UroScience, Faculdade de Ciências Médicas da Universidade Estadual de Campinas - UNICAMP - Campinas, SP, Brasil.
AC Camargo Cancer Center - Sao Paulo, SP, Brasil.
Int Braz J Urol. 2023 Jan-Feb;49(1):158-160. doi: 10.1590/S1677-5538.IBJU.2022.0249.
To show a total transabdominal robotic approach to an extensive recalcitrant vesicourethral anastomotic stenosis (VUAS) after open radical prostatectomy (ORP) with end-to-end anastomosis. While there is very little literature on the matter and even fewer videos showing the actual surgical view with a step-by-step explanation in complex cases, VUAS robotic transabdominal surgery provides better view and reach, with potentially better continence results, without the need for pubectomy.
A 72-year-old male was submitted to a failed ORP for Gleason 3+4 localized cancer 2 years before, where the wrong plane of dissection left behind prostate remnants and the seminal vesicles, which evolved with a complex stenosis and recurrent episodes of acute urinary retention (AUR) that started two weeks after the first catheter removal. Five endoscopic procedures in total were unsuccessful and AUR reoccurred. A vesico-urethral cystography (VUC) and multiparametric prostate and urethral MRI found the seminal vesicles with prostate remnants, two centimeters urethral stenosis from bladder neck to bulbar urethra and periurethral fibrosis with no evidence of residual tumor. PSA was 1.2 and prostate biopsy showed no tumor on prostate remnant. A transabdominal robotic approach was chosen.
Prostate residue, bladder neck and periurethral fibrosis were excised, with healthy mucosa found on both ends. End-to-end anastomosis was successful. Drain and catheter were removed on the 1st and 14th post-operative day, respectively, with good urinary stream. A VUC at 30 days showed a patent bladder neck. Incontinence was 3 pads/day after catheter removal and decreased to 1 pad/day after 180 days.
VUAS may reach 15% (1, 2) and endourologic therapies are first-line choices, however, recalcitrant cases require reconstruction (3-6). The most common approach is perineal, with high incontinence rates, reaching >90% (7, 8). The retropubic alternative has better but also discouraging numbers of up to 58% incontinence rates (9). Though with 100% social continence results, the 2021 European guidelines still could not recommend the robotic procedure as standard of care due to evidence limited to anecdotal reports (10-12).
展示一种完全经腹机器人入路治疗开放性根治性前列腺切除术（ORP）后复杂难治性膀胱尿道吻合口狭窄（VUAS）的方法，该吻合口采用端端吻合。尽管关于这个问题的文献很少，甚至更少的视频展示了在复杂病例中实际的手术视图，并逐步进行了解释，但 VUAS 机器人经腹手术提供了更好的视野和可达性，潜在地提高了控尿效果，同时无需进行耻骨上切除术。
一名 72 岁男性在 2 年前因 Gleason 3+4 局限性前列腺癌接受了失败的 ORP，错误的解剖平面导致前列腺残留和精囊遗留，随后出现了复杂的狭窄和反复发生的急性尿潴留（AUR），第一次拔除导尿管后两周开始出现 AUR。总共进行了 5 次内镜手术，但均未成功，AUR 再次发生。膀胱尿道造影（VUC）和多参数前列腺和尿道 MRI 发现精囊和前列腺残留，从膀胱颈部到球部尿道有两厘米的尿道狭窄，以及尿道周围纤维化，无肿瘤残留证据。PSA 为 1.2，前列腺活检显示前列腺残留无肿瘤。选择了经腹机器人入路。
切除了前列腺残留、膀胱颈部和尿道周围纤维化，两端发现健康的黏膜。成功进行了端端吻合。引流管和导尿管分别于术后第 1 天和第 14 天拔除，尿液流率良好。术后 30 天的 VUC 显示膀胱颈部通畅。拔除导尿管后，失禁量为每天 3 片尿垫，180 天后减少至每天 1 片尿垫。
VUAS 可能达到 15%（1,2），腔内治疗是一线选择，然而，难治性病例需要重建（3-6）。最常见的方法是经会阴入路，但失禁率很高，达到 >90%（7,8）。耻骨后入路的替代方法有更好的效果，但也令人沮丧，失禁率高达 58%（9）。尽管 2021 年欧洲指南报告了 100%的社交控尿效果，但由于证据仅限于轶事报告，仍然不能将机器人手术推荐为标准治疗（10-12）。
