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目的:介绍保留Retzius间隙的机器人辅助腹腔镜前列腺癌根治术(RARP)的初步临床经验和疗效。方法:分析2013年6月~2017年1月8例行保留Retzius间隙的RARP手术患者的资料。患者年龄56~71岁,中位年龄64岁,体质指数(BMI)19.7~24.1kg/m2,中位数21.6kg/m2。术前前列腺特异抗原(PSA)4.18~11.04μg/L,平均7.50μg/L。国际勃起功能指数(IIEF-5)≥21分6例,<21分2例。术前穿刺活检病理TNM分期T1c期4例,T2a期3例,T2b期1例。Gleason评分3+2=5分1例,3+3=6分7例。D’Amico风险分层均为低风险。手术使用4臂da Vinci Si手术系统,经腹腔建立操作通道。由Douglas腔上方的壁层腹膜切开,分离显露双侧输精管和精囊,悬吊提起双侧精囊,切开Denonvillier筋膜,分离前列腺后壁直至前列腺尖部,重新悬吊壁层腹膜,沿精囊前表面向前上方分离显露并离断膀胱颈部,筋膜内层面钝性分离前列腺前表面及两侧直至尖部,双连发钛夹处理离断前列腺侧蒂,最后离断前列腺尖部,将切除的前列腺置于标本袋内,由12点位开始双针逆时针方向连续吻合膀胱颈部及远端尿道残端。最后关闭Douglas腔前方的壁层腹膜。结果:本组8例保留Retzius间隙的RARP手术均顺利完成。手术时间75~120min,平均90min。术中出血量50~200 ml,平均110 ml,均未输血。术后病理检查分期pT2a期5例,pTM 2b期2例,pT2c期1例;1例手术切缘阳性,Gleason评分3+2=5分1例,3+3=6分6例,3+4=7分1例。术后拔除尿管时间14~21d,平均17d,拔管后控尿均满意,无尿失禁。术后住院天数4~7d,平均5d。术后随访4~41个月,平均14个月,无尿道狭窄,未观察到生化复发。术后3个月6例患者勃起功能满意,IIEF-5≥21分。结论:保留Retzius间隙的RARP手术具有解剖合理性,对肿瘤根治疗效好,能有效保护血管神经束,术后性功能及尿控恢复满意。但仍需积累更多病例进行长期前瞻性的对照研究以证实其疗效。
Objective: To introduce the preliminary clinical experience and curative effect of robotic assisted laparoscopic radical prostatectomy (RARP) with Retzius clearance. METHODS: Data from June 2013 to January 2017 in 8 RARP patients with Retzius clearance were routinely performed. Patients aged 56-71 years, median age 64 years old, body mass index (BMI) 19.7 ~ 24.1kg / m2, the median 21.6kg / m2. Preoperative prostate-specific antigen (PSA) 4.18 ~ 11.04μg / L, an average of 7.50μg / L. International erectile function index (IIEF-5) ≥ 21 points in 6 cases, <21 points in 2 cases. Preoperative biopsy TNM staging T1c 4 cases, T2a 3 cases, T2b 1 case. Gleason score 3 + 2 = 5 points in 1 case, 3 + 3 = 6 points in 7 cases. D’Amico risk stratification are low risk. Surgery using 4-arm da Vinci Si surgical system, the establishment of the operating channel through the abdominal cavity. The parietal peritoneum was excised from the top of the Douglas cavity, the bilateral vas deferens and seminal vesicles were dissected, the bilateral seminal vesicles were suspended, the Denonvillier fascia was dissected, the posterior wall of the prostate was dissected up to the tip of the prostate and the parietal peritoneum was resuspended. The anterior surface of the anterior surface of the bladder is separated and exposed, the inner surface of the fascia is blunted to separate the anterior surface of the prostate and the two sides until it reaches the tip, the double- Prostate resection will be placed in the specimen bag, starting at 12 o’clock two-needle counter-clockwise continuous anastomosis bladder neck and distal urethral stump. Close the parietal peritoneum in front of the Douglas cavity. Results: All the 8 cases of RARP with Retzius clearance were successfully completed. Surgery time 75 ~ 120min, an average of 90min. Intraoperative bleeding 50 ~ 200 ml, an average of 110 ml, no blood transfusion. There were 5 patients with pT2a stage, 2 patients with pTM2b stage, and 1 patient with pT2c stage after operation. There were 1 case with positive margins of surgery, 1 case with Gleason score of 3 + 2 = 5, 6 cases with 3 + 3 = 6, 4 = 7 points in 1 case. After removal of the catheter time 14 ~ 21d, an average of 17d, urine control after extubation were satisfactory, incontinence. Postoperative hospital stay 4 ~ 7d, an average of 5d. The patients were followed up for 4 to 41 months with an average of 14 months without urethral stricture and no biochemical recurrence was observed. 6 patients after 3 months of erectile function satisfactory, IIEF-5 ≥ 21 points. CONCLUSION: RARP with Retzius clearance is anatomical and rational. It has good curative effect on the tumor and can effectively protect the vascular bundle. The postoperative sexual function and urinary control are satisfactory. However, more cases still need to be accumulated for long-term prospective controlled studies to confirm its efficacy.