Hernandez David J, Epstein Jonathan I, Trock Bruce J, Tsuzuki Toyonori, Carter H Ballentine, Walsh Patrick C
James Buchanan Brady Urological Institute and The Department of Pathology, The Johns Hopkins Medical Institutions, Baltimore, Maryland, USA.
J Urol. 2005 Feb;173(2):446-9. doi: 10.1097/01.ju.0000151135.80249.c9.
We determined the frequency of positive surgical margins (PSMs) in patients with extraprostatic extension (EPE) in the region of the neurovascular bundle (NVB) who underwent open radical retropubic prostatectomy by 2 experienced surgeons.
A total of 204 men with EPE in the region of the NVB underwent surgery by 2 experienced surgeons. The frequency of PSMs in the area of the NVB as well as the nerve sparing status of each lobe of the prostate were determined through a retrospective investigation of the pathology database as well as the physician's database. The recovery of sexual function was determined and compared to controls.
The age, clinical stage, biopsy Gleason sum and serum prostate specific antigen of the patients operated on by surgeons 1 and 2 were similar. Surgeon 1 widely excised at least 1 neurovascular bundle in 16% of the patients and surgeon 2 in 63%. The overall frequency of PSMs at the NVB was 5.9% for surgeon 1 and 5.8% for surgeon 2. Of the evaluable patients followed for 12 months or longer 83.5% of those operated on by surgeon 1 were potent compared to 63.8% of those operated on by surgeon 2.
Visual and tactile assessment during open surgery by an experienced surgeon provides valuable information on when and where it is safe to preserve the neurovascular bundle in patients with EPE in the region of the NVB. Surgical approaches in which tactile sensation is muted or absent, laparoscopic and robotic, need to undergo a similar evaluation to determine whether magnification of the operative field is sufficient to overcome the lack of haptic feedback and ability to palpate the tissue.
我们确定了由两位经验丰富的外科医生进行开放性耻骨后根治性前列腺切除术的、在神经血管束（NVB）区域有前列腺外侵犯（EPE）的患者中，阳性手术切缘（PSM）的发生率。
共有204名在NVB区域有EPE的男性患者由两位经验丰富的外科医生进行了手术。通过对病理数据库以及医生数据库的回顾性调查，确定了NVB区域PSM的发生率以及前列腺各叶的神经保留情况。对性功能的恢复情况进行了测定并与对照组进行比较。
由外科医生1和外科医生2进行手术的患者的年龄、临床分期、活检Gleason评分总和以及血清前列腺特异性抗原相似。外科医生1在16%的患者中广泛切除了至少1条神经血管束，而外科医生2为63%。外科医生1在NVB处PSM的总体发生率为5.9%，外科医生2为5.8%。在随访12个月或更长时间的可评估患者中，外科医生1手术的患者中有83.5%性功能正常，而外科医生2手术的患者中这一比例为63.8%。
经验丰富的外科医生在开放手术过程中的视觉和触觉评估，为在NVB区域有EPE的患者中何时以及何处安全保留神经血管束提供了有价值的信息。触觉感觉减弱或缺失的手术方法，即腹腔镜手术和机器人手术，需要进行类似的评估，以确定手术视野的放大是否足以克服触觉反馈的缺失和触诊组织的能力不足。
