经腹膜外途径腹腔镜下根治性前列腺切除术治疗局限性前列腺癌（附27例报告）

doi:10.19558/j.cnki.10-1020/r.2019.03.008

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摘要目的探讨经腹膜外途径腹腔镜技术处理局限性前列腺癌的手术要点与临床应用价值。方法 2013年7月–2017年10月,共施行经腹膜外途径腹腔镜下根治性前列腺切除术27例,25例为术前经直肠前列腺穿刺活检确诊,另外2例为TURP后病理发现。患者中位年龄61（52~73）岁;中位BMI为22.3（20.1~26.1）kg/m²;中位前列腺体积（术前经直肠B超测量）44.8（32.3~94.6）cm³;术前中位PSA 11.6（5.6~28.7）μg/L。术前Gleason评分5分3例,6分13例,7分8例,8分3例;术前盆腔CT及MRI检查均未见明显肿大的淋巴结和精囊侵犯,核素骨扫描检查未见骨转移,肿瘤临床分期T_1b 2例,T_1C 9例,T_2a 8例,T_2b 6例,T_2C 2例;均采用四孔法经腹膜外途径完成腹腔镜下根治性前列腺切除。结果 27例手术均获成功,无一例中转开放。中位手术时间135（75~215）min;中位失血量145（55~450）mL,术中术后均未输血。术中发生直肠损伤1例,在腔镜下予以及时发现并缝合修补,术后恢复良好;术后病理检查切缘阳性2例。术后5例出现漏尿,均在3~10 d后消失;术后2~3周拔除尿管,3例拔除尿管后即能满意控尿;3个月后11例恢复控尿,其余13例活动时出现轻中度压力性尿失禁,均在6~12个月内恢复控尿;保留性神经的10例患者中有6例术后恢复勃起功能。术后平均随访18（1~48）个月,无尿道狭窄,3例出现生化复发。结论经腹膜外途径腹腔镜下根治性前列腺切除术是一种安全、有效的微创手术方法,用于治疗局限性前列腺癌可以获得满意的肿瘤控制和功能保留。

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关键词 ：前列腺癌, 根治性前列腺切除术, 腹腔镜, 腹膜外途径

Abstract：Objective: To explore the key technical points and clinical value of extraperitoneal laparoscopic radical prostatectomy (ELRP) in the treatment of localized prostate cancer.Methods: A total of 27 patients who underwent ELRP from July 2013 to October 2017 were retrospectively analyzed. Two of the patients were diagnosed by transurethral resection of the prostate (TURP), and the rest 25 patients were preoperatively confirmed by transrectal prostate biopsy. The median age of the patients was 61 years (52-73 years); the median body mass index (BMI) was 22.3 kg/m² (20.1-26.1 kg/m²). The median prostate volume measured by transrectal ultrasound (TRUS) was 44.8 cm³ (32.3-94.6 cm³); The preoperative median preoperative prostate specific antigen (PSA) was 11.6 μg/L (5.6-28.7 μg/L). The preoperative Gleason sum was 5 in 3 patients, 6 in 13, 7 in 8, and 8 in 3 patients. No lymph node or seminal vesicle involvement was found by CT or MR and radionuclide bone scan revealed no metastasis. The preoperative clinical stage was T_1b, T_1C, T_2a, T_2b, T_2C in 2, 9, 8, 6 and 2 patients respectively. All the procedures were performed by extraperitoneal laparoscopic approach with four-port. Results: All the operations were successfully performed with no need for open conversion. The median operative time was 135 (75-215) min. The total estimated blood loss was 145 (55-450) mL and no need for transfusion was reported. One patient had intraoperative rectal injury which was successfully closed laparoscopically without a need for conversion, and this patient had an uneventful recovery with no sequelae. There were 2 patients with positive surgical margins: 1 was apical and 1 was posterolateral. Urine leakage occurred in 5 patients and disappeared three to ten days later. The catheter was removed within 2-3 weeks after the operation, and complete continence was found in 3 patients immediately after catheter removal. Three months postoperation continence recovered in 11 patients, and moderate stress incontinence with occasional urine leakage during normal activity in 13 patients recovered (no need for a pad) in 6-12 months after the operation. Six out of the 10 patients with nerve-sparing had potency after 12 months. Biochemical recurrence occurred in 3 patients and no anastomotic stricture was found after a mean follow-up of 18 months (range 1-48). Conclusions: ELRP is a safe and effective minimally invasive procedure for localized prostate cancer, which can obtain satisfactory oncological and functional outcomes.

Key words： prostate cancer: radical prostatectomy laparoscopy extraperitoneal approach

收稿日期: 2018-09-03

通讯作者: 王超,wangchao321@126.com

引用本文:

王超, 郑美霞, 贾国, 路建磊, 郭洪波, 朱新胜, 胡平, 乌热依木·托合孙, 蓟亚妮. 经腹膜外途径腹腔镜下根治性前列腺切除术治疗局限性前列腺癌（附27例报告）[J]. 微创泌尿外科杂志, 2019, 8(3): 178-184.
WANG Chao, ZHENG Meixia, JIA Guo, LU Jianlei, GUO Hongbo, ZHU Xinsheng, HU Ping, Wureyimu.Tuohesun, JI Yani. Extraperitoneal laparoscopic radical prostatectomy for localized prostate cancer: a report of 27 cases. JOURNAL OF MINIMALLY INVASIVE UROLOGY, 2019, 8(3): 178-184.

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http://journal20.magtechjournal.com/Jwk_zgmnwk/CN/abstract/abstract1506.shtml 或 http://journal20.magtechjournal.com/Jwk_zgmnwk/CN/Y2019/V8/I3/178

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