Division of Oncology/Unit of Urology, Urological Research Institute, IRCCS Ospedale San Raffaele, Milan, Italy; Department of Urology, Vita-Salute San Raffaele University, Milan, Italy; OLV Vattikuti Robotic Surgery Institute, Melle, Belgium.
Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milano, Italy.
Eur Urol. 2017 Feb;71(2):249-256. doi: 10.1016/j.eururo.2016.05.008. Epub 2016 May 18.
Limited data are available on the role of robot-assisted radical prostatectomy (RARP) in patients with locally advanced prostate cancer (PCa).
To describe our surgical technique of extrafascial RARP and extended pelvic lymph node dissection (ePLND) in locally advanced PCa.
DESIGN, SETTING, AND PARTICIPANTS: Ninety-four patients with clinical stage ≥T3 undergoing RARP with ePLND at three European centers between 2011 and 2015 were retrospectively evaluated.
Surgery was performed using the DaVinci Si system. The anatomically defined ePLND included nodes overlying the external iliac axis, those in the obturator fossa, and around the internal iliac artery up to the ureter. RARP was performed using an extrafascial approach where the Denonvillers' fascia was dissected free and left on the posterior surface of the seminal vesicles.
Perioperative outcomes consisted of operative time, blood loss, length of hospital stay, and complications occurred within 30 d after surgery. Biochemical recurrence (BCR) was defined as two consecutive prostate-specific antigen values ≥0.2ng/ml. Kaplan-Meier analyses assessed time to BCR and clinical recurrence. Multivariable Cox regression analyses assessed predictors of BCR.
Median operative time, blood loss, and length of hospital stay were 230min, 200ml, and 6 d. Overall, 12 (12.7%) patients experienced complications and five (5.3%), four (4.3%), and three (3.2%) patients had Clavien I, II, and III/IV complications. Overall, 72 (76.6%), 35 (37.2%), and 30 (32.3%) patients had pT3/4, pN1, and positive margins. The median number of nodes removed was 16. Overall, 19 (20.2%) and 21 (22.3%) patients received adjuvant radiotherapy and hormonal therapy. The median follow-up was 23.5 mo. At 3-yr follow-up, the BCR- and clinical recurrence-free survival rates were 63.3% and 95.8%. Pathologic stage, Gleason score, and positive margins represented predictors of BCR (all p≤0.03). Our study is limited by its retrospective nature and by the follow-up duration.
RARP represents a well-standardized, safe, and oncological effective option in patients with locally advanced PCa. Pathologic stage, Gleason score, and positive margins should be considered to select patients for multimodal approaches.
Robot-assisted surgery represents a well-standardized, safe, and oncological effective option in men with locally advanced prostate cancer. Two out of three patients treated with this approach are free from recurrence at 3-yr follow-up. Pathologic stage, Gleason score, and positive surgical margins represent predictors of BCR and should be considered to select patients for multimodal approaches.
局部晚期前列腺癌（PCa）患者中机器人辅助根治性前列腺切除术（RARP）的作用数据有限。
描述我们在局部晚期 PCa 中进行筋膜外 RARP 和扩大盆腔淋巴结清扫术（ePLND）的手术技术。
设计、设置和参与者：2011 年至 2015 年间，在欧洲的三个中心，对 94 名临床分期≥T3 的患者进行了筋膜外 RARP 和 ePLND 的回顾性评估。
手术采用达芬奇 Si 系统进行。解剖定义的 ePLND 包括覆盖髂外轴的淋巴结、闭孔窝内的淋巴结和髂内动脉周围的淋巴结，直到输尿管。RARP 采用筋膜外方法进行，即游离 Denonvillers 筋膜并将其留在精囊的后表面上。
围手术期结局包括手术时间、出血量、住院时间和术后 30 天内发生的并发症。生化复发（BCR）定义为两次连续前列腺特异性抗原值≥0.2ng/ml。Kaplan-Meier 分析评估 BCR 和临床复发的时间。多变量 Cox 回归分析评估 BCR 的预测因素。
中位手术时间、出血量和住院时间分别为 230min、200ml 和 6d。总体而言，12 名（12.7%）患者发生并发症，5 名（5.3%）、4 名（4.3%）和 3 名（3.2%）患者发生 Clavien I、II 和 III/IV 级并发症。总体而言，72 名（76.6%）、35 名（37.2%）和 30 名（32.3%）患者为 pT3/4、pN1 和阳性切缘。切除的淋巴结中位数为 16 个。总体而言，19 名（20.2%）和 21 名（22.3%）患者接受了辅助放疗和激素治疗。中位随访时间为 23.5 个月。在 3 年随访时，BCR 和临床无复发生存率分别为 63.3%和 95.8%。病理分期、Gleason 评分和阳性切缘是 BCR 的预测因素（均 p≤0.03）。我们的研究受到回顾性研究性质和随访时间的限制。
RARP 是一种标准化、安全且具有肿瘤疗效的选择，适用于局部晚期 PCa 患者。病理分期、Gleason 评分和阳性切缘应考虑用于选择接受多模式治疗的患者。
机器人辅助手术是局部晚期前列腺癌患者的一种标准化、安全且具有肿瘤疗效的选择。三分之二接受这种方法治疗的患者在 3 年随访时无复发。病理分期、Gleason 评分和阳性切缘是 BCR 的预测因素，应考虑用于选择接受多模式治疗的患者。
Zotero 插件