后入路机器人辅助逆行松解神经血管束的根治性前列腺切除术的疗效

The efficiency of retzius-sparing robot-assisted laparoscopic radical prostatectomy with retrograde release of the neurovascular bundle

目的探讨后入路机器人辅助逆行松解神经血管束的根治性前列腺切除术的临床疗效。方法去回顾性分析2021年1月至2022年1月天津医科大学第二医院收治的113例前列腺癌患者的临床资料,所有患者均接受机器人辅助经后入路根治性前列腺切除术(RS-RARP),根据前列腺尖部包膜和神经血管束分离方向将患者分为优化组51例和标准组62例。优化RS-RARP是指钝性分离狄氏筋膜并向前游离至前列腺尖部,然后沿尖部左右分离,紧贴尖部和前列腺包膜逆向松解两侧神经血管束(NVB)。优化组和标准组的年龄分别为(67.5±6.4)岁和(67.7±6.1)岁,体质量指数分别为(25.0±3.2)kg/m^(2)和(24.9±3.1)kg/m^(2),前列腺体积分别为(42.8±15.4)ml和(41.0±17.9)ml,术前前列腺特异性抗原(PSA)分别为(13.5±13.1)ng/ml和(11.9±16.0)ng/ml,术前国际勃起功能指数-5(IIEF-5)评分分别为(15.0±4.0)分和(14.8±4.2)分,Gleason评分分别为(7.2±0.8)分和(7.1±0.9)分,差异均无统计学意义(P>0.05)。优化组和标准组临床分期cT_(2)期、cT,期分别为35例和40例、16例和22例;术前新辅助治疗分别为5例和11例,差异均无统计学意义(P>0.05)。比较两组的手术时间、术中出血量、术后引流管留置时间、住院时间、术后切缘阳性率和并发症情况。术后2周拔除尿管,随访患者尿控恢复情况,术后1个月随访IEF-5评分和PSA情况。即刻尿控定义为拔除尿管当日使用尿垫量≤1块。采用log-rank检验比较两组患者尿失禁情况的差异。结果本研究113例手术均顺利完成,中位随访时间16(14,21)个月,随访时间间隔≤3个月。优化组和标准组的手术时间分别为(79.7±26.6)min和(149.8±40.1)min,术中出血量分别为(54.9±24.7)ml和(110.0±83.2)ml,差异均有统计学意义(P<0.01)。优化组和标准组术后引流管留置时间分别为(5.3±2.1)d和(5.5±2.1)d,住院时间分别为(7.6±2.1)d和(8.5±2.3)d,术后病理切缘阳性率分别为19.6%(10/51)和24.2%(15/62),差异均无统计学意义(P>0.05)。优化组和标准组即刻尿控率分别为86.3%(44/51)和69.4%(43/62),差异有统计学意义(P=0.033);术后IIEF-5评分分别为(13.2±3.3)分和(11.0±4.3)分,差异有统计学意义(P=0.012)。Kaplan-Meier曲线分析结果显示,优化组尿失禁发生风险更低(HR=0.78,95%CI0.53~1.14,P=0.020)。结论逆行松解神经血管束的RS-RARP手术时间短、术中出血少,可以更好地保护患者的尿控功能和性功能。

Objective To explore the clinical efficacy of retzius-sparing robot-assisted laparoscopic radical prostatectomy with retrograde release of the neurovascular bundle.Methods From January 2021 to January 2022,the clinical data of 113 patients with retzius-sparing robot-assisted laparoscopic radical prostatectomy(RS-RARP)was retrospectively analyzed.The ages of the optimized group and the standard group were(67.5±6.4)years and(67.7±6.1)years,and the body mass index(BMI)was(25.0±3.2)kg/m^(2)and(24.9±3.1)kg/m^(2),respectively.The prostate volume was(42.8±15.4)ml and(41.0±17.9)ml,the preoperative PSA was(13.5±13.1)ng/ml and(11.9±16.0)ng/ml,and the preoperative IIEF-5 score was(15.0±4.0)and(14.8±4.2)points,respectively.Gleason scores were(7.2±0.8)points and(7.1±0.9)points,respectively,with no statistical significance(P>0.05).The clinical stages of cT,and cT,were 35 and 40 cases in the optimized group and 16 and 22 cases in the standard group,respectively.There were 5 and 1l cases of preoperative neoadjuvant therapy,respectively,with no statistical significance(P>0.05).The optimized RS-RARP is the blunt dissection of the denonvilliers fascia and forward to the apex of prostate,and retrograde release of the NVB.The operation time,intraoperative blood loss,drainage tube retention time,days of hospital stay,positive rate of pathological margin and incidence of complications were compared.The recovery of urinary continence was evaluated at 2 weeks after the catheter was removed,and the postoperative IIEF-5 score and PSA were followed up at 1 month after the surgery.Immediate urinary continence was defined as the use of 1 pad on the day of radical prostatectomy.Follow-up intervals were no more than 3 months.The log-rank test compared urinary incontinence rates between the two modalities.Results All 113 cases of surgery were completed,and median follow-up was 16 months.The operation time was(79.7±26.6)min and(149.8±40.1)min,and the intraoperative blood loss was(54.9±24.7)ml and(110.0±83.2)ml,respectively,and the difference was statistically significant(P<0.01).The retention time of postoperative drainage tube was(5.3±2.1)d and(5.5±2.1)d in the optimal group and the standard group,and the days of hospital stay was(7.6±2.1)d and(8.5±2.3)d,respectively.The positive rate of postoperative pathological margin was 19.6%(10/51)and 24.2%(15/62),respectively.There was no significant difference(P>0.05).immediate urinary continence was 86.3%(44/51)and 69.4%(43/62)in the optimized group and the standard group,respectively,and the difference was statistically significant(P=0.033).Postoperative IEF-5 scores were(13.2±3.3)and(11.0±4.3),respectively,and the difference was statistically significant(P=0.012).Kaplan-Meier analysis showed that the risk of urinary incontinence was lower in the optimized group(P=0.02).Conclusions The optimized RS-RARP might shorten the operation time,reduce intraoperative bleeding,and help the recovery of urinary continence and sexual function to a great extent.