保留"尿道系膜"的腹腔镜下前列腺根治性切除术后尿控情况的研究

doi:10.3877/cma.j.issn.1674-3253.2024.01.004

目的

探讨保留"尿道系膜"的腹腔镜下前列腺根治性切除术（LRP）对中高危前列腺癌（PCa）患者术后即刻尿控、早期尿控恢复的安全性及有效性。

方法

回顾性分析2021年7月至2021年11月同一术者所行的18例LRP患者病例资料，所有患者均保留"尿道系膜"。平均年龄为（69±7）岁，平均前列腺体积（45±16）ml，术前PSA≥10 ng/ml 13例，BMI为（24.1±2.5）kg/m²。

结果

18例患者顺利完成手术，手术时间299（267，397）min；术中失血量50（50，100）ml。术后病理均为前列腺腺泡型腺癌，Gleason评分9分4例，8分2例，7分8例，6分4例；术后TNM分期为T_2a～T₄期；4例患者术后切缘阳性（22%）。术后平均留置尿管时间（11±5） d。4例患者出现术后并发症，Clavien-DindoⅡ级2例，其中1例尿道感染，1例伤口感染；Clavien-DindoⅢ级2例，1例拔管后尿潴留；1例吻合口瘘尿。术后3个月复查PSA未见生化复发。拔管后即刻、1周、1个月及3个月尿控恢复率分别为61%、72%、77%及83%。

结论

LRP时保留"尿道系膜"及其附着对中高危PCa术后早期尿控恢复是一种可行的术式。

关键词: 尿道系膜, 前列腺切除术, 尿控, 前列腺癌, 解剖

Objective

To investigate the safety and efficacy of immediate and early recovery of postoperative urinary continence by retaining the urethral mesentery during laparoscopic radical prostatectomy (LRP) in patients with moderate and high-risk prostate cancer (PCa).

Methods

The clinical data of 18 LRP patients who underwent the same operation from July 2021 to November 2021 were retrospectively analyzed. All patients retained the urethral mesentery. The mean age was (69±7) years, the mean prostate volume was (45±16) ml, ther were 13 cases of preoperative prostate specific antigen (PSA) ≥10 ng/ml, and body mass index (BMI) was (24.1±2.5) kg/m².

Results

18 patients were completed the operation successfully, the median operation time was 299(267, 397) minutes and the median intraoperative blood loss was 50(50, 100) ml. Postoperative pathology was all prostate adenocarcinoma, Gleason score was 9 in 4 cases, 8 in 2 cases, 7 in 8 cases, and 6 in 4 cases. Postoperative TNM stage was T_2a-T₄. Surgical margins were positive in 4 patients (22%). The average indwelling time of catheter was (11±5) days. Postoperative complications occurred in 4 patients. Among them 2 cases were Clavien-Dindo class Ⅱ, including 1 urinary tract infection and 1 wound infection. 2 cases were Clavien-Dindo grade Ⅲ, including 1 urinary retention after extubation and 1 anastomotic leakage. PSA re-examination 3 months after the operation showed no biochemical recurrence. The continence rate was 61%, 72%, 77% and 83% immediately, 1 week, 1 month and 3 months after extubation.

Conclusion

Retaining the urethral mesentery improves early recovery of urinary continence after LRP in middle and high risk PCa patients.

Key words: Urethral mesentery, Radical prostatectomy, Urinary control, Prostate cancer, Anatomy

表1 18例前列腺癌患者术前临床资料(4例术前诊断BPH，术后病理诊断PCa)

年龄(岁)	BMI(kg/m²)	前列腺体积(ml)	tPSA[ng/ml，(例)]		临床分期(例)					穿刺Gleason评分(例)
69±7	24.1±2.5	45±16	PSA<10	PSA≥10	T_1c	T_2b	T_2c	T_3b	T₄	6	7	8	9
69±7	24.1±2.5	45±16	5	13	2	3	5	3	1	3	4	4	3

表1 18例前列腺癌患者术前临床资料(4例术前诊断BPH，术后病理诊断PCa)

年龄(岁)	BMI(kg/m²)	前列腺体积(ml)	tPSA[ng/ml，(例)]		临床分期(例)					穿刺Gleason评分(例)
69±7	24.1±2.5	45±16	PSA<10	PSA≥10	T_1c	T_2b	T_2c	T_3b	T₄	6	7	8	9
69±7	24.1±2.5	45±16	5	13	2	3	5	3	1	3	4	4	3

表2 18例前列腺癌患者腹腔镜前列腺根治性切除术术中及术后情况

手术时间(min)	失血量(ml)	神经保留(例)		盆腔淋巴结清扫(例)		术后病理分期(例)			术后Gleason评分(例)				病理切缘阳性(例)	拔除尿管时间(d)
299(267，397)	50(50，100)	无	有	无	标准	T_2a～2c	T_3a～3c	T₄	6分	7分	8分	9分	4	11±5
299(267，397)	50(50，100)	18	0	0	18	10	6	2	4	8	2	4	4	11±5

表2 18例前列腺癌患者腹腔镜前列腺根治性切除术术中及术后情况

手术时间(min)	失血量(ml)	神经保留(例)		盆腔淋巴结清扫(例)		术后病理分期(例)			术后Gleason评分(例)				病理切缘阳性(例)	拔除尿管时间(d)
299(267，397)	50(50，100)	无	有	无	标准	T_2a～2c	T_3a～3c	T₄	6分	7分	8分	9分	4	11±5
299(267，397)	50(50，100)	18	0	0	18	10	6	2	4	8	2	4	4	11±5

图1 腹腔镜下前列腺根治性切除术保留"尿道系膜"等解剖结构手术图片和示意图注：a为常规技术，即尿道系膜被剥离，尿道被裸化；b为研究技术，即尿道系膜保留，尿道不裸化；c为尿道系膜示意图

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Retention of urethral mesangium during laparoscopic radical prostatectomy for recovery of urinary control in prostate cancer

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Retention of urethral mesangium during laparoscopic radical prostatectomy for recovery of urinary control in prostate cancer