摘要
目的:探讨应用保留Retzius间隙机器人腹腔镜筋膜内和筋膜外根治性前列腺切除术（Rs-RARP）治疗局限性前列腺癌的策略选择和技术要领。方法:2022年8月至2023年8月中山大学附属第三医院泌尿外科由同一高年资术者完成的Rs-RARP术共30例，其中20例D'Amico风险分层中低危患者行完全筋膜内手术，10例高危患者行筋膜外手术。所有手术均利用达芬奇机器人系统完成。手术方法为首先建立机器人操作平台后显露道格拉斯窝，游离双侧输精管和精囊腺。筋膜内技术要领：在紧贴前列腺后方、侧方和前方分别钝性推开狄氏筋膜前层，离断侧韧带和Aphrodite面纱下方游离显露尿道；筋膜外技术要领：在前列腺后方、侧方和前方分别锐性剪开狄氏筋膜前层，离断侧韧带打开盆筋膜和Aphrodite面纱上方游离显露尿道。离断尿道完整切除前列腺后双针倒刺线连续吻合膀胱颈后尿道。结果:30例患者均顺利完成手术，无中转开放和转前入路，围手术期无严重并发症发生。完全筋膜内手术患者的手术时间、术中失血量、膀胱颈尿道吻合时间和导尿管留置时间比筋膜外手术患者的更短（P<0.05）。30例患者术后病理显示pT2 12例，pT3a 12例，pT3b 6例。完全筋膜内和筋膜外T3期患者中分别发现2例和1例手术切缘阳性；术后随访两组患者各有1例出现生化复发（PSA>0.2 ng/ml）。两组患者拔除导尿管后即刻控尿率55%和10%（P<0.05），1个月后控尿率80%和60%（P>0.05）。两组患者IEEF-5评分≥18术后1个月分别是20%和0，术后3个月分别是35%和20%。结论:筋膜内与筋膜外Rs-RARP治疗局限性前列腺癌均安全可行，中低危患者可选择筋膜内技术，局部高危患者可选择筋膜外技术，近期随访控瘤、控尿和勃起功能恢复效果满意，远期效果需进一步随访。
Abstract
Objective:To explore the intrafascial and extrafascial techniques of Retzius-sparing robot-assisted radical prostatectomy (Rs-RARP) in the treatment of localized prostate cancer.Methods:From August 2022 to August 2023, 30 cases of Rs-RAPR were performed by the same senior surgeon in the Department of Urology, the Third Affiliated Hospital of Sun Yat-sen University, 20 low and medium-risk patients with D'Amico risk stratification who underwent intrafascial surgery and 10 high-risk patients underwent extrafascial surgery. All surgeries were performed by the da Vinci robotic system. The surgical method was after establishing the robotic platform, the Douglas fossa was revealed, and then the vas deferens and seminal vesicles were freed. Intrafascial techniques: the urethra can be exposed after bluntly pushing away the anterior layer of denonvillier’s fascia close to the back of the prostate, dissecting the lateral ligament laterally, and mobilizing the front under the Aphrodite veil. Extrafascial techniques: cutting the anterior layer of Denonvillier’s fascia sharply behind the prostate, dissecting the lateral ligament laterally to open the pelvic fascia, and mobilizing above the Aphrodite veil to expose the urethra. Finally, the bladder neck and posterior urethra are continuously anastomosed with double-needle barbed sutures.Results:All 30 patients with Rs-RARP were completed, there was no conversion to open and traditional surgery, and no serious complications occurred in the perioperative period. The operation time, intraoperative blood loss, bladder neck urethral anastomosis time and urinary catheter indwelling time were shorter in patients with complete intrafascial surgery than in patients with extrafascial surgery (P<0.05). The postoperative pathology of 30 patients showed pT2 12 cases, pT3a 12 cases, and pT3b 6 patients. 2 patients with intrafascial and extrafascial T3 stage were found to have positive surgical margins, respectively, and 1 patient in each group had biochemical recurrence (PSA>0.2 ng/ml). The urinary continence rates of the two groups were 55% and 10% immediately after removal of the catheter (P<0.05), and the continence rate after 1 month was 80% and 60% (P>0.05). The IEEF-5 scores of the two groups were 20% and 0% ≥18 months after surgery, and 35% and 20% in 3 months after surgery.Conclusions:The treatment of localized prostate cancer with Rs-RARP is safe and feasible, and it is recommended to choose intrafascial technology for intermediate and low-risk Pca patients, and the extrafascial technique for local high-risk patients. The short-term follow-up effect of tumor control, urinary continuation, and erectile function recovery is satisfactory, and the long-term effect requires further follow-up.
基金项目
国家自然科学基金面上项目(82272840)
广东省自然科学基金(2021A1515010129)
万方数据