胡文豪++++++周小波
[摘要] 目的 對(duì)比分析經(jīng)腹腔途徑腹腔鏡下前列腺癌根治術(shù)(TLRP)與開(kāi)放性手術(shù)的治療效果。 方法 對(duì)來(lái)我院診治的80例前列腺癌患者的臨床資料進(jìn)行回顧性分析,其中腹腔鏡組40例行經(jīng)腹腔途徑腹腔鏡下前列腺癌根治術(shù),對(duì)照組40例行開(kāi)放性前列腺癌根治術(shù),記錄并比較兩組患者的手術(shù)時(shí)間、術(shù)中出血量、術(shù)后腸功能恢復(fù)時(shí)間、術(shù)后住院時(shí)間及并發(fā)癥情況。 結(jié)果 腹腔鏡組手術(shù)時(shí)間為(326.9±63.5)min,顯著長(zhǎng)于對(duì)照組;腹腔鏡組術(shù)中出血量達(dá)(390.2±67.8)mL,顯著少于對(duì)照組(P<0.01);腹腔鏡組術(shù)后腸功能恢復(fù)時(shí)間為(3.12±0.51)d,顯著短于對(duì)照組,腹腔鏡組住院時(shí)間為(8.2±1.3)d,顯著短于對(duì)照組,差異有顯著性(P<0.05)。腹腔鏡組術(shù)后并發(fā)癥發(fā)生率為10.0%,顯著低于對(duì)照組的25.0%,差異有顯著性(P<0.05)。 結(jié)論 經(jīng)腹腔途徑腹腔鏡下前列腺癌根治術(shù)(TLRP)和開(kāi)放性手術(shù)均為治療前列腺癌的有效方法,但經(jīng)腹腔途徑腹腔鏡下前列腺癌根治術(shù)(TLRP)較開(kāi)放性手術(shù)更具優(yōu)勢(shì),并發(fā)癥少,值得廣泛推廣和應(yīng)用。
[關(guān)鍵詞] 腹腔鏡下前列腺癌根治術(shù)(TLRP);經(jīng)腹腔途徑;開(kāi)放性手術(shù);并發(fā)癥
[中圖分類(lèi)號(hào)] R737.25 [文獻(xiàn)標(biāo)識(shí)碼] A [文章編號(hào)] 1673-9701(2015)12-0012-04
Study of transperitoneal laparoscopic radical prostatectomy (TLRP) and the control of the open operation
HU Wenhao1 ZHOU Xiaobo2
1.Department of Urology, Ningbo City Yinzhou People's Hospital in Zhejiang Province,Ningbo 315000, China; 2.Department of Urology, Sir Run Run Shaw Hospital Affiliated to Zhejiang University Medical College, Hangzhou 310016, China
[Abstract] Objective To compare and analyze the effect of transperitoneal laparoscopic radical prostatectomy (TLRP) and open operation. Methods The clinical data of 80 cases of prostate cancer in our hospital were analyzed retrospectively, including 40 cases of laparoscopic group with transperitoneal laparoscopic radical prostatectomy, 40 cases of control group with open prostate cancer,the operation time, bleeding, the operation quantity, postoperative intestinal function recovery time, postoperative hospitalization time and complications were recorded and compared between the two groups. Results The operation time of laparoscopic group was (326.9±63.5) min, was significantly longer than the control group; the amount of bleeding in laparoscopic operation group was reached (390.2±67.8)mL, significantly less than the control group (P<0.01); the laparoscopic group postoperative intestinal function recovery time was (3.12±0.51) days, was significantly shorter than that in the control group, the hospitalization time of laparoscopic patients (8.2±1.3) days, was significantly shorter than that in control group, compared with control group, the difference was significant (P<0.05). The incidence of postoperative complications of laparoscopic was 10.0%, significantly lower than the incidence of postoperative complications in 25.0% of control group, the difference was significant (P<0.05). Conclusion Transperitoneal laparoscopic radical prostatectomy (TLRP) and open operation are the effective methods for treating prostate cancer, but the transperitoneal laparoscopic radical prostatectomy (TLRP) has more advantages compared with open operation, fewer complications, and is worthy of popularization and application.
[Key words] Laparoscopic radical resection of prostate cancer (TLRP); Transperitoneal; Open operation; Complications
前列腺癌(prostate cancer,Pca)是泌尿外科的常見(jiàn)惡性腫瘤之一,近年來(lái)發(fā)病率逐年增高。對(duì)于早期、局限性前列腺癌多通過(guò)根治性手術(shù)達(dá)到治愈的目的,其中開(kāi)放性前列腺癌根治術(shù)(open radical prostatectomy,ORP)、腹腔鏡前列腺癌根治術(shù)(1aparoscopic radical prostatectomy,LRP)為常用手術(shù)方法之一[1]。腹腔鏡前列腺癌根治術(shù)具有視野清晰、術(shù)中出血少,并發(fā)癥發(fā)生率低、患者住院時(shí)間短、死亡率低等優(yōu)點(diǎn)。本研究旨在對(duì)比分析經(jīng)腹腔途徑腹腔鏡下前列腺癌根治術(shù)(TLRP)與開(kāi)放性前列腺癌根治術(shù)的手術(shù)效果。
1 資料與方法
1.1一般資料
回顧性分析我院2012年12月~2014年12月診治的80例前列腺癌患者,年齡最小52歲,最大82歲,平均(67.3±6.2)歲;病灶 1.5~5.0 cm。TNM分期:T1b 18例,T2a 40例,T2b 22例。其中40例行經(jīng)腹腔腹腔鏡下前列腺癌根治術(shù)(腹腔鏡組),其余40例行開(kāi)放性前列腺癌根治術(shù)(對(duì)照組),兩組前列腺癌患者的年齡、病史、臨床表現(xiàn)等基線(xiàn)資料比較,差異不顯著(P>0.05),具有可比性,見(jiàn)表1。
表1 兩組前列腺癌患者一般資料比較
1.2 手術(shù)方法
對(duì)照組采用開(kāi)放性手術(shù)治療,采取氣管插管全麻,患者采取仰臥位,在臍與恥骨聯(lián)合間行腹正中腹膜外切口。先清掃盆腔淋巴結(jié)、前列腺表面的脂肪組織,暴露盆內(nèi)筋膜、恥骨前列腺韌帶、背深靜脈淺支。剪刀離斷恥骨前列腺韌帶,3-0無(wú)損傷線(xiàn)貫穿縫合2針并離斷背深靜脈叢,剪斷尿道。分離后方的狄氏筋膜和直腸前組織。從前方切開(kāi)前列腺膀胱連接部位直達(dá)黏膜,確認(rèn)雙側(cè)輸尿管開(kāi)口后離斷膀胱頸后壁。以組織鉗向頭側(cè)牽拉膀胱頸后壁,結(jié)扎切斷其后方的輸精管并游離精囊,縫合尿道斷端。
腹腔鏡組經(jīng)腹腔途徑行前列腺癌根治術(shù),于臍下緣切口常規(guī)建立CO2氣腹,于膀胱直腸返折近端2 cm處切開(kāi)腹膜,分離雙側(cè)射精管及精囊,向尖部游離前列腺后壁。于膀胱前壁腹膜返折處切開(kāi)腹膜,顯露恥骨后間隙及盆內(nèi)筋膜,切開(kāi)盆內(nèi)筋膜,沿前列腺筋膜與包膜之間游離前列腺兩側(cè)壁至前列腺尖部。切斷或部分切斷恥骨前列腺韌帶,縫扎背深靜脈復(fù)合體。超聲刀橫斷膀胱頸部,Hemo lok夾閉血管束,切斷兩側(cè)前列腺側(cè)蒂。緊貼前列腺包膜離斷背深靜脈復(fù)合體和尖部尿道。從膀胱頸部6點(diǎn)開(kāi)始,連續(xù)縫合膀胱頸與后尿道,留置22F氣囊尿管,最后縫合膀胱頸前壁。經(jīng)擴(kuò)大的臍部切口取出前列腺,盆腔放置引流管。
1.3 觀察指標(biāo)
記錄并比較兩組入選患者的手術(shù)時(shí)間、術(shù)中出血量、術(shù)后腸功能恢復(fù)時(shí)間、術(shù)后住院時(shí)間及并發(fā)癥(主要包括切口感染、吻合口漏、尿失禁及其他等)情況。
1.4 統(tǒng)計(jì)學(xué)方法
采用SPSS 13.0統(tǒng)計(jì)學(xué)軟件進(jìn)行數(shù)據(jù)分析,計(jì)數(shù)資料采用χ2檢驗(yàn),計(jì)量資料采用t檢驗(yàn),P<0.05為差異有統(tǒng)計(jì)學(xué)意義。
2結(jié)果
2.1 兩組手術(shù)觀察指標(biāo)比較
腹腔鏡組40例患者均順利完成手術(shù),手術(shù)時(shí)間250~400 min,術(shù)中出血量約150~900 mL。腹腔鏡組手術(shù)時(shí)間為(326.9±63.5)min,顯著長(zhǎng)于對(duì)照組;腹腔鏡組術(shù)中出血量達(dá)(390.2±67.8)mL,顯著少于對(duì)照組,差異有顯著性(P<0.01);腹腔鏡組術(shù)后腸功能恢復(fù)時(shí)間(3.12±0.51)d,顯著短于對(duì)照組,腹腔鏡組住院時(shí)間(8.2±1.3)d,顯著短于對(duì)照組,差異有顯著性(P<0.05)。見(jiàn)表2。
表2 兩組手術(shù)觀察指標(biāo)比較(x±s)
2.2 兩組患者術(shù)后并發(fā)癥比較
腹腔鏡組術(shù)后并發(fā)癥發(fā)生率為10.0%,顯著低于對(duì)照組的25.0%,差異有顯著性(P<0.05)。見(jiàn)表3。4例患者出現(xiàn)吻合口尿漏,經(jīng)引流及支持等保守治療后均在2周內(nèi)治愈。
3 討論
前列腺癌已成為世界范圍內(nèi)男性發(fā)病率第2位的惡性腫瘤,位居腫瘤致死病因的第6位[2]。前列腺癌根治術(shù)是根除局限性前列腺癌的最佳方法。開(kāi)放性前列腺癌根治術(shù)、腹腔鏡前列腺癌根治術(shù)為常用手術(shù)方法之一。傳統(tǒng)的開(kāi)放性根治性前列腺切除不僅需要切除病灶,而且要對(duì)前列腺周?chē)嚓P(guān)組織進(jìn)行清掃,手術(shù)傷口大、出血量多、住院時(shí)間長(zhǎng)[3]。腹腔鏡前列腺癌根治術(shù)的前列腺癌的適應(yīng)證為T(mén)1b~T2期,要求患者無(wú)明顯心、肺疾病,Gleason評(píng)分≤7分,可耐受較長(zhǎng)時(shí)間的氣腹壓力。腹腔鏡前列腺癌根治術(shù)的手術(shù)入路可經(jīng)腹腔內(nèi),也可經(jīng)腹膜外。本研究腹腔鏡組入選的40例患者均經(jīng)腹腔途徑進(jìn)行治療,經(jīng)腹途徑空間大,易于分離前列腺與直腸間粘連。術(shù)中可采用可吸收線(xiàn)縫扎或血管結(jié)扎束壓榨,減少術(shù)中出血[4]。如恥骨后靜脈叢出血,可經(jīng)Trocar置入小紗布?jí)K,壓住出血點(diǎn),配合吸引器,看清出血點(diǎn)后以雙極電凝和縫扎止血。TLRP在手術(shù)開(kāi)始時(shí)易放置Trocars,且手術(shù)在腹腔內(nèi)的操作空間大,可有效地減少尿道吻合與游離膀胱的張力[5,6]。與開(kāi)放性手術(shù)比較,經(jīng)腹腔腹腔鏡下前列腺癌根治術(shù)(TLRP)視野及解剖結(jié)構(gòu)清晰,出血少、創(chuàng)傷小、恢復(fù)快。本研究表2結(jié)果顯示,腹腔鏡組術(shù)中出血量顯著少于對(duì)照組(P<0.01);腹腔鏡組術(shù)后腸功能恢復(fù)時(shí)間(3.12±0.51)d,顯著短于對(duì)照組,腹腔鏡組患者住院時(shí)間(8.2±1.3)d,顯著短于對(duì)照組(P<0.05)。與葛光炬等[7]報(bào)道的觀點(diǎn)是一致的。孫燕兵等[8]將經(jīng)腹腔途徑腹腔鏡下前列腺癌根治術(shù)(TLRP)42例作為T(mén)LRP組;經(jīng)腹膜外腹腔鏡下前列腺癌根治術(shù)(ELRP)30例作為ELRP組,開(kāi)放性手術(shù)治療30例作為ORP組,結(jié)果顯示TLRP組術(shù)中輸血率低于ORP組,住院天數(shù)顯著短于ORP組,TLRP組術(shù)后尿失禁發(fā)生率低于ORP組組(P<0.05),進(jìn)一步證實(shí)經(jīng)腹腔途徑腹腔鏡下前列腺癌根治術(shù)較開(kāi)放性手術(shù)具有創(chuàng)傷小、疼痛小、拔管快和恢復(fù)快的優(yōu)點(diǎn)。研究證實(shí),腹腔鏡前列腺癌根治術(shù)引起的較少見(jiàn)的并發(fā)癥包括術(shù)后48 h內(nèi)前腹壁腹膜外血腫、短期閉孔神經(jīng)麻痹、腎功能衰竭、出血、肉眼血尿及吻合口瘺,48 h到1月的并發(fā)癥包括尿潴留、吻合口漏恥骨炎、深靜脈血栓形成、尿路感染、會(huì)陰部血腫、淋巴囊腫、腸麻痹等[9-16]。本研究表3結(jié)果顯示,與開(kāi)放性前列腺癌根治術(shù)比較,腹腔鏡組術(shù)后并發(fā)癥發(fā)生率為10.0%,顯著低于對(duì)照組的25.0%(P<0.05)。其中尿失禁的發(fā)生主要由于尿道膜部外括約肌受損或膀胱頸處尿道內(nèi)括約肌受損引起,要求術(shù)中保留膀胱頸肌環(huán),可以提高術(shù)后尿控率。本研究腹腔鏡組和對(duì)照組均未出現(xiàn)直腸損傷,主要體會(huì)是術(shù)中盡量保持視野及解剖層次清晰,處理前列腺尖部時(shí)盡量貼近前列腺表面,對(duì)直腸前壁滲血不要過(guò)度使用電凝。為了有效防止和減少手術(shù)并發(fā)癥的發(fā)生,手術(shù)前必須進(jìn)行充分的術(shù)前準(zhǔn)備,同時(shí)通過(guò)術(shù)中熟練的操作技術(shù)、適當(dāng)?shù)氖中g(shù)器械及細(xì)致的術(shù)后觀察及時(shí)處理[14,17]。
綜上,我們認(rèn)為經(jīng)腹腔途徑腹腔鏡下前列腺癌根治術(shù)(TLRP)和開(kāi)放性手術(shù)均為治療前列腺癌的有效方法,但經(jīng)腹腔途徑腹腔鏡下前列腺癌根治術(shù)(TLRP)較開(kāi)放性手術(shù)更具優(yōu)勢(shì),并發(fā)癥少,值得廣泛推廣和應(yīng)用。
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(收稿日期:2015-01-15)