Catalona W J, Bigg S W
Division of Urologic Surgery, Washington University School of Medicine, St. Louis, Missouri.
J Urol. 1990 Mar;143(3):538-43; discussion 544. doi: 10.1016/s0022-5347(17)40013-9.
To examine the efficacy of nerve-sparing radical retropubic prostatectomy in preserving sexual potency and urinary continence, and in providing complete tumor excision we analyzed the records of the first 250 consecutive patients with clinical stage A or B prostate cancer treated since this operation was adopted at our institution. Over-all, sexual potency was preserved in 71 of 112 patients (63%) who underwent bilateral nerve-sparing prostatectomy and 13 of 33 (39%) who underwent a unilateral nerve-sparing procedure with a minimum of 6 months of followup. Preservation of potency correlated with patient age (p equals 0.0035, chi-square) and was significantly (p less than 0.001, chi-square) higher in patients with pathologically organ-confined tumors (72%) than in those with pathologically extracapsular tumors (51%). Of 192 patients followed for at least 6 months 188 (98%) achieved urinary continence postoperatively. Over-all, apparent complete tumor excision as defined by organ-confined tumor with negative surgical margins and undetectable postoperative prostate specific antigen levels was achieved in 14 preoperatively potent patients (42%) who underwent a unilateral and 67 (59%) who underwent a bilateral nerve-sparing procedure. Completeness of tumor excision correlated with tumor stage. In approximately 45% of the patients incomplete tumor excision was owing to seminal vesicle and/or lymph node involvement or positive bladder neck margins that could not be attributed to the nerve-sparing modification. However, improper application of the nerve-sparing technique may have contributed in the others. We were unable to detect microscopic penetration of the capsule or distinguish between gross extracapsular tumor extension and periprostatic fibrosis at operation. We conclude that with proper application of nerve-sparing radical retropubic prostatectomy, potency can be preserved in the majority of patients without compromising the adequacy of tumor excision. The completeness of tumor excision appears to be determined primarily by the extent of the tumor. Therefore, patient selection is important. Patients with focal, well differentiated tumors are ideal candidates for a nerve-sparing procedure, while those with high volume, poorly differentiated tumors may be at a higher risk for positive surgical margins. The benefits of wide excision of the neurovascular bundles remain to be demonstrated formally.
为了研究保留神经的耻骨后根治性前列腺切除术在保留性功能和尿失禁以及实现肿瘤完整切除方面的疗效，我们分析了自本院采用该手术以来连续治疗的首批250例临床分期为A或B期前列腺癌患者的记录。总体而言，在接受双侧保留神经前列腺切除术的112例患者中，71例（63%）保留了性功能；在接受单侧保留神经手术的33例患者中，13例（39%）保留了性功能，随访时间至少为6个月。性功能的保留与患者年龄相关（p = 0.0035，卡方检验），病理上肿瘤局限于器官内的患者（72%）性功能保留率显著高于病理上肿瘤侵犯包膜外的患者（51%）（p < 0.001，卡方检验）。在192例随访至少6个月的患者中，188例（98%）术后实现了尿失禁。总体而言，14例术前有性功能的患者（42%）接受单侧保留神经手术，67例（59%）接受双侧保留神经手术，实现了如病理上肿瘤局限于器官内、手术切缘阴性且术后前列腺特异性抗原水平不可检测所定义的明显肿瘤完整切除。肿瘤切除的完整性与肿瘤分期相关。在大约45%的患者中，肿瘤切除不完整是由于精囊和/或淋巴结受累或膀胱颈切缘阳性，这不能归因于保留神经的术式改变。然而，在其他患者中可能是由于保留神经技术应用不当所致。我们在手术中无法检测到包膜的微小穿透，也无法区分大体上的包膜外肿瘤扩展和前列腺周围纤维化。我们得出结论，正确应用保留神经的耻骨后根治性前列腺切除术，大多数患者可以保留性功能，而不影响肿瘤切除的充分性。肿瘤切除的完整性似乎主要由肿瘤范围决定。因此，患者选择很重要。局限性、高分化肿瘤患者是保留神经手术的理想候选人，而肿瘤体积大、低分化肿瘤患者手术切缘阳性的风险可能更高。广泛切除神经血管束的益处仍有待正式证实。
