Ahlering Thomas E, Eichel Louis, Edwards Robert A, Lee David I, Skarecky Douglas W
Department of Urology, University of California, Irvine, Medical Center, Orange, California 92868-3298, USA.
Urology. 2004 Dec;64(6):1224-8. doi: 10.1016/j.urology.2004.08.021.
To describe a technique using the da Vinci robotic system that enhances one's ability to visualize and dissect the apex and reduce surgical margins. An important outcome of radical prostatectomy is the reduction of iatrogenic positive margins in organ-confined prostate cancer.
The clinical data of our first 140 consecutive robot-assisted radical prostatectomies were divided into two groups: group 1, cases 1 to 50; and group 2, cases 51 to 140. After reviewing the surgical margin data and appropriate video clips of our initial 50 patients, we altered our technique. Initially, we had used two sutures to control the dorsal venous complex (DVC), one proximally and distally. The prostate was freed, and, finally, the DVC and urethra were divided. However, a bundle of fat obscured the apex, leading to positive apical margins. We developed the following method. First, we removed all of the fat overlying the DVC and prostate. Second, we divided the puboprostatic ligaments and dissected the levator fibers to expose and increase the DVC length fully. Finally, we stapled and divided the DVC using a vascular stapler.
The two groups were clinically comparable. Overall, the pathologic margin rate improved from 36% in group 1 to 16.7% in group 2. In group 1, 9 (27.3%) of 33 pT2 tumors had positive margins versus 3 (4.7%) of 64 pT2 tumors in group 2 (P = 0.003).
The data demonstrate that this change in technique for robotic prostatectomy resulted in a more defined apical dissection and a statistically significant reduction in positive margins in patients with organ-confined disease.
描述一种使用达芬奇机器人系统的技术，该技术可增强可视化和解剖前列腺尖部的能力，并减少手术切缘。根治性前列腺切除术的一个重要结果是减少局限性前列腺癌的医源性切缘阳性情况。
我们对连续进行的140例机器人辅助根治性前列腺切除术的临床数据进行分组：第1组为第1至50例；第2组为第51至140例。在回顾了最初50例患者的手术切缘数据及相关视频片段后，我们改进了技术。最初，我们使用两根缝线控制背侧静脉复合体（DVC），一根在近端，一根在远端。游离前列腺，最后切断DVC和尿道。然而，一束脂肪遮挡了前列腺尖部，导致尖部切缘阳性。我们研发了以下方法。首先，去除覆盖在DVC和前列腺上的所有脂肪。其次，切断耻骨前列腺韧带，解剖提肌纤维以充分暴露并增加DVC长度。最后，使用血管吻合器钉合并切断DVC。
两组在临床上具有可比性。总体而言，病理切缘率从第1组的36%降至第2组的16.7%。在第1组中，33例pT2肿瘤中有9例（27.3%）切缘阳性，而第2组64例pT2肿瘤中有3例（4.7%）切缘阳性（P = 0.003）。
数据表明，这种机器人前列腺切除术技术的改变使前列腺尖部解剖更清晰，对于局限性疾病患者，切缘阳性情况在统计学上有显著减少。
