊层面、狄氏间隙层面3个解剖层面(recognize three anatomical layers,R);保留尿道括约肌和膀胱颈(preserve urethral sphincter and bladder neck,P);连续行尿道吻合(continuous anastomosis between urethra and bladder neck,C),特别注意3、5、7、9点方向4针。记录手术时间、术中出血量、住院时间和术后并发症。结果本组102例手术均顺利完成。手术时间平均92(55~156)min。出血量平均105(55~185)ml。无中转开放手术。1例(0.98%)术前中度贫血患者(血红蛋白65 g/L)术后予输血治疗。病理检查结果显示15例(14.70%)切缘阳性。术后1周内2例(1.96%)发生尿外渗,经牵拉尿管并延长尿管留置时间后恢复正常。术后随访(26.4±3.5)个月。术后6个月11例(10.78%)出现PSA复发;术后12个月2例发生Ⅰ~Ⅱ度尿失禁,1例发生排尿困难。结论C.R.P.C.四步法腹腔镜根治性前列腺切除术易学易记,能够使初学者掌握根治性前列腺切除术的程序化手术操作步骤。本方法术后并发症少,肿瘤控制效果较好。

Objective To summarize the preliminary experience of extraperitoneal laparoscopic radical prostatectomy(C.R.P.C.four-step)for localized prostate cancer and the outcomes based on early follow-up.Methods A total of 102 prostate cancer patients were screened by prostate specific antigen(PSA)and diagnosed by prostate magnetic resonance imaging and prostatic puncture biopsy with cT1c-cT3b,with average age of(67±5)years old,average preoperative total PSA value of(45.32±18.33)ng/ml,and average prostate volume was(42±12)cm^3.All these patients underwent extraperitoneal laparoscopic radical prostatectomy by the four-step technique,abbreviating as C.R.P.C.[C:control DVC(dorsal deep venous complex).R:recognize three anatomical layers(prostate and bladder junction,seminal vesicle,and Denonvilliers’fascia surface).P:preserve urethral sphincter and bladder neck.C:continuous anastomosis between urethra and bladder neck(4 key needles at 3,5,7 and 9 o’clock)].The operative time,estimated blood loss,length of hospital stay and postoperative complications were recorded,and the postoperative PSA was followed up.Results All the 102 cases were successfully treated by laparoscopic radical prostatectomy.The operative time was from 55 to 156 min(mean 92 min),and the estimated blood loss was from 55 to 185 ml(mean 105 ml).There was no case converted of open surgery,only one case received blood transfusion for postoperative hemorrhage(0.98%),and positive surgical margin was found in 15 case(14.70%)by pathological examination.Postoperative urinary extravasation within one week occurred in 2(1.96%)cases,and resolved after tensioning the catheter and prolonging the indwelling time.During the follow-up period of 12 to 45 months,2 cases were incontinent(gradeⅠ-Ⅱ),and the other cases(98.04%)had no incontinence or dysuria.However,11 cases(10.78%)developed to biochemical recurrence within 6 months after the operation.Conclusions The C.R.P.C.four-step technique of lparoscopic radical prostatectomy is easily to be grasped and performed by the greenhand urologists,and was efficient and safe.