Nielsen Matthew E, Schaeffer Edward M, Marschke Penny, Walsh Patrick C
The James Buchanan Brady Urological Institute, The Johns Hopkins Medical Institutions, Baltimore, Maryland 21287-2101, USA.
J Urol. 2008 Dec;180(6):2557-64; discussion 2564. doi: 10.1016/j.juro.2008.08.047. Epub 2008 Oct 19.
Recent anatomical studies have shown that branches of the cavernous nerves running adjacent to the prostate at the apex travel more anteriorly than previously recognized. Outcomes of robot assisted radical prostatectomy suggest improved postoperative sexual outcomes following high anterior release of the levator fascia. We prospectively evaluated the effect of high anterior release on oncological and sexual function outcomes following open radical retropubic prostatectomy.
A total of 167 patients with clinically localized prostate cancer with a preoperative Sexual Health Inventory for Men score of greater than 21 underwent radical retropubic prostatectomy with bilateral nerve sparing and selective high anterior release, as performed by a single surgeon. Data on postoperative sexual function were collected by an independent third party. Sexual function outcomes at 12 months were defined as 1) a Sexual Health Inventory for Men score of 16 or greater and/or a satisfaction score of 4 or greater and 2) a Sexual Health Inventory for Men score of 22 or greater.
Because unilateral high anterior release was equivalent to bilateral high anterior release for both definitions (p >0.3), they were combined into 1 group for analyses. Patients undergoing high anterior release were more likely to achieve a Sexual Health Inventory for Men score of 16 or greater and/or a satisfaction score of 4 (93% vs 77%, p = 0.007), and a Sexual Health Inventory for Men score of 22 or greater (70% vs 54%, p = 0.07) at 1 year. Return to baseline (a Sexual Health Inventory for Men score of 22 or greater) was even higher among patients receiving high anterior release who were more sexually active (greater than 1 attempt per week) preoperatively (78% vs 52%, p <0.05). The improved outcomes in potency achieved with high anterior release did not increase the likelihood of a positive surgical margin.
Unilateral or bilateral high anterior release of the levator fascia in open radical retropubic prostatectomy provides excellent oncological results and is associated with improved postoperative sexual function.
近期的解剖学研究表明，海绵体神经分支在前列腺尖部与前列腺相邻处走行比之前认为的更靠前。机器人辅助根治性前列腺切除术的结果提示，耻骨后筋膜高位前侧松解术后性功能改善。我们前瞻性评估了耻骨后根治性前列腺切除术中高位前侧松解对肿瘤学及性功能结局的影响。
共有167例临床局限性前列腺癌患者，术前男性性健康量表（Sexual Health Inventory for Men，SHIM）评分大于21，接受了由同一位外科医生实施的双侧神经保留及选择性高位前侧松解的耻骨后根治性前列腺切除术。术后性功能数据由独立第三方收集。12个月时的性功能结局定义为：1）男性性健康量表评分16分及以上和/或满意度评分4分及以上；2）男性性健康量表评分22分及以上。
因为对于这两种定义，单侧高位前侧松解与双侧高位前侧松解效果相当（p>0.3），所以将它们合并为一组进行分析。接受高位前侧松解的患者在1年时更有可能达到男性性健康量表评分16分及以上和/或满意度评分4分（93%对77%，p = 0.007），以及男性性健康量表评分22分及以上（70%对54%，p = 0.07）。术前性活动较频繁（每周超过1次）的接受高位前侧松解的患者恢复至基线水平（男性性健康量表评分22分及以上）的比例更高（78%对52%，p<0.05）。高位前侧松解在恢复勃起功能方面取得的更好结局并未增加手术切缘阳性的可能性。
耻骨后根治性前列腺切除术中单侧或双侧耻骨后筋膜高位前侧松解可获得良好的肿瘤学结果，并与术后性功能改善相关。
