侵犯膀胱颈的T_(4)期前列腺癌根治性手术的疗效分析

Analysis of curative effect of radical surgery for T_(4)stage prostate cancer invading bladder neck

目的探讨侵犯膀胱颈的T_(4)期前列腺癌行根治性前列腺切除术(RP)的疗效。方法回顾性分析华中科技大学同济医学院附属协和医院2013年4月至2021年3月收治的22例侵犯膀胱颈的T_(4)期前列腺癌行RP患者的临床资料。年龄(64.09±6.33)岁;术前血前列腺特异性抗原(PSA)57.70(39.40,68.56)ng/ml;术前MRI或PSMA-PET检查明确膀胱颈受侵犯,其中术前临床分期T_(4)N_(0)M_(0)期9例,T_(4)N_(1)M_(0)期10例,T_(4)N_(1)M_(1)期3例;存在尿潴留16例。患者术前均未接受新辅助内分泌治疗或化疗。22例行腹腔镜或机器人辅助腹腔镜RP及盆腔淋巴结清扫。分析手术情况、并发症及随访结果。结果22例手术均顺利完成,无中转开放。手术时间(184.27±34.82)min,术中出血量(210.91±83.03)ml,引流管留置时间(4.73±1.03)d,胃肠功能恢复时间中位值3(2,3)d,术后住院时间(6.68±1.39)d。术后病理Gleason评分7分1例,8分3例,9分18例;切缘阳性率81.82%(18/22);病理分期T_(4)N_(0)M_(0)期5例,T_(4)N_(1)M_(0)期14例,T_(4)N_(1)M_(1)期3例,其中合并包膜外或精囊侵犯20例(90.91%)。术后>3级并发症发生率为9.09%(2/22),均为前尿道狭窄,予尿道扩张后治愈。术后3个月尿控恢复率为90.91%(20/22),16例术前存在尿潴留的患者术后均能正常排尿。术后22例均辅助雄激素剥夺治疗,13例(59.09%)辅助放疗;术后第1次复查PSA(辅助治疗前)中位值2.53(0.51,5.44)ng/ml。术后中位随访32(3~98)个月,中位生存期未达到;12例带瘤生存,7例无瘤生存;2例分别在术后71个月和84个月因前列腺癌死亡,1例术后28个月因心脏疾病死亡。结论对侵犯膀胱颈的T_(4)期前列腺癌患者行RP,能够有效解除患者尿潴留症状,手术并发症发生率低,虽然切缘阳性率较高,但通过结合术后辅助治疗肿瘤控制情况满意,可作为侵犯膀胱颈的T_(4)期前列腺癌局部治疗的选择之一,其远期疗效有待进一步随访观察。

Objective To investigate the curative efficacy of radical prostatectomy(RP)for T_(4)stage prostate cancer invading bladder neck.Methods The clinical data of 22 patients with T_(4)stage prostate cancer invading bladder neck treated with RP from April 2013 to March 2021 were analyzed retrospectively.The mean age of the patients was(64.09±6.33)years,and the preoperative blood PSA was 57.70(39.40,68.56)ng/ml.Preoperative MRI or PSMA-PET examination revealed bladder neck invasion,including 16 cases(72.73%)of urinary retention.Clinical stage of T_(4)N_(0)M_(0) accounted for 40.91%(9/22),T_(4)N_(1)M_(0)accounted for 45.45%(10/22),and T_(4)N_(1)M_(1) accounted for 13.64%(3/22).Preoperative patients were not treated with neoadjuvant endocrine or chemotherapy.Laparoscopic or robotic assisted laparoscopic radical prostatectomy and pelvic lymph node dissection were performed.Results The 22 operations were successfully completed without conversion.The operation time was(184.27±34.82)min,the amount of intraoperative bleeding was(210.91±83.03)ml,the retention time of drainage tube was(4.73±1.03)days,the recovery of gastrointestinal function took 3(2,3)days,and the postoperative hospital stay was(6.68±1.39)days.Postoperative pathology showed that the Gleason score of 7 points accounted for 4.54%(1/22),8 points accounted for 13.64%(3/22),and 9 points accounted for 81.82%(18/22).The positive rate of margin was 81.82%(18/22).Pathological stage of T_(4)N_(0)M_(0) accounted for 22.73%(5/22),T_(4)N_(1)M_(0)accounted for 63.64%(14/22),and T_(4)N_(1)M_(1) accounted for 13.64%(3/22),of which extracapsular or seminal vesicle invasion accounted for 90.91%(20/22).The incidence of postoperative complications above grade 3 was 9.09%(2/22),and the rate of urinary control recovery after 3 months of surgery was 90.91%(20/22).16 patients with preoperative urinary retention were able to urinate normally after operation.All patients were treated with adjuvant androgen deprivation therapy(ADT)with or without antiandrogens,and 13 cases(59.09%)were treated with adjuvant radiotherapy.The postoperative PSA value before adjuvant treatment was 2.53(0.51,5.44)ng/ml.The median survival time was not reached.Two patients died of prostate cancer at 71 and 84 months and one patient died of heart disease at 28 months.Conclusions RP surgery could effectively relieve the condition of urinary retention with low incidence of operative complications.Although the positive rate of surgical margin is high,RP could be used as one of the treatment options for T_(4)stage prostate cancer invading bladder neck,while the long-term effect is still needed to be further analyzed.