Rassweiler Jens, Seemann Othmar, Schulze Michael, Teber Dogu, Hatzinger Martin, Frede Thomas
Department of Urology, Klinikum Heilbronn, University of Heidelberg, Germany.
J Urol. 2003 May;169(5):1689-93. doi: 10.1097/01.ju.0000062614.56629.41.
There is an ongoing debate about the benefits of laparoscopic radical prostatectomy compared to the open retropubic approach. We compared the last 219 patients treated with open retropubic prostatectomy with 438 patients treated with laparoscopic radical prostatectomy at our institution, focusing on operative data, complications and mid-term outcome.
From December 1994 to November 1999 a total of 219 patients were treated with open prostatectomy and pelvic lymph node dissection (group 1). From March 1999 to September 2002, 219 patients underwent early (group 2) and 219 underwent late (group 3) laparoscopic radical prostatectomy and pelvic lymph node dissection. The same surgeons performed both operations. All 3 groups were similar with respect to mean patient age, mean prostate specific antigen value, median Gleason score, previous transurethral resection of the prostate and neoadjuvant treatment, although there was a slight stage shift in favor of the 2 laparoscopic groups.
Mean operating time was significantly shorter after open surgery (196 minutes) compared to the early laparoscopic group (288) but it did not differ significantly from the late laparoscopic group (218). Mean blood loss (1,550 versus 1,100 versus 800 cc) and transfusion rates (55.7% versus 30.1% versus 9.6%) in groups 1 to 3 favored the laparoscopic groups. The complication rate in groups 1 to 3 was lower for laparoscopy (19.2% versus 13.7% versus 6.4%), but the spectrum differed. The early laparoscopic group had a higher incidence of rectal injuries (1.8% versus 3.2% versus 1.4% in groups 1 to 3, respectively) and urinary leakage (0.5% versus 2.3% versus 0.9%), whereas more lymphoceles (6.9% versus 0% versus 0%), wound infection (2.3% versus 0.5% versus 0%), embolism/pneumonia (2.3% versus 0.5% versus 0.5%) and anastomotic strictures (15.9% versus 6.4% versus 4.1%) occurred after open surgery. The amount of postoperative analgesia was significantly greater after open surgery (50.8 versus 33.8 versus 30.1 mg. in groups 1 to 3, respectively). Median catheter time was longer after open retropubic prostatectomy (12 versus 7 versus 7 days in groups 1 to 3, respectively) but the continence rates were similar in all 3 groups at 12 months (89.9% versus 90.3% versus 91.7%). The rate of positive margins did not differ significantly in groups 1 to 3 (28.2% versus 21.0% versus 23.2%), prostate specific antigen recurrence was equivalent related to the different observation periods.
Laparoscopic radical prostatectomy is technically demanding, with an initially longer operative time, higher incidence of rectal injuries and urinary leakage. The overall outcome after 219 cases favors the laparoscopic approach. Consequently, at our institution laparoscopic radical prostatectomy has become the method of choice.
关于腹腔镜根治性前列腺切除术与开放性耻骨后入路手术相比的益处，一直存在争论。我们将本院最后219例行开放性耻骨后前列腺切除术的患者与438例行腹腔镜根治性前列腺切除术的患者进行了比较，重点关注手术数据、并发症及中期结果。
1994年12月至1999年11月，共有219例患者接受了开放性前列腺切除术及盆腔淋巴结清扫术（第1组）。1999年3月至2002年9月，219例患者接受了早期腹腔镜根治性前列腺切除术及盆腔淋巴结清扫术（第2组），另外219例接受了晚期腹腔镜根治性前列腺切除术及盆腔淋巴结清扫术（第3组）。两组手术均由相同的外科医生完成。所有3组患者在平均年龄、平均前列腺特异性抗原值、中位Gleason评分、既往经尿道前列腺切除术及新辅助治疗方面均相似，不过在分期上，两个腹腔镜组略有优势。
与早期腹腔镜组（288分钟）相比，开放性手术的平均手术时间显著更短（196分钟），但与晚期腹腔镜组（218分钟）相比差异不显著。第1至3组的平均失血量（1550对1100对800毫升）及输血率（55.7%对30.1%对9.6%）表明腹腔镜组更具优势。第1至3组腹腔镜手术的并发症发生率更低（19.2%对13.7%对6.4%），但并发症类型有所不同。早期腹腔镜组直肠损伤（分别为1.8%对3.2%对1.4%）及尿漏（0.5%对2.3%对0.9%）的发生率更高，而开放性手术后出现更多的淋巴囊肿（6.9%对0%对0%）、伤口感染（2.3%对0.5%对0%）、栓塞/肺炎（2.3%对0.5%对0.5%）及吻合口狭窄（15.9%对6.4%对4.1%）。开放性手术后术后镇痛量显著更大（第1至3组分别为50.8对33.8对30.1毫克）。开放性耻骨后前列腺切除术后中位导尿管留置时间更长（第1至3组分别为12天对7天对7天），但所有3组在12个月时的控尿率相似（89.9%对90.3%对91.7%）。第1至3组切缘阳性率差异不显著（28.2%对21.0%对23.2%），前列腺特异性抗原复发情况在不同观察期内相当。
腹腔镜根治性前列腺切除术技术要求高，最初手术时间较长，直肠损伤及尿漏发生率较高。219例患者的总体结果显示腹腔镜手术更具优势。因此，在本院，腹腔镜根治性前列腺切除术已成为首选方法。
