Initial exploration and prognostic analysis of the application for Retzius space preservation technique in robot-assisted radical cystectomy with reproductive tract and sexual nerve preservation in males
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摘要: 目的 探索保留Retzius间隙技术在男性机器人辅助腹腔镜保留生殖道和性神经的根治性膀胱全切术应用的临床疗效。方法 收集2022年1月—2023年10月在华中科技大学同济医学院附属同济医院收治的16例采用保留Retzius间隙技术行机器人辅助腹腔镜保留生殖道和性神经的根治性膀胱全切术+原位回肠新膀胱的男性患者临床资料。患者年龄38~65岁，平均48.9岁；体重指数18.6~30.5 kg/m2，平均24.3 kg/m2；美国麻醉科医师协会评分1~3分，平均2分；国际勃起功能指数-5(international index of erectile function-5，IIEF-5)评分11~25分，平均18.7分。所有患者膀胱尿路上皮癌诊断成立，影像学无局部进展及远处转移，排除原发前列腺癌可能。9例术前分期cT2~T3a期患者行新辅助化疗降期至cT0~1期，7例患者为cTa~1G3期。患者均有强烈意愿保留尿控及性功能，遂行保留Retzius间隙技术保留生殖道和性神经的机器人辅助根治性膀胱切除+原位回肠新膀胱重建术。术后3个月开始随访患者的肿瘤学和功能学状态。结果 16例手术过程均顺利，无术中转开放手术。手术时间205~421 min，平均279.8 min；术中出血量75~400 mL，平均150.6 mL；术后患者住院时间12~18 d，平均12.2 d。术后有2例患者出现麻痹性肠梗阻，经保守治疗后好转，余无明显术后相关严重并发症。术后6个月，15例(93.8%)患者恢复日间及夜间尿控，10例(62.5%)患者IIEF-5评分达12分以上，其中6例(37.5%)患者可自行射精，中位随访时间14.3(12~30)个月，未见肿瘤复发及转移。结论 对于严格筛选的男性患者，行保留Retzius间隙技术保留生殖道及性功能的机器人辅助根治性膀胱切除原位回肠新膀胱重建临床安全可行，在兼顾肿瘤控制的同时，实现更好尿控和性及生殖功能保留。大样本、长期随访研究需要进一步探索和验证。
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关键词:
- 膀胱肿瘤 /
- 保留Retzius间隙技术 /
- 生殖道 /
- 性功能 /
- 机器人辅助根治性膀胱全切术
Abstract: Objective To explore the clinical efficacy of the Retzius space preservation technique in robot-assisted laparoscopic radical cystectomy with reproductive tract and sexual nerve preservation in males.Methods The data of 16 patients with bladder cancer who underwent robot-assisted laparoscopic radical cystectomy with reproductive tract and sexual nerve preservation using the Retzius space preservation technique, along with orthotopic ileal neobladder reconstruction from January 2022 to October 2023 were retrospectively reviewed. The mean age was 48.9 years(range: 38-65 years), and the mean body mass index was 24.3 kg/m2(range 18.6-30.5 kg/m2). The mean American Society of Anesthesiologists(ASA) score was 2(range: 1-3), and the mean International Index of Erectile Function-5(IIEF-5) score was 18.7(range: 11-25). All patients were diagnosed with urothelial carcinoma of the bladder, with no evidence of local progression or distant metastasis, and primary prostate cancer was excluded. Nine patients with cT2-T3a stage tumors underwent neoadjuvant chemotherapy to downstage cT0-1, and 7 patients had cTa-1G3 stage tumors. All patients expressed a strong desire to preserve urinary continence and sexual function, leading to the performance of the Retzius space preservation technique for reproductive tract and sexual nerve preservation in robot-assisted radical cystectomy with orthotopic ileal neobladder reconstruction. Postoperative follow-up of oncological and functional outcomes began three months after surgery.Results All the cases were completed robotically without conversion. The average operation time was 279.8 min(205-421 min) and average estimated blood loss was 150.6 mL(range: 75-400 mL). The average postoperative hospital stay was 12.2 days(range: 12-18 days). Two patients developed postoperative paralytic ileus, which improved after conservative treatment, and no other significant surgery-related complications were observed. At six months postoperatively, 15 patients(93.8%) regained daytime and nighttime urinary continence, and 10 patients(62.5%) had an IIEF-5 score above 12, with 6 patients(37.5%) able to ejaculate. The average follow-up was 14.3 months(range: 12-30 months), and no recurrence or distant metastasis was found in this study.Conclusion For carefully selected male cases, robot-assisted radical cystectomy with the Retzius space preservation technique for reproductive tract and sexual function preservation, combined with orthotopic ileal neobladder reconstruction, is clinically safe and feasible. This approach provides effective tumor control while achieving better preservation of urinary continence, sexual, and reproductive functions. Future studies with larger sample size and long-term follow-up are needed to further explore and validate these findings. -
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