目的 探讨膀胱黏膜光滑程度(BMS)与腹腔镜根治性前列腺切除术(LRP)后早期(3个月)控尿功能恢复的相关性.方法 回顾性分析北京大学第三医院2016年1月至2020年3月收治的192例前列腺癌患者行LRP的临床资料.年龄(69.1±8.0)岁,穿刺前前列腺特异性抗原(PSA)12.23(7.45,20.36)ng/ml;穿刺 Gleason 评分＜7 分和≥7 分者分别为 69 例(35.9％)和 123 例(64.1％);临床分期T1～2期92例(47.9％),T3期100例(52.1％).所有患者于前列腺穿刺活检前完善MRI检查,术前MRI测量前列腺体积(PV)为35.4(26.3,51.1)ml;膜性尿道长度(MUL)为(13.9±3.5)mm;前列腺突入膀胱深度(IPPL)＜5 mm 者 128 例(66.7％),IPPL≥5 mm 者 64 例(33.3％).根据 MRI 影像将 BMS分为4个分级:0级,膀胱黏膜完全光滑;1级,膀胱黏膜可见少量不平整凹凸;2级,膀胱黏膜可见深入肌层的裂隙,深度≤1/2膀胱壁厚度,或出现膀胱憩室;3级,膀胱裂隙深度＞1/2膀胱壁厚度,或裂隙进展成为小块状的肌层缺失.本研究BMS为0级63例(32.8％),1级95例(49.5％),2～3级34例(17.7％).术后自第1个月起每月对患者的控尿功能恢复情况进行随访.以全天不需要使用尿垫为控尿功能恢复,每日使用≥1个尿垫为尿失禁.应用logistic多因素回归分析影响术后早期控尿功能恢复的危险因素.采用Kaplan-Meier法绘制LRP术后患者控尿功能恢复曲线,log-rank检验比较各组间术后控尿功能恢复曲线的差异.结果 所有手术均顺利完成.术后1、3、6、12个月患者控尿率分别为40.1％(77/192)、57.8％(111/192)、71.9％(138/192)和 90.1％(173/192).术后早期(3 个月)尿失禁的单因素分析中,PV＜40 ml患者的尿失禁比例低于≥40 ml者[33.0％(38/115)与55.8％(43/77)]、MUL＜14 mm 患者尿失禁比例高于 MUL≥14 mm 者[75.7％(56/74)与 21.2％(25/118)],IPPL＜5 mm患者的尿失禁比例低于≥5 mm患者[26.6％(34/128)与73.4％(47/64)]、BMS 0级患者尿失禁比例低于BMS 1级、2～3级患者[23.8％(15/63)与47.4％(45/95)与61.8％(21/34)],差异均有统计学意义(P＜0.05).多因素分析结果显示MUL、IPPL和BMS是术后早期(3个月)尿失禁发生的独立危险因素(均P＜0.05).log-rank检验示不同PV、MUL、IPPL和BMS分组术后控尿功能恢复的差异均有统计学意义(P＜0.05).结论 BMS高分级是术后早期尿失禁发生的独立危险因素,术前MUL、IPPL和BMS与LRP术后控尿功能恢复存在相关性,此研究结果还需要更大规模的临床研究证实.
Predictive value of bladder mucosal smoothness for early recovery of urinary continence after laparoscopic radical prostatectomy
Objective To investigate the correlation between bladder mucosal smoothness(BMS)and early urinary continence recovery following laparoscopic radical prostatectomy(LRP).Methods A retrospective analysis was conducted on the clinical data of 192 prostate cancer patients who underwent LRP at Peking University Third Hospital between January 2016 and March 2020.The patients'average age was(69.1±8.0)years old,and the median pre-biopsy PSA level was 12.23(7.45,20.36)ng/ml.There were 69 patients(35.9％)with a Gleason score＜7 and 123 patients(64.1％)with a Gleason score ≥7.Clinical staging showed that 92 patients(47.9％)were in stage T1/T2,and 100 patients(52.1％)were in stage T3.All patients underwent MRI before prostate biopsy.The preoperative MRI measured the prostate volume(PV)as 35.4(26.3,51.1)ml,and membranous urethral length(MUL)as(13.9±3.5)mm.The intravesical prostatic protrusion length(IPPL)was＜5 mm in 128 patients(66.7％)and ≥5 mm in 64 patients(33.3％).All patients completed MRI examination before biopsy,BMS was defined into four grades according to MRI:grade 0,the bladder mucosa is completely smooth;grade 1,a small amount of unevenness and bumps can be seen in the bladder mucosa;grade 2,fissures can be seen in the bladder mucosa,less than half of the bladder wall,or bladder diverticulum;grade 3,the bladder fissure exceeds half of the bladder wall,or fissure progresses to a small loss of muscularis.In this study,there were 63 patients(32.8％)with grade 0,95 patients(49.5％)with grade 1,and 34 patients(17.7％)with grade 2-3.Postoperatively,patients were followed up monthly from the first month onwards to assess urinary continence recovery,defined as not requiring pads throughout the day.Logistic multivariate regression analysis was used to identify risk factors affecting early postoperative urinary continence recovery,and log-rank test was used to compare postoperative urinary continence recovery curves among different groups.Results All surgeries were successfully completed.The complete urinary continence rates at 1,3,6,and 12 months postoperatively were 40.1％(77/192),57.8％(111/192),71.9％(138/192),and 90.1％(173/192),respectively.In the univariate analysis of urinary incontinence,the proportion of urinary incontinence was lower in patients with PV＜40 ml than that in patients with PV ≥40 ml[33.0％(38/115)vs.55.8％(43/77),P＜0.05].The proportion of urinary incontinence in patients with maximum urethral length(MUL)＜14 mm was higher than that in patients with MUL ≥14 mm[75.7％(56/74)vs.21.2％(25/118),P＜0.05].The proportion of urinary incontinence in patients with the interpubic prostate length(IPPL)＜5 mm was lower than that in patients with IPPL ≥5 mm[26.6％(34/128)vs.73.4％(47/64),P＜0.05].The proportion of urinary incontinence was lower in the group with a BMS of 0 compared to those with BMS of 1 and BMS of 2-3[23.8％(15/63)vs.47.4％(45/95)vs.61.8％(21/34),P＜0.05].These results indicated that the differences in urinary incontinence proportions across these indicators are statistically significant.Multivariate analysis indicated that MUL,IPPL,and BMS were independent risk factors for early postoperative urinary incontinence(all P＜0.05).The log-rank test demonstrated that differences in postoperative urinary continence recovery among groups with different PV(P＜0.05),MUL,IPPL,and BMS were all statistically significant(all P＜0.05).Conclusions Higher BMS grades are an independent risk factor for early postoperative urinary incontinence.Preoperative MUL,IPPL,PV,and BMS are correlated with urinary continence recovery after LRP.These findings require further validation in larger clinical studies.
ProstatectomyBladder mucosal smoothnessUrinary continenceLaparoscopic surgeryPredictive value
万方数据
维普
