目的:介绍保留Retzius间隙的机器人辅助腹腔镜前列腺癌根治术(RARP)的初步临床经验和疗效.方法:分析2013年6月~2017年1月8例行保留Retzius间隙的RARP手术患者的资料.患者年龄56~71岁,中位年龄64岁,体质指数(BMI)19.7~24.1 kg/m2,中位数21.6 kg/m2.术前前列腺特异抗原(PSA)4.18~11.04 μg/L,平均7.50 μg/L.国际勃起功能指数(IIEF-5)≥21分6例,<21分2例.术前穿刺活检病理TNM分期T1c期4例,T2a期3例,T2b期1例.Gleason评分3+2=5分1例,3+3=6分7例.D''Amico风险分层均为低风险.手术使用4臂da Vinci Si手术系统,经腹腔建立操作通道.由Douglas腔上方的壁层腹膜切开,分离显露双侧输精管和精囊,悬吊提起双侧精囊,切开Denonvillier筋膜,分离前列腺后壁直至前列腺尖部,重新悬吊壁层腹膜,沿精囊前表面向前上方分离显露并离断膀胱颈部,筋膜内层面钝性分离前列腺前表面及两侧直至尖部,双连发钛夹处理离断前列腺侧蒂,最后离断前列腺尖部,将切除的前列腺置于标本袋内,由12点位开始双针逆时针方向连续吻合膀胱颈部及远端尿道残端.最后关闭Douglas腔前方的壁层腹膜.结果:本组8例保留Retzius间隙的RARP手术均顺利完成.手术时间75~120 min,平均90 min.术中出血量50~200 ml,平均110 ml,均未输血.术后病理检查分期pT2a期5例,pTM2b期2例,pT2c期1例;1例手术切缘阳性,Gleason评分3+2=5分1例,3+3=6分6例,3+4=7分1例.术后拔除尿管时间14~21 d,平均17 d,拔管后控尿均满意,无尿失禁.术后住院天数4~7 d,平均5 d.术后随访4~41个月,平均14个月,无尿道狭窄,未观察到生化复发.术后3个月6例患者勃起功能满意,IIEF-5≥21分.结论:保留Retzius间隙的RARP手术具有解剖合理性,对肿瘤根治疗效好,能有效保护血管神经束,术后性功能及尿控恢复满意.但仍需积累更多病例进行长期前瞻性的对照研究以证实其疗效.%Objective:To investigate the feasibility of the Retzius-sparing robot-assisted laparoscopic radical prostatectomy (RARP) and report the functional and oncologic results of our first 8 cases.Methods:From June 2013 to January 2017,8 patients with clinically localized prostate cancer underwent this new approach for RARP.The patients were aged from 56 to 71 years old (mean 64),and the BMI was 19.7-24.1 kg/m2 (mean 21.6 kg/m2).The mean preoperative PSA was 7.50 (4.18-11.04) μg/L.Six patients had IIEF-5 ≥21,and 2 IIEF-5 <21.For the biopsy Gleason Score,7 patients were scored 3+3=6,and the other 1 was scored 3+2=5.All of them were in a low D''Amico risk classification.The operation was performed using a 4 arm da Vinci Si operating system,and theworking channel was set up transperitoneally.The parietal peritoneum was incised at the anterior surface of the Douglas space.Seminal vesicles and deferens vasa were isolated and incised.Denonvillier''s fascia was separated by the posterolateral surface of the prostate in an antegrade direction,reaching the prostatic apex,and then the bladder neck was isolated and dissected.The NVB was dissected using double interrupted titanium clips.The resected prostate was placed in a specimen bag after dissecting the prostatic apex.The anastomosis was performed using a continuous suture starting from the 12 o''clock position.The parietal peritoneum at the Douglas space level was finally closed.Results:All the operations were successfully performed.The total operative time was 75-120 min (mean 90 min).The blood loss was 50-200 mL (mean 110 mL) and no blood transfusion was required.Pathologic stage was pT2a in 5 patients,pT2b in 2 patients and pT2c in 1 patient,with positive surgical margin in one case.The postoperative pathologic Gleason score was 3+2=5 in 1 patient,3+3=6 in 6 patients,and 3+4=7 in 1 patient.The catheter was removed after a mean of 17 (range:14-21) days.No intra-operative complications occurred.The mean hospital stay was 5 (mean 4-7) days after surgery.All the cases were continent after removal of the catheter.No cases demonstrated vesicourethral stricture and biochemical recurrence during a postoperative follow-up period of 4-41 months.Three months after the operation,6 patients had satisfactory erectile function (IIEF-5 ≥21).Conclusions:The Retzius-sparing RARP is oncologically safe and results in high early continence and potency rates.Long-term,prospective,comparative,and possibly randomized studies are needed.
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