Bollens R, Vanden Bossche M, Roumeguere T, Damoun A, Ekane S, Hoffmann P, Zlotta A R, Schulman C C
Department of Urology, Erasme Hospital, University Clinics of Brussels, Route de Lennik, 808, B-1070 Brussels, Belgium.
Eur Urol. 2001 Jul;40(1):65-9. doi: 10.1159/000049750.
After an initial experience using transperitoneal laparoscopic radical prostatectomy as described by Vallancien and Guillonneau, we developed a pure extraperitoneal approach. This approach seems more comparable to the open technique and avoid potential risks of specific complications due to the transperitoneal approach. We evaluated the perioperative parameters (blood loss, operating time, transfusion rate) and postoperative results (oncological results, continence and potency) after our first 50 cases.
Between September 1999 and September 2000, we performed 50 laparoscopic radical prostatectomy. On average, patients were 63.3 years old (range 47-71), had preoperative mean PSA values of 9.14 ng/ml (1.1-23). Median Gleason score was 6 (4-10) with 2.5 (1-6) positive biopsies for a mean prostate volume of 40 cm(3) (17.5-95.0). Clinical stage was T1, T2a, T2b and T3 in 46.3, 41.5, 9.8 and 2.4% of the cases, respectively. We used a pure extraperitoneal approach and we performed a descending technique starting with the dissection at the bladder neck. The seminal vesicles dissection is comparable to the open approach.
42 extraperitoneal and 8 transperitoneal procedures were performed (2 in the initial experience, 3 because of previous abdominal surgery and 3 because of incidental peritoneal opening). Mean operative time was 317 min, mean blood loss 680 cm(3), transfusion rate of 13%. 1 patient/50 was converted to an open procedure. Pathological stage was pT1a, pT2a, pT2b, pT2c, pT3a and pT3b in 2.2, 8.5, 42.5, 2.2, 34 and 10.6% of cases, respectively. Positive surgical margins were observed in 22% of cases. The potency rate after neurovascular bilateral bundle preservation was 43% at 3 months (n = 7) and 67% at 6 months and (n = 6) without any further treatment. The continence rate (no pad) was 39% at 3 months and 85% at 6 months. Detectable postoperative PSA at 3 month was observed in 2 patients only. Two major complications occurred: one acute transient renal failure one uretrorectal fistula at day 20.
The extraperitoneal laparoscopic radical prostatectomy results seem comparable to transperitoneal laparoscopic radical prostatectomy or open surgery. This approach is reproducible and seems to avoid the potential risks of intraperitoneal injury. Long-term follow up and comparative series are however necessary to further evaluate these new techniques.
在按照瓦朗西安和吉约诺描述的方法首次尝试经腹腹腔镜根治性前列腺切除术后，我们开发了一种纯腹膜外入路。这种入路似乎与开放手术技术更具可比性，并且避免了经腹入路导致特定并发症的潜在风险。我们评估了前50例患者的围手术期参数（失血量、手术时间、输血率）和术后结果（肿瘤学结果、控尿和性功能）。
1999年9月至2000年9月期间，我们进行了50例腹腔镜根治性前列腺切除术。患者平均年龄63.3岁（范围47 - 71岁），术前平均前列腺特异抗原（PSA）值为9.14 ng/ml（1.1 - 23）。 Gleason评分中位数为6（4 - 10），平均活检阳性数为2.5（1 - 6）个，平均前列腺体积为40 cm³（17.5 - 95.0）。临床分期为T1、T2a、T2b和T3的病例分别占46.3%、41.5%、9.8%和2.4%。我们采用纯腹膜外入路，并采用从膀胱颈开始解剖的下行技术。精囊解剖与开放手术方法类似。
共进行了42例腹膜外手术和8例经腹手术（2例为最初经验中的手术，3例因既往腹部手术，3例因意外打开腹膜）。平均手术时间为317分钟，平均失血量为680 cm³，输血率为13%。50例中有1例患者转为开放手术。病理分期为pT1a、pT2a、pT2b、pT2c、pT3a和pT3b的病例分别占2.2%、8.5%、42.5%、2.2%、34%和10.6%。22%的病例观察到手术切缘阳性。保留双侧神经血管束后，3个月时性功能恢复率为43%（n = 7），6个月时为67%（n = 6），无需进一步治疗。3个月时控尿率（无需使用尿垫）为39%，6个月时为85%。仅2例患者在术后3个月可检测到PSA。发生了2例主要并发症：1例急性短暂性肾衰竭，1例在术后第20天发生输尿管直肠瘘。
腹膜外腹腔镜根治性前列腺切除术的结果似乎与经腹腹腔镜根治性前列腺切除术或开放手术相当。这种入路具有可重复性，似乎避免了腹腔内损伤的潜在风险。然而，需要长期随访和对比系列研究来进一步评估这些新技术。
