Catalona W J
Department of Surgery, Washington University Medical Center, St. Louis, Missouri.
Urol Clin North Am. 1990 Nov;17(4):819-26.
Our results show that by using the nerve-sparing radical retropubic prostatectomy, potency can be preserved in the majority of appropriately selected patients without compromising the adequacy of tumor excision. However, proper patient selection is important. Patients with focal, well-differentiated tumors, especially young patients with stage A or B1 tumors, are ideal candidates. In patients with more extensive and less well-differentiated tumors, there is a higher risk of incomplete tumor excision. Although we suspect that the adequacy of tumor excision is determined more by the extent of the tumor than by the technique of radical prostatectomy used, we believe that nerve-sparing surgery should be used with great caution, if at all, in patients with extensive or high-grade tumors. In these patients, microscopic extracapsular tumor extension is extremely common, can be impossible to detect at the time of operation, and is less likely to be adequately encompassed by nerve-sparing techniques. On the other hand, our current data provide little evidence that excision of the neurovascular bundles is beneficial. It is possible that more extensive resections will not materially alter the incidence of positive margins or cure rates. Finally, it might be argued that all forms of radical prostatectomy are inappropriate for patients with poorly differentiated clinical stage B2 prostate cancer for whom there are no really effective treatment options. We continue to recommend radical prostatectomy for these patients based on the finding that patients with clinical stage B2 disease who have organ-confined tumors can be expected to have excellent long-term disease-free survival rates similar to those of clinical stage B1 patients. In the remaining patients who are clinically understaged, the prospects for the minimal microscopic tumor remaining being controlled with adjunctive radiation therapy may be better than those of controlling the bulky primary tumor with radiation therapy alone. This hypothesis will need to be tested in a randomized clinical trial.
我们的研究结果表明，采用保留神经的耻骨后根治性前列腺切除术，在大多数经过适当选择的患者中可以保留性功能，而不会影响肿瘤切除的彻底性。然而，正确选择患者很重要。患有局灶性、高分化肿瘤的患者，尤其是患有A期或B1期肿瘤的年轻患者，是理想的候选者。对于肿瘤范围更广、分化程度更低的患者，肿瘤切除不完全的风险更高。尽管我们怀疑肿瘤切除的彻底性更多地取决于肿瘤的范围，而非所采用的根治性前列腺切除术技术，但我们认为，对于患有广泛或高级别肿瘤的患者，即使要进行保留神经手术，也应极其谨慎。在这些患者中，显微镜下的包膜外肿瘤侵犯极为常见，在手术时可能无法检测到，并且保留神经的技术不太可能充分切除。另一方面，我们目前的数据几乎没有证据表明切除神经血管束有益。更广泛的切除可能不会实质性地改变切缘阳性率或治愈率。最后，可能有人会认为，对于临床分期为B2期、分化差的前列腺癌患者，所有形式的根治性前列腺切除术都不合适，因为他们没有真正有效的治疗选择。基于临床分期为B2期且肿瘤局限于器官内的患者有望获得与临床分期为B1期患者相似的出色长期无病生存率这一发现，我们继续推荐对这些患者进行根治性前列腺切除术。在其余临床分期低估的患者中，用辅助放疗控制残留的微小肿瘤的前景可能比仅用放疗控制巨大原发肿瘤的前景更好。这一假设需要在一项随机临床试验中进行验证。
