保留Retzius间隙和尿...积良性前列腺增生的临床研究_陈鑫楠.pdf

NJA中华男科学杂志National Journal of AndrologyZhonghua Nan Ke Xue Za Zhi2022，28(11):1006 1010http:/www androl cn论著Clinical esearch(临床研究)保留 etzius 间隙和尿道的机器人辅助单纯前列腺切除术治疗大体积良性前列腺增生的临床研究陈鑫楠，方昌华，杜霖，王昊，王文帝，张成伟，秦海翔，邓永明，邱雪峰，庄君龙，张士伟，徐林峰，甘卫东，李笑弓，郭宏骞，张古田(南京医科大学鼓楼临床医学院泌尿外科，江苏 南京 210008)【摘要】目的:报告保留 etzius 间隙和尿道的机器人辅助单纯前列腺切除术治疗大体积前列腺增生(80 ml)的安全性及疗效。方法:回顾性分析 2019 年 8 月至 2021 年 6 月进行的 24 例保留 etzius 间隙和尿道的机器人辅助单纯前列腺切除术的临床资料，患者年龄 68 5(55 80)岁，体质量指数 25 1(20 5 34 9)kg/m2，术前前列腺体积 1324(856 2357)ml，tPSA 10 8(0 5 37 9)g/L，IPSS 25(3 35)分，QOL 5(3 8)分。24例中术前因尿潴留导尿 12 例，膀胱造瘘 1 例，合并肾积水 2 例，膀胱结石和膀胱憩室 1 例;14 例经前列腺穿刺活检排除前列腺癌。术后随访时间为3 21 个月。记录手术时长、术中失血量、术后第1 天血红蛋白下降值、输血率、术中术后并发症;对比分析患者术前后 IPSS、QOL、最大尿流率(Qmax)、残余尿量(PV)、IIEF、男性性健康问卷(MSHQ)评分变化。结果:24 例患者均顺利完成保留 etzius 间隙和尿道的机器人辅助单纯前列腺切除术，手术时间 175(100 285)min，失血量 200(50 800)ml，术后第 1 天血红蛋白下降值 25(4 57)g/L，术后留置引流管时间 3(2 7)d，留置尿管时间 12(4 18)d，有 6 例(25%)进行了术中输血治疗;1 例患者术后 1 个月因血尿行经尿道电凝止血术，1 例术后 12 个月因膀胱颈口条索状组织黏连行经尿道膀胱颈口瘢痕组织黏连电切术，其余患者未发生其他并发症。术后患者 IPSS 3(1 7)分、QOL 2(0 3)分、Qmax19 6(9 9 32 1)ml/s、PV 0(0 34 9)ml，均较术前有明显改善(P 0 05)。IIEF 20(19 24)分、MSHQ 评分 14(13 14)分，未见明显下降(P 0 05)。结论:保留 etzius 间隙和尿道的机器人辅助单纯前列腺切除术是一种安全、有效的治疗大体积前列腺增生的微创方法，可改善患者术后排尿功能。【关键词】机器人辅助前列腺切除术;后入路手术;良性前列腺增生;排尿功能;并发症中图分类号:697+32文献标志码:Adoi:10 13263/j cnki nja 2022 11 006Trans-Douglas etziusspace-sparing robot-assisted simple prostatectomyfor large-volume benign prostate hyperplasiaCHEN Xin-nan，FANG Chang-hua，DU Lin，WANG Hao，WANG Wen-di，ZHANG Cheng-wei，QIN Hai-xiang，DENG Yong-ming，QIU Xue-feng，ZHUANG Jun-long，ZHANG Shi-wei，GAN Wei-dong，LI Xiao-gong，GUO Hong-qian，ZHANG Gu-tianDepartment of Urology，Nanjing Drum Tower Hospital/Gulou School of Clinical Medicine，Nanjing Medical Univer-sity，Nanjing，Jiangsu 210008，China【Abstract】Objective:To report the safety and efficacy of trans-Douglas etziusspace-sparing robot-assisted simple prostatec-tomy(SS-ASP)in the treatment of large-volume BPHMethods:This retrospective study included 24 cases of large-volume6001作者简介:陈鑫楠(1996-)，女，江苏无锡市人，医师，硕士研究生，从事泌尿外科工作。Email:chenxinnan123456163 com通讯作者:张古田，Email:zhang gutian nju edu cnXU Li n-f eng,(80 ml)BPH treated by trans-Douglas SS-ASP from August 2019 to June 2021 The patients ranged in age from 55 to 80(mean68 5)years，with an average body mass index of 25 1(20 5 34 9)kg/m2，median prostate volume of 132 4(85 6 235 7)ml，and preoperative tPSA of 10 8(0 5 37 9)ng/ml，IPSS of 25(3 35)and quality of life(QOL)score of 5(3 8)Before sur-gery，12 of the patients received catheterization for urinary retention，1 underwent cystostomy，2 were complicated with hydronephrosis，1 had stones and diverticulum in the bladder，and 14 were excluded from the cases of PCa by prostatic biopsy The operation time，in-traoperative blood loss，hemoglobin level on the first day after surgery，blood transfusion，and intra-and postoperative complicationswere recorded The patients were followed up for 3 to 21 months postoperatively Comparisons were made before and after operation inthe IPSS，maximum urinary flow rate(Qmax)，postvoid residual volume(PV)，QOL score，IIEF score and Male Sexual HealthQuestionnaire(MSHQ)scoreesults:Trans-Douglas SS-ASP was successfully completed in all the 24 cases，with a mean oper-ation time of 175(100 285)min，intraoperative blood loss of 200(50 800)ml，hemoglobin decrease of 25(4 57)g/L on thefirst day after surgery，postoperative drainage tube indwelling of 3(2 7)d，and urinary catheterization of 12(4 18)d Six(25%)of the patients received intraoperative blood transfusion，1 underwent transurethral electrocoagulation hemostasis 1 month aftersurgery because of postoperative bleeding，and 1 received transurethral resection of the cicatrical adhesive tissue of the bladder neck 12months after surgery No other complications occurred postoperatively The IPSS(3 1 7)，Qmax(19 6 9 9 32 1ml/s)，PV(0 0 34 9ml)and QOL score(2 0 3)of the patients were significantly improved after surgery(P 0 05)，but nostatistically significant differences were observed in the IIEF(20 19 24)and MSHQ scores(14 13 14)as compared with thebaseline(P 0 05)Conclusion:Trans-Douglas SS-ASP is a safe and effective minimally invasive method for the treatment oflarge-volume(80 ml)BPH，which can improve the urinary function of the patient after operation【Key words】robot-assisted simple prostatectomy;trans-Douglas approach;benign prostate hyperplasia;urinary function;com-plicationsCorrespondence to:ZHANG Gu-tian，email:zhang gutian nju edu cneceived:August 23，2022;accepted:October 10，2022良性前列腺增生(BPH)引起的下尿路症状(LUTS)影响着许多中老年男性的生活质量。对于大体积 BPH 患者(80 ml)，欧美和国内泌尿外科指南推荐开放前列腺摘除手术(open simple prosta-tectomy，OSP)等干预方法，OSP 是治疗大体积 BPH一种有效的手术方式1，可以彻底解除梗阻，但有留置尿管时间较长、创伤大、出血多、术后住院时间长的缺点。随着微创技术的发展，相比于 OSP，内镜和腹腔镜下前列腺切除术具有创伤小、失血量少、住院时间短的优点，但仍有高达 38%89%的患者会出现术后射精功能异常。解剖学研究表明，保护精阜环周组织(横向 7 5 mm，近端 10 mm)是避免术后逆向射精的首要条件2。2018 年 Wang 等3、2020 年意大利都灵大学的 Porpiglia 等4 相继报道了保留尿道(urethral sparing，US)的机器人辅助腹腔镜单纯前列腺切除术(urethral sparing robot-assis-ted simple prostatectomy，usASP)，但是针对中叶突出的病例，常规经耻骨后、经膀胱入路不可避免的需要经膀胱切开腺体表面粘膜才能切除突入膀胱腔内的中叶腺体。我们开展了保留 etzius 间隙和尿道的机器人辅助单纯前