新辅助雄激素剥夺治疗后行非保留神经的根治性前列腺切除术后的尿失禁

Horie S, Tobisu K I, Fujimoto H, Doi N, Kakizoe T

Urology Service, National Cancer Center Hospital, Tokyo, Japan.

Urology. 1999 Mar;53(3):561-7. doi: 10.1016/s0090-4295(98)00541-x.

OBJECTIVES

The impact of non-nerve-sparing retropubic radical prostatectomy (RRP) for prostate cancer combined with neoadjuvant androgen deprivation on urinary control is not well documented. We examined the incidence and severity of urinary incontinence after such therapy and determined the etiologic factors causing this complication.

METHODS

We examined the postoperative continence status of 104 consecutive patients admitted to the National Cancer Center Hospital who underwent RRP with wide resection of the pelvic nerves after neoadjuvant androgen deprivation. Incontinence was scored according to the number of pads used daily by the patient for urinary leakage. The severity of incontinence was analyzed according to patient age, weight of resected specimen, status of cancer stage, duration of neoadjuvant androgen blockade therapy, preoperative length of membranous urethra, and duration of urethral catheterization after surgery. We also measured the configuration and diameter of the reconstructed bladder neck by retrograde cystourethrography.

RESULTS

In 104 patients examined, the percentage of patients who became dry postoperatively was 22% at 1 month, 47% at 3 months, 69% at 6 months, and 78% at 1 year. Of 81 patients who became dry postoperatively at any interval, 22 (27%) became continent within 1 month of RRP, 49 (61 %) were continent within 3 months, 71 (88%) became continent by 6 months, and another 10 (12%) became continent between 6 and 12 months postoperatively. Of 48 patients who were followed up for more than 1 year and for whom continence status at 1 month after surgery was available, all patients who used 1 to 2 pads per day (13 of 13) at 1 month after surgery regained continence by 1 year after surgery. However, only 62% of patients (16 of 26) who required more than 3 pads per day at 1 month after surgery became dry by 1 year after surgery. Only age (older than 70 years) and large prostate size (weight of surgical specimen more than 40 g) temporarily influenced the recovery of urinary continence after surgery. Dilation of the bladder neck evaluated by retrograde cystourethrography was prominent in severely incontinent patients in the immediate postoperative period.

CONCLUSIONS

Our experience in patients who undergo non-nerve-sparing RRP after neoadjuvant androgen deprivation closely matches published surveys of patient-reported complications. Postoperative incontinence is not a major contraindication for non-nerve-sparing RRP after neoadjuvant endocrine therapy. Dilation of the bladder neck affected the recovery from incontinence, highlighting the importance of adequate reconstruction of the bladder neck.

目的

对于前列腺癌患者，新辅助雄激素剥夺治疗联合非保留神经的耻骨后根治性前列腺切除术（RRP）对尿控的影响尚无充分文献记载。我们研究了该治疗后尿失禁的发生率和严重程度，并确定了导致这一并发症的病因。

方法

我们检查了国立癌症中心医院连续收治的104例患者的术后控尿情况，这些患者在接受新辅助雄激素剥夺治疗后接受了RRP及盆腔神经广泛切除。根据患者每日用于尿失禁的尿垫数量对尿失禁进行评分。根据患者年龄、切除标本重量、癌症分期、新辅助雄激素阻断治疗持续时间、术前膜部尿道长度以及术后尿道导尿持续时间分析尿失禁的严重程度。我们还通过逆行膀胱尿道造影测量了重建膀胱颈的形态和直径。

结果

在检查的104例患者中，术后1个月、3个月、6个月和1年时术后无尿的患者百分比分别为22%、47%、69%和78%。在术后任何时间点达到无尿的81例患者中，22例（27%）在RRP后1个月内实现控尿，49例（61%）在3个月内实现控尿，71例（88%）在6个月时实现控尿，另外10例（12%）在术后6至12个月实现控尿。在48例随访超过1年且有术后1个月控尿情况的患者中，术后1个月每天使用1至2个尿垫的所有患者（13例中的13例）在术后1年恢复控尿。然而，术后1个月每天需要使用超过3个尿垫的患者中，只有62%（26例中的16例）在术后1年实现无尿。只有年龄（70岁以上）和前列腺体积大（手术标本重量超过40 g）暂时影响术后尿失禁的恢复。术后即刻，通过逆行膀胱尿道造影评估，膀胱颈扩张在严重尿失禁患者中较为突出。