Petros J A, Catalona W J
Division of Urologic Surgery, Washington University School of Medicine, St. Louis, Missouri.
J Urol. 1991 May;145(5):994-7. doi: 10.1016/s0022-5347(17)38511-7.
Among 335 radical retropubic prostatectomies an antegrade dissection was used in 30 because of difficulty in developing the usual planes of dissection during apical dissection. The adequacy of tumor resection, preservation of sexual potency and urinary continence were compared in patients who underwent the antegrade dissection and those who underwent the standard retrograde nerve-sparing radical retropubic prostatectomy. Histopathological evaluation revealed no significant difference in the over-all completeness of tumor excision between the group having an antegrade dissection (16 of 30, 53% completely excised) and those having a retrograde dissection (177 of 305, 58% completely excised) (p = 0.62). Patients with clinically localized but pathological stage C disease undergoing an antegrade dissection and a nerve-sparing procedure had a significantly higher incidence of positive lateral margins (9 of 12, 75%) than the comparable group undergoing a retrograde dissection (40 of 99, 40%) (p = 0.02). The incidence of positive apical margins was similar in both groups, with 5 of 14 (36%) of the antegrade stage C cases (36%) having positive apical margins compared to 37 of 117 of the retrograde stage C cases (32%) (p = 0.65). Sexual potency was preserved in 5 of 6 patients (83%) treated with an antegrade dissection who had both neurovascular bundles preserved and were followed for at least 6 months, compared to 86 of 142 (61%) who underwent retrograde dissection (difference not significant, p = 0.26). Potency was preserved in 6 of 13 evaluable patients (46%) undergoing unilateral antegrade nerve-sparing procedure compared to 21 of 48 evaluable patients (44%) undergoing unilateral retrograde nerve-sparing procedure (p = 0.88). Of 22 patients followed for 1 year 21 (95%) have regained urinary continence. We conclude that the antegrade approach to radical retropubic prostatectomy provides results that are comparable to those achieved with the standard retrograde approach but that when an antegrade approach is chosen because of periprostatic fibrosis, bilateral preservation of the neurovascular bundles may result in a higher incidence of positive surgical margins.
在335例耻骨后根治性前列腺切除术中，30例因尖部解剖时难以形成常规解剖平面而采用顺行解剖。比较了接受顺行解剖的患者与接受标准逆行保留神经的耻骨后根治性前列腺切除术的患者在肿瘤切除的充分性、性功能保留和尿失禁方面的情况。组织病理学评估显示，顺行解剖组（30例中的16例，53%完全切除）和逆行解剖组（305例中的177例，58%完全切除）之间肿瘤切除的总体完整性无显著差异（p = 0.62）。临床局限性但病理分期为C期的患者接受顺行解剖和保留神经手术时，阳性侧缘的发生率（12例中的9例，75%）显著高于接受逆行解剖的可比组（99例中的40例，40%）（p = 0.02）。两组尖部切缘阳性率相似，顺行C期病例中14例中的5例（36%）尖部切缘阳性，逆行C期病例中117例中的37例（32%）尖部切缘阳性（p = 0.65）。6例接受顺行解剖且双侧神经血管束均保留并随访至少6个月的患者中有5例（83%）性功能得以保留，而接受逆行解剖的142例中有86例（61%）（差异无统计学意义，p = 0.26）。13例可评估的接受单侧顺行保留神经手术的患者中有6例（46%）性功能得以保留，而48例可评估的接受单侧逆行保留神经手术的患者中有21例（44%）（p = 0.88）。在随访1年的22例患者中，21例（95%）恢复了尿失禁。我们得出结论，耻骨后根治性前列腺切除术的顺行入路提供的结果与标准逆行入路相当，但因前列腺周围纤维化而选择顺行入路时，双侧保留神经血管束可能导致手术切缘阳性率更高。
