Extraperitoneal laparoscopic radical prostatectomy: comparison of three-port versus four-port surgeries

目的 比较同一外科医生行三孔法经腹膜外途径腹腔镜下根治性前列腺切除术(extraperitoneal laparoscopic radical prostatectomy,ELRP)与传统四孔法ELRP的近期临床疗效,分析三孔法ELRP治疗局限性前列腺癌的安全性和有效性.方法 回顾性分析2010年1 1月至2014年10月同一外科医生收治的200例行ELRP的前列腺癌患者的临床资料,分为三孔法组(95例)和四孔法组(105例).三孔法ELRP是在传统四孔法Cleveland术式的基础上,省略右侧髂前上棘内侧穿刺孔简化而成.患者年龄(66.8±15.5)岁,总前列腺特异性抗原(tPSA)(15.3±12.4) μg/L.两组患者的年龄、体质指数、术前tPSA、临床分期、术前是否行新辅助内分泌治疗、经尿道前列腺切除手术史、糖尿病史等指标比较差异均无统计学意义(P＞0.05).三孔法组经直肠B超前列腺体积为(35.6±16.7)ml,四孔法组为(42.2±24.7)ml,组间比较差异有统计学意义(P＜0.05).比较两组的手术时间、术中出血量、术后住院天数、术后腹腔引流管留置时间、术后Gleason评分、病理分级、手术切缘情况、术后生化复发率、术后尿失禁发生率等.结果 三孔法组和四孔法组手术时间分别为(81.0±18.6)、(103.6±34.6)min,术中出血量分别为(102.6±75.8)、(217.5±182.9)ml,切缘阳性率分别为13.7％ (13/95)和27.6％ (29/105),术后Gleason评分＞7分者分别为9、29例,组间比较差异均有统计学意义(P＜0.05).两组术后住院天数、术后腹腔引流管留置时间、病理分期比较差异均无统计学意义(P＞0.05).三孔法组83例(87.4％)获随访,随访时间5 ～19个月,中位时间11个月;四孔法组92例(87.6％)获随访,随访时间17 ～52个月,中位时间27个月.两组术后生化复发率及术后3、6、12个月尿失禁发生率比较差异均无统计学意义(P＞0.05).结论 与四孔法相比,三孔法ELRP手术时间、术中出血量、病理切缘等效果相对较好,近期肿瘤控制和术后控尿功能恢复情况相似.对于有丰富腹腔镜手术经验的医师,可行三孔法ELRP治疗局限性前列腺癌.Objective To compare the perioperative outcomes and short-term efficacy of three-port extraperitoneal laparoscopic radical prostatectomy (ELRP) and four-port ELRP.Methods Two hundred patients who had undergone ELRP for prostate cancer by a single surgeon from November 2010 to October 2014 were retrospectively analyzed.Among them,95 cases underwent three-port ELRP and 105 cases underwent four-port ELRP.On the basis of traditional four-port ELRP,three-port ELRP was characterized by the omission of the trocar on the inner side of right anterior superior iliac spine.The mean age was 66.8 ± 15.5 years,and mean total prostate specific antigen (tPSA) was 15.3 ± 12.4 μg/L.There were no significant differences including age,body mass index,tPSA,clinical stages,acceptance of neoadjuvant hormone therapy,history of transurethral resection of the prostate,history of diabetes mellitus between the 2 groups (P ＞ 0.05).Patients in three-port ELRP group had significantly smaller prostate volume than fourport group (35.6 ± 16.7 ml versus 42.2 ± 24.7 ml,P ＜ 0.05).The clinical factors as operative time,estimated blood loss,hospital stay,drainage tube keeping days,pathological Gleason scores,pathological stages,positive surgical margin rates,biochemical recurrence rates and urinary incontinence rates were compared between the 2 groups.Results The three-port group had significantly shorter operative time than the four-port group (81.0 ± 18.6 min versus 103.6 ±34.6 min),less estimated blood loss (102.6 ±75.8 ml versus 217.5 ± 182.9 ml),less positive surgical margin rates (13.7％ versus 27.6％).There were 9 patients having Gleason scores more than 7 in the three-port ELRP group and 29 patients in four-port ELRP group (P ＜ 0.05).There were no significant differences of hospital stay,drainage tube keeping days,pathological stages between the 2 groups (P ＞ 0.05).Eighty-three cases in the three-port ELRP group (87.4％) were followed up for 5-19 months with the median time of 11 months.Ninety-two cases in fourport ELRP group (87.6％) were followed up for 17-52 months and the median time was 27 months.There were no significant differences of biochemical recurrence rates and urinary incontinence rates between the 2 groups(P ＞ 0.05).Conclusions Compared to four-port ELRP,three-port ELRP can provide shorter operative time,less blood loss,better negative surgical margin rates,similar oncological control and recovery of postoperative continence.In experienced hands,three-port ELRP could be a feasible and effective option for localized prostate cancer.中文核心期刊要目总览(PKU)中国科技核心期刊(ISTIC)中国科学引文数据库(CSCD)8595-5993