De Concilio Bernardino, Silvestri Tommaso, Justich Matteo, Vedovo Francesca, Zeccolini Guglielmo, Celia Antonio
Department of Urology, San Bassiano Hospital, Bassano del Grappa, Italy.
Urological Clinic, Cattinara Hospital-ASUITS, University of Trieste, Italy.
Urology. 2018 May;115:185. doi: 10.1016/j.urology.2018.01.025. Epub 2018 Mar 13.
To present a novel surgical concept by using the trans-Douglas approach to perform a robotic-assisted simple prostatectomy (RASP) for high-volume benign prostate hyperplasia. This transposition from oncological surgery enables performance of a better bladder neck sparing adenomectomy with good functional results.
The index patient is a 67-year-old man with a history of severe urinary flow outlet obstruction. Combination medical therapy is not effective. Transrectal ultrasound scan detected a 130-cm enlarged prostate with middle lobe. The International Prostate Symptoms Score (IPSS) was 30. The patient was scheduled for a RASP with a trans-Douglas approach to preserve the bladder neck. The patient was put in 30° Trendelenburg position. Six ports were placed across the lower abdomen: four 8-mm robotic trocars and 2 assistant trocars (12 and 5 mm). The parietal peritoneum was incised at the anterior surface of the Douglas space, according to the access to the prostate described by Bocciardi. The Denonvillier fascia was opened, seminal vesicles were exposed, and above the vesicles, the prostatic capsule was incised. The adenoma, together with the middle lobe, was split by the capsule from the base to the verumontanum. The bladder neck was advanced and remodeled to the distal urethral mucosa and then closed to the prostatic capsule by a double-layer suture. The peritoneal breach was closed.
The operation time was 120 minutes. Blood loss was 80 cc. There was no perioperative or postoperative complication. The catheter was removed after 4 days. Uroflowmetry showed a peak flow of 30 mL/s. Pathologic examination was negative for tumor. After 60 days, the IPSS score was 8.
Trans-Douglas-RASP is a safe and effective minimally invasive treatment for benign prostate hyperplasia. It is a novel technique to perform bladder neck sparing prostatic adenomectomy and could be 1 more field of application of robotic technology.
提出一种新的手术理念，即采用经Douglas间隙入路行机器人辅助单纯前列腺切除术（RASP）治疗重度良性前列腺增生。这种从肿瘤手术转变而来的术式能够更好地保留膀胱颈进行腺瘤切除术，并取得良好的功能效果。
索引患者为一名67岁男性，有严重的尿流出口梗阻病史。联合药物治疗无效。经直肠超声检查发现前列腺增大至130cm，伴有中叶增生。国际前列腺症状评分（IPSS）为30分。该患者计划采用经Douglas间隙入路行RASP以保留膀胱颈。患者取30°头低脚高位。在下腹部置入6个端口：4个8mm机器人套管针和2个辅助套管针（12mm和5mm）。根据Bocciardi描述的前列腺入路方式，在Douglas间隙前表面切开壁层腹膜。打开Denonvillier筋膜，暴露精囊，在精囊上方切开前列腺包膜。将腺瘤连同中叶从包膜处自基底向精阜分离。将膀胱颈推进并重塑至远端尿道黏膜，然后通过双层缝合与前列腺包膜缝合。关闭腹膜裂口。
手术时间为120分钟。失血80cc。无围手术期或术后并发症。4天后拔除导尿管。尿流率检查显示峰值尿流为30mL/s。病理检查肿瘤为阴性。60天后，IPSS评分为8分。
经Douglas间隙RASP是一种治疗良性前列腺增生安全有效的微创治疗方法。它是一种保留膀胱颈的前列腺腺瘤切除术的新技术，可能成为机器人技术的又一应用领域。
