单孔经膀胱机器人根治性前列腺切除术:一种保护术后尿控的新术式

Single-port transvesical robot assisted radical prostatectomy:a novel approach to preserve postoperative urinary continence

目的:描述单孔经膀胱入路机器人根治性前列腺切除术(Single-port transvesical robot-assisted radical prostatectomy,STvRARP)的手术技术,并分析短期疗效。方法:前瞻性收集和分析南昌大学第一附属医院2019年9月~2020年1月收治的5例STvRARP患者的临床资料。患者年龄(61.7±6.8)岁,体重指数(28.3±6.2)kg/m^2,术前tPSA(13.4±3.3)ng/ml,术前Gleason评分中位值6分(6~7分),前列腺体积(31.5±9.4)ml,术前IIEF-5评分中位值18分(17~23分)。术前临床分期cT2aN0M0期3例,cT2bN0M0期1例,cT2cN0M0期1例。所有患者术前尿控均正常。STv RARP术手术步骤:构建皮肤-膀胱操作通道,放置4通道单孔导管,直视下放置各操作器械,沿尿道内口环形切开,先从后方依次分离两侧输精管和精囊,分离前列腺后表面直至前列腺尖部,随后在侧方分离两侧神经血管束,在前方分离前列腺前表面直至尖部,最后分离、离断尿道、移除标本,完成膀胱-尿道吻合、直视下分层关闭膀胱及皮肤切口。结果:5例手术均顺利完成,无中转开放或其他术式,无输血,无严重术中、术后并发症发生。手术时间(105.0±25.0)min,术中失血量(50.0±20.0)ml。术后病理示pT2a期2例、pT2b期2例、pT2c期1例,Gleason评分中位值6分(6~7分);切缘阳性1例(20%,位于前列腺尖部)。术后7d拔除导尿管,5例均即刻实现尿控。5例随访时间3~7个月,随访期内尚未见生化复发(tPSA<0.2ng/ml)。所有患者术后尚未尝试性活动,4名患者自述恢复夜间阴茎勃起。结论:STvRARP术是治疗低风险局限性前列腺癌的可选术式,术后即刻尿控较理想,肿瘤控制和术后勃起功能仍有待长期随访观察。

Objective:To introduce the technique and report the short-term outcomes of single-port transvesical robot assisted radical prostatectomy(STvRARP).Methods:5 cases of STvRARP for localized prostate cancer performed by a single surgical team between September 2019 and January 2020 were prospectively collected and reviewed.Preoperative data of patient swere collected:patient age(61.7±6.8)years,BMI(28.3±6.2)kg/m2,tPSA(13.4±3.3)ng/ml,biopsy Gleason score 6(6~7),prostate volume(31.5±9.4)ml and IIEF-5 score 18(17~23).Preoperative study revealed 3 cases of cT2aN0M0,1 case of cT2bN0M0 and 1 case of cT2cN0M0.All patients were continent preoperatively.Surgical techniques:After a percutaneous transvesical access was developed,a 4-channel single port was placed along with all instruments under direct vision.A circumferential incision was made around the internal urethral orifice.Initially,posterior dissection of bilateral vas deferens and seminal vesicles was performed,followed by posterior dissection towards the apex.Lateral dissection of neurovascular bundles was performed before anterior dissection towards the apex.The exposed urethra was transected and specimen was removed.Vesicourethral anastomosis and closure of bladder and skin incision were performed in a standard fashion.Results:All 5 cases were successfully performed with robot without conversion,transfusion or other major intraoperative and postoperative complications.Postoperative pathology confirmed 2 pT2a cases,2 pT2b cases and 1 pT2c case,and Gleason score was 6(6~7).1 case was reported positive surgical margin(20%,at the apex).Operative time was(105.0±25.0)min.Estimated blood loss was(50.0±20.0)ml.Urethral catheter was removed at postoperative 7-day.5 patients achieved urinary continence(0 pads)immediately after the removal of urinary catheter.During a 3~7 months follow-up,no biochemical recurrence was noted(tPSA<0.2ng/ml).All patients did not resume sexual activity yet.4 patients claimed nocturnal penile tumescence.Conclusion:The transvesical approach on single-port platform is a valid alternative of performing RARP in patients bearing localized low-risk prostate cancer.Tumor control and preservation of erectile function remain to be determined in long-term follow-up.