经膀胱机器人辅助腹腔镜根治性前列腺切除术治疗钬激光前列腺剜除术后前列腺癌的手术技巧与疗效分析

Transvesical robot-assisted laparoscopic radical prostatectomy for treatment of prostate cancer after holmium laser enucleation of prostate:surgical techniques and efficacy

目的探讨经膀胱途径机器人辅助腹腔镜根治性前列腺切除术(RARP)治疗钬激光前列腺剜除术(HoLEP)后前列腺癌的可行性、安全性及短期尿控效果。方法2016年8月至2019年4月,12例HoLEP术后确诊前列腺癌患者在我科行经膀胱途径纵切口RARP。患者年龄为60~69岁,术前前列腺特异抗原(PSA)为1.5~8.7 ng/mL,HoLEP术后Gleason评分均≤7分,术前TNM分期T1a^T1b期。所有患者均经HoLEP术后病理确诊为前列腺癌,均未接受内分泌治疗。记录手术时间、术中出血量、住院时间等。结果12例经膀胱途径RARP均顺利完成,无术中转开放手术者。手术时间115~130 min,平均(116.2±15.1)min;术中出血量80~210 mL,平均(125.1±20.3)mL;术后住院时间5~9 d,平均(6.7±1.7)d。术后7 d拔除导尿管。无严重手术并发症。11例(91.7%)获得即时尿控,1例2周后无漏尿。术后病理提示8例患者Gleason评分为6分,2例患者Gleason评分为7分,1例患者Gleason评分为8分,1例术后病理未见癌组织。1例Gleason评分8分的患者前列腺尖部切缘阳性。术后随访3~30个月,所有患者3个月后均获得良好尿控。结论前期HoLEP手术在一定程度上增加了根治性前列腺切除术的难度。经膀胱途径纵切口行筋膜内RARP治疗HoLEP术后前列腺癌在技术上是可行的,在达到肿瘤根治目的的同时尽量完整保留尿控功能相关的前列腺周围解剖结构,可在术后短期拔除导尿管并早期恢复尿控功能。

Objective To investigate the feasibility,safety and short-term recovery of urinary continence of the transvesical robot-assisted laparoscopic radical prostatectomy(RARP)for treatment of prostate cancer after holmium laser enucleation of prostate(HoLEP).Methods From Aug.2016 to Apr.2019,12 patients confirmed with post-HoLEP prostatic cancer underwent transvesical RARP.The age of the patients ranged from 60 to 69 years.The preoperative prostatespecific antigen(PSA)was 1.5-8.7 ng/mL.The post-HoLEP Gleason score was≤7 in all the 12 patients and preoperative TNM stage ranged from T1a-T1b.All patients were diagnosed as having prostate cancer by pathology after HoLEP,and none of them received endocrine therapy.The operation time,intraoperative blood loss and length of hospital stay were recorded.Results The operations of all the 12 cases were successfully completed without conversion to open surgery.The operation time was(116.2±15.1)min(115-130 min),the estimated blood loss was(125.1±20.3)mL(80-210 mL),and the postoperative hospital stay was(6.7±1.7)d(5-9 d).The catheter was removed 7 days after operation.No serious complications occurred.Eleven patients(91.7%)had immediate recovery of urinary continence,and one patient had no urine leakage after 2 weeks.Postoperative pathology showed that Gleason score was 6 in eight patients,7 in two patients,8 in one patient,and cancer tissue was not found in one patient.One patient with Gleason score of 8 was positive on the surgical margin at the apex of prostate.During 3 to 30 months of follow-up,all patients regained urinary continence 3 months postoperatively.Conclusion Early HoLEP surgery may increase the difficulty of radical prostatectomy.The transvesical RARP is a safe and technically feasible treatment for prostate cancer after HoLEP.The anatomical structure around the prostate associated with urinary continence is preserved as much as possible while achieving the goal of radical resection.The urethral catheter can be removed shortly after surgery and the urinary continence can be restored early.