神经保留机器人辅助腹腔镜前列腺切除术联合羊膜：中期结果。
Nerve spare robot assisted laparoscopic prostatectomy with amniotic membranes: medium term outcomes.
机构信息
AdventHealth Global Robotics Institute, 380 Celebration Place, Celebration, FL, 34747, USA.
Harvard University, Cambridge, MA, 02138, USA.
出版信息
J Robot Surg. 2022 Oct;16(5):1219-1224. doi: 10.1007/s11701-022-01370-4. Epub 2022 Jan 11.
dHACM is a source of factors including cytokines that allow anti-inflammatory and proliferative elements to be utilized for wound and ulcer management. We present our experience of using dHACM in a cohort of patients undergoing nerve-sparing (NS) robot-assisted laparoscopic prostatectomy (RALP). Our objective is to investigate the functional and oncological outcomes of NS after placing amniotic or dehydrated human amnion/chorion membrane (dHACM) on preserved neurovascular bundles (NVBs). From 2013 to 2019, our institution performed transperitoneal multi-port da Vinci robotic prostatectomy. The NVBs are spared by releasing their fascial planes posteriorly, followed by an anterior release of the plane at a similar level. Once the retrograde release of the NVB is performed then 599 patients underwent placement of dHACM graft (AmnioFix by MiMedx, Marietta, GA, USA). The graft was cut into two 4 × 1 cm pieces and laid over the NVB as a wrap. In order to inform the urological community of oncological and functional outcomes, we excluded patients with less than 12 months follow up (n = 64), benign prostatic hyperplasia (n = 5), and unilateral NS (n = 1). 529 (88%) patients were included in this study who underwent a partial or full bilateral NS with dHACM. 529 patients were followed-up for a median (IQR) of 42 months (25-89). Demographics include median (IQR) age 57 years (52-62), median preoperative SHIM score of 24 (21-15), and AUASS of 5 (2-11). Full NS was performed in 74% (391/529). Pathological staging was pT2 = 399 (75%), pT3a = 107 (20%), pT3b = 19 (4%) and pT4 = 4 (1%) with N1 = 3 (0.6%). The number of patients with PSM was 86 (16%), and the overall BCR in the entire cohort was 10%. Postoperatively, 434 (82%) were sexually active. Median time to potency was 119 (37-420) days and time to continence was 42 (23-91) days. Regarding full vs partial NS: median post op SHIM score 18 (13-20) vs 15 (6-20), median time to potency 92 (35-365) days vs 184 (42-560) days, and median time to continence 42 (23-91) days vs 44 (30-92) days. Age > 55 vs ≤ 55 years: median post op SHIM score 18 (12-20) vs 15 (10-20), median time to potency 167 days (42-549) vs 80 (35-288) days, and median time to continence 42 (25-116) days vs 42 (29-76) days. In our series the application of amniotic membrane/dHACM has led to acceptable post RALP outcomes. The BCR rate of 10% in addition to the recovery of potency at a median time of 3 months and continence at 6 weeks is an encouraging result of dHACM. Our findings indicate that dHACM allowed for an even faster period for continence recovery which was independent of grade of NS. Future comparative studies may further assess the impact of new amniotic membrane types on the functional and oncological outcomes after RALP.
dHACM 是一种包括细胞因子在内的多种因子的来源，可利用其促进伤口和溃疡的愈合。我们报告了在一组接受保留神经血管束（NVB）的神经保留（NS）机器人辅助腹腔镜前列腺切除术（RALP）的患者中使用 dHACM 的经验。我们的目的是研究在保留的 NVB 上放置羊膜或脱水人羊膜/绒毛膜（dHACM）后 NS 的功能和肿瘤学结果。从 2013 年到 2019 年，我们的机构进行了经腹腔多端口达芬奇机器人前列腺切除术。通过释放其筋膜平面来保留 NVB，然后在类似的水平上进行前平面释放。一旦进行逆行释放 NVB，就有 599 例患者接受了 dHACM 移植物（美国米德克斯的 AmnioFix）。将移植物切成 2 个 4×1cm 的小块，包裹在 NVB 上。为了向泌尿科医生通报肿瘤学和功能学结果，我们排除了随访时间少于 12 个月的患者（n=64）、良性前列腺增生患者（n=5）和单侧 NS 患者（n=1）。本研究纳入了 529 例（88%）接受部分或完全双侧 NS 和 dHACM 的患者。对 529 例患者进行了中位数（IQR）42 个月（25-89）的随访。人口统计学包括中位数（IQR）年龄 57 岁（52-62），术前 SHIM 评分中位数 24 分（21-15），AUASS 为 5 分（2-11）。74%（391/529）的患者行完全 NS。病理分期为 pT2=399 例（75%）、pT3a=107 例（20%）、pT3b=19 例（4%）和 pT4=4 例（1%），N1=3 例（0.6%）。有 86 例（16%）患者出现 PSM，整个队列的总体 BCR 为 10%。术后，434 例（82%）患者有性生活。勃起功能恢复的中位时间为 119 天（37-420 天），尿控恢复的中位时间为 42 天（23-91 天）。关于完全与部分 NS：术后 SHIM 评分中位数 18（13-20）与 15（6-20），勃起功能恢复时间中位数 92（35-365）与 184（42-560），尿控恢复时间中位数 42（23-91）与 44（30-92）。年龄>55 岁与≤55 岁：术后 SHIM 评分中位数 18（12-20）与 15（10-20），勃起功能恢复时间中位数 167 天（42-549）与 80 天（35-288），尿控恢复时间中位数 42（25-116）与 42（29-76）。在我们的研究中，应用羊膜/脱水人羊膜/绒毛膜导致了 RALP 术后可接受的结果。BCR 率为 10%，加上 3 个月时勃起功能恢复和 6 周时尿控恢复的中位时间为 10%，这是 dHACM 的一个令人鼓舞的结果。我们的研究结果表明，dHACM 使尿控恢复更快，与 NS 分级无关。未来的对照研究可能会进一步评估新型羊膜对 RALP 后功能和肿瘤学结果的影响。
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