经会阴机器人辅助单孔腹腔镜根治性前列腺切除术的应用研究

Application of perineal single-port robot-assisted radical prostatectomy

目的探讨经会阴机器人辅助单孔腹腔镜根治性前列腺切除术的应用效果方法回顾性分析浙江大学医学院附属邵逸夫医院2019年7月至2022年7月由单术者开展的60例经会阴机器人辅助单孔腹腔镜根治性前列腺切除术患者的临床资料。年龄(65.9±7.6)岁,体质量指数(24.1±2.9)kg/m²。18例既往共接受23次腹部手术。中位前列腺体积32.7(23.8,41.2)ml。中位基线前列腺特异性抗原(PSA)8.8(6.8,12.6)ng/ml。术前穿刺病理Cleason评分6分21例,7分35例,8分4例。临床分期T,期12例,T,期48例。患者取头低足高约15°的过度截石位。于两侧坐骨结节连线中点上方约2cm处做一3~5cm切口。切开会阴中心腱,牵开肛门外括约肌,沿直肠前平面向前游离至前列腺,置入一次性多通道腹腔镜手术人路系统并连接机器人手术器械。横向切开尿道直肠肌,打开狄氏筋膜后层,暴露并切断双侧精囊和输精管壶腹。近尿道处分离出前列腺包膜层面并沿该层面在前列腺两侧进行筋膜内钝性分离。在前列腺尖部与尿道连接处完整游离尿道后切断该处膜部尿道。游离并离断膀胱颈。切除前列腺和精囊,行膀胱尿道吻合。留置会阴部引流管。记录手术情况、围手术期并发症、术后尿控恢复情况(尿控恢复定义为每天使用尿垫≤1块)及肿瘤学控制结果。结果本研究60例手术均顺利完成,无中转开放或增加手术操作孔。中位总手术时间200.0(153.8,236.3)min,中位控制台操作时间107.5(90.0,150.0)min,中位术中出血量50.0(50.0,100.0)ml。切缘阳性率为8.3%(5/60)。术后1、3个月51例获得随访,尿控率分别为43.1%(22/51)、64.7%(33/51),PSA不可检测率分别为94.1%(48/51)、96.1%(49/51);术后6、12个月50例获得随访,尿控率分别为92.0%(46/50)、98.0%(49/50),PSA不可检测率分别为94.0%(47/50)、100.0%(50/50)。1例(1.7%)术后9个月出现生化复发。12例(20.0%)出现围手术期并发症,包括2例急性呼吸窘迫综合征、1例直肠损伤、1例输尿管损伤、2例切口愈合不良、3例切口感染、2例泌尿系感染和1例膀胱颈-尿道口吻合口狭窄。结论经会阴机器人辅助单孔腹腔镜根治性前列腺切除术可以作为局限性前列腺癌的治疗手段,对于有复杂腹部或盆腔手术史的患者是一种可选择的方案,在术后早期尿控恢复方面有一定优势。术中应注意会阴区解结构,选择合适的切口位置,同时对切口采用针对性的保护措施,以降低围手术期并发症发生风险。

Objective To investigate the effect of perineal single-port robot-assisted radical prostatectomy.Methods A retrospective analysis was conducted on clinical data from 60 patients who underwent perineal single-port robot-assisted laparoscopic radical prostatectomy at our hospital between July 2019 and July 2022.The mean age of the patients was(65.9±7.6)years and the mean BMI was(24.1±2.9)kg/m².The median(IQR)prostate volume was 32.7(23.8,41.2)ml,and the median(IQR)preoperative PSA value was 8.8(6.8,12.6)ng/ml.Preoperative pathology revealed a Gleason score of 6 in 21 patients,Cleason score of 7 in 35 patients and Cleason score of 8 in 4 patients.There were 12 patients clinically staged as T,and 48 patients as T2.A total of 18 patients underwent a total of 23 previous abdominopelvic surgeries.The patient is placed in an exaggerated lithotomy position with the head down and feet elevated approximately 15°.A 3-5 cm incision was made approximately 2 cm above on the midperineum between the bilateral ischial tuberosities.Next,the rectourethral muscle was divided,and the space anterior to the rectum was developed by blunt dissection.The levator ani muscles were separated to expose Denonvilliers'fascia.Then,the disposable multi-channel laparoscopic surgical access system is inserted with a surgical wound protector.Denonvilliers'fascia was incised transversely and the ampulla of the vas deferens,which were subsequently divided.Blunt separation is performed on both sides along the capsule of the prostate,and then,the vascular pedicles of the prostate are ligated.The membranous urethra was severed after complete urethral separation at the tip of the prostate at the urethral junction.The bladder neck was freed and dissected.The prostate and seminal vesicles were removed and a vesicourethral anastomosis is performed.A perineal drain were left in place.Preoperative and postoperative variables,complications,early urinary continence rate(Return of urinary continence status was defined as using no more than one safety pad per day)and oncological outcomes of patients were recorded.Results All 60 surgeries were successfully completed without conversions or additional incisions.The median(IQR)total operative time was 200.O(153.8,236.3)min,the median(IQR)console operating time was 107.5(90.0,150.0)min and the median(IQR)estimated blood loss was 50.0(50.0,100.0)ml.Positive surgical margins were detected in five patients(8.3%).The continence rate was 43.1%(22/51),64.7%(33/51),92.0%(46/50)and 98.0%(49/50),and the PSA undetectable rate was 94.6%(48/51),98.2%(49/51),96.6%(47/50)and 100%(50/50)at the 1,3,6,and 12 months after surgery.Only 1(1.7%)patient experienced biochemical recurrence 9 months after surgery.The overall complication rate was 20%,including two cases of acute respiratory distress syndrome,one case of rectal injury,one case of urinary tract injury,two cases of poor wound healing,three cases of incision infection,two cases of urinary tract infection and one case of bladder neck-urethral orifice anastomotic stricture.Conclusions Perineal single-port robot-assisted radical prostatectomy might be safe and feasible surgical treatments for localized prostate cancer,especially for patients with a history of complex abdominal or pelvic surgery.It also showed advantages in early continence.The anatomical structure of the perineal region should be considered,and the correct incision position should be chosen.Specific incision protection measures should also be used for the incision in this particular area of the perineal region to reduce the risk of perioperative complications.