Comparison of the efficacy of Retzius-sparing robot-assisted radical prostatectomy versus conventional anterior approach robot-assisted radical prostatectomy for the treatment of patients with prostate cancer with protruded median lobe
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摘要: 目的 比较分析保留Retzius间隙机器人根治性前列腺切除术(Retzius-sparing robot-assisted radical prostatectomy，Rs-RARP)与传统前入路机器人根治性前列腺切除术(conventional anterior approach robot-assisted radical prostatectomy，c-RARP)治疗前列腺癌伴前列腺中叶突出患者临床疗效。方法 回顾性分析2016年6月—2023年12月于解放军总医院第三医学中心泌尿外科医学部分别接受Rs-RARP和c-RARP治疗的245例前列腺伴中叶突出(术前MR中T2加权序列的正中矢状面测量膀胱颈到前列腺中叶突出部分的最大距离>0.5 cm)患者的临床资料，其中41例接受Rs-RARP治疗，204例接受c-RARP治疗。Rs-RARP术式在处理膀胱颈时利用膀胱自然悬吊并向尾侧牵张前列腺，在分离过程中暴露并最大化保留膀胱前列腺肌(vesicoprostatic muscle，VPM)，于腺体和括约肌之间的间隙，充分游离后离断膀胱颈。c-RARP术式首先打开Retzius间隙，不常规结扎背深静脉复合体，依次处理膀胱颈、前列腺蒂和尿道；最后进行耻骨前列腺韧带的重建。通过倾向性评分1∶2匹配，纳入Rs-RARP组41例，c-RARP组82例。比较2组手术时间、术中出血量、术后病理切缘阳性率和即刻尿控等围手术期相关指标和术后1年之内的尿控结局。结果 2组手术时间、出血量、术后住院时间及术后切缘阳性率比较均差异无统计学意义。与c-RARP组比较，Rs-RARP组术后即刻尿控率(46.3% vs 19.5%，P=0.002)、术后2个月尿控率(73.2% vs 52.4%，P=0.027)、术后6个月尿控率(100.0% vs 81.7%，P=0.007)以及术后12个月尿控率(100.0% vs 84.1%，P=0.007)更好。结论 与c-RARP比较，Rs-RARP在治疗前列腺癌伴中叶突出患者同样安全、有效，同时具有更好的术后短期及远期尿控。
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关键词:
- 保留Retzius间隙机器人根治性前列腺切除术 /
- 前列腺癌 /
- 前列腺中叶突出
Abstract: Objective To compare and analyze the clinical efficacy of Retzius-sparing robot-assisted radical prostatectomy(Rs-RARP) versus conventional anterior approach robot-assisted radical prostatectomy(c-RARP) for the treatment of patients with prostate cancer with protruded median lobe.Methods A retrospective analysis was conducted on 245 patients with prostate cancer with a protruded median lobe (maximum distance from the bladder neck to the protruded median lobe of the prostate >0.5 cm as measured in the median sagittal plane of T2-weighted sequences in the preoperative MR) who underwent Rs-RARP and c-RARP at our center from June 2016 to December 2023, inclouding 41 cases of Rs-RARP and 204 cases of c-RARP. The Rs-RARP procedure utilized the natural suspension of the bladder and retraction of the prostate to the caudal side in the management of the bladder neck, exposing and maximizing the preservation of the vesicoprostatic muscle (VPM) during the detachment process in the gap between the gland and sphincter, and dissecting the bladder neck after adequate freeing. The c-RARP procedure utilized the traditional transperitoneal anterior approach (retropubic approach) pathway. By propensity score matching, 41 cases in the Rs-RARP group and 82 cases in the c-RARP group were finally enrolled. The perioperative-related indicators such as operation time, estimated blood loss, positive surgical margin and immediate urinary control and urinary control outcomes within 1 year after operation were compared between the two groups.Results There were no statistical differences between the two groups in terms of operative time, estimated blood loss, postoperative hospitalization time or positive surgical margin. Compared with the c-RARP group, the urinary control rates in the Rs-RARP group were higher in the immediate postoperative period(46.3% vs 19.5%, P=0.002), in the 2-month postoperative period(73.2% vs 52.4%, P=0.027), in the 6-month postoperative period(100.0% vs 81.7%, P=0.007) and 12 months postoperatively(100.0% vs 84.1%, P=0.007).Conclusion Compared with c-RARP, Rs-RARP is equally safe and effective in the treatment of patients with prostate cancer with protruded median lobe, as well as having better postoperative short-and long-term urinary control. -
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表 1 245例前列腺癌患者基线资料
例(%)，X±S，M(IQR) 项目 匹配前 匹配后 Rs-RARP组(41例) c-RARP组(204例) t/Z/χ2 P值 Rs-RARP组(41例) c-RARP组(82例) t/Z/χ2 P值 年龄/岁 67.24±7.13 65.59±6.93 1.366 0.173 67.24±7.13 66.34±6.48 0.683 0.496 BMI/(kg/m2) 24.16±2.57 24.98±2.73 -1.766 0.079 24.16±2.57 24.64±2.37 -1.032 0.304 tPSA/(ng/mL) 10.12(13.16) 14.63(21.04) -2.328 0.020 10.12(13.16) 13.55(15.63) -1.475 0.141 前列腺体积/mL 38.94(23.66) 34.81(24.35) -0.939 0.349 38.94(23.66) 36.86(23.76) -0.306 0.762 PML距离/cm 0.95(0.55) 0.82(0.43) -0.830 0.408 0.95(0.55) 0.82(0.49) -0.427 0.672 合并症 高血压 19(46.3) 75(36.8) 1.324 0.250 19(46.3) 36(43.9) 0.066 0.798 糖尿病 8(19.5) 38(18.6) 0.018 0.895 8(19.5) 18(22.0) 0.098 0.755 内分泌治疗 1(2.4) 68(33.3) 16.106 < 0.001 1(2.4) 5(6.1) 0.788 0.375 临床TNM分期 -2.521 0.011 -0.609 0.544 2a 7(17.1) 39(19.1) 7(17.1) 17(20.7) 2b 23(56.1) 48(23.5) 23(56.1) 35(42.7) 2c 9(22.0) 99(48.5) 9(22.0) 22(26.8) 3a 1(2.4) 6(2.9) 1(2.4) 3(3.7) 3b 1(2.4) 12(5.9) 1(2.4) 5(6.1) ISUP分级 -0.357 0.723 -0.039 0.974 1 8(19.5) 54(26.5) 8(19.5) 20(24.4) 2 10(24.4) 41(20.1) 10(24.4) 14(17.1) 3 9(22.0) 45(22.1) 9(22.0) 19(23.2) 4 11(26.8) 36(17.6) 11(26.8) 21(25.6) 5 3(7.3) 28(13.7) 3(7.3) 8(9.8) 
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表 2 2组患者围术期结局比较
例(%)，X±S，M(IQR) 指标 Rs-RARP组(41例) c-RARP组(82例) t/Z/χ2 P值 手术时间/min 136.37±29.36 146.00±56.44 -1.245 0.308 EBL/mL 50.00(50.00) 50.00(50.00) -0.284 0.777 术后住院天数/d 4.00(1.00) 4.00(3.00) -0.763 0.445 PSM 16(39.0) 31(37.8) 0.017 0.896
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表 3 2组患者术后尿控情况比较
例(%) 时间 Rs-RARP组(41例) c-RARP组(82例) χ2 P值 即刻尿控 19(46.3) 16(19.5) 9.664 0.002 术后尿控1个月 19(46.3) 28(34.1) 1.722 0.189 术后尿控2个月 30(73.2) 43(52.4) 4.869 0.027 术后尿控3个月 35(85.4) 59(72.0) 2.730 0.098 术后尿控6个月 41(100.0) 67(81.7) 8.542 0.003 术后尿控12个月 41(100.0) 69(84.1) 7.268 0.007
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