耻骨后腹膜外途径腹腔镜前列腺癌根治术（RELRP）相关解剖及手术标准程序化研究

发布时间：2018-05-28 23:59

本文选题：前列腺癌根治术 + 前列腺尖部　；参考：《山东大学》2017年博士论文

【摘要】：[研究背景]解剖学研究对于外科手术具有根本性的意义,正如著名学者Robert P.Myer所指出的:一个熟悉解剖的外科医师,能让患者出血更少、切缘更好、功能保存更满意。1905年Hugh Hampton Young首次开展经会阴途径前列腺癌根治术,1947年Milin首次描述耻骨后途径前列腺癌根治术,1987年Walsh正式提出了解剖性前列腺根治切除的概念,1992年Schuessler开展第一例经腹腔途径腹腔镜前列腺癌根治术(LRP),1997年Raboy报道了首例经腹膜外途径腹腔镜前列腺癌根治术(RELRP),2000年Binder及Vallancein首次开展机器人辅助腹腔镜前列腺癌根治术(RALRP)。在国内,由于医疗资源有限,特别是县级以下基层医院医疗器械配置不足,RALRP手术虽然独具优势但尚难以普及,而LRP手术对医疗设备要求相对较低---在国内多数县级医院甚至发达地区的乡镇医院腹腔镜已经是常规配备,这导致了 LRP逐渐成为了目前国内治疗局限性前列腺癌最主流的手术方式。近年来,随着LRP手术开展例数的增加和外科医生手术经验的积累,学界改良和规范了许多具体的手术操作技巧和步骤。更重要的是,解剖学者对于前列腺周围解剖结构的研究不断深入,为该术式的持续进化和演进提供了最根本的理论支撑和实践指导。但LR P手术兼具切除和重建的过程,需要兼顾肿瘤切除的最大化及功能结构损伤的最小化,手术步骤繁复、技术难度大、学习曲线陡峭漫长,一直是泌尿外科最具挑战性的手术。目前对前列腺及周围结构的局部精细解剖尚存较多疑问,经典的解剖学教科书及图谱对于前列腺及周围精细结构缺乏详尽的描述甚至部分描述间相互矛盾,远远不能满足指导临床手术的理论需求。特别是对于膀胱颈部及前列腺尖部区域重要结构的精细测量数据甚至精确定性描述均尚属空白。前列腺位于盆腔深部,其周围有精密复杂的筋膜及神经血管结构,其底部及尖部则有复杂的控尿相关结构。近年来国内外对于前列腺周围的筋膜结构以及耻骨前列腺韧带(PPL)、背血管复合体(DVC)在总体性的定性层面上有所认识,但仍缺乏对相关结构参数的精确测量数据,特别是对于前列腺尖部及膀胱颈部的精细解剖测量目前基本尚属空白。如前列腺尖部,相关结构几何空间狭小、人种间/个体间变异大,解剖研究难度很大,但又是泌尿外科医生和解剖学者必须面对和解决的课题,因为其解剖结构与手术的顺利进行和术后病人切缘阳性率、控尿功能及性功能的保持和恢复密切相关,而后者又直接影响到病人的术后生存时间及生活质量。例如,术中保持足够的尖部尿道长度以及及维持膜部尿道进入尿生殖膈的生理角度有助于术后患者控尿功能的恢复,而探究背血管复合体、耻骨前列腺韧带及尿道横纹括约肌之间精确的相对位置关系显然有助于避免术中游离PPL、缝扎DVC时误伤尿道横纹括约肌及盆底肌群,并为术中进行"尿道前方悬吊"提供条件。再如,膜部尿道四周均有大量神经纤维出现,其很有可能是走行于前列腺后外侧的神经血管束(NVB)在靠近前列腺尖部并继续向远端走行过程中的空间位置二次分布,术中如何最大限度地保护这些神经纤维与前列腺癌根治术后患者勃起及控尿功能的恢复密切相关,但这些神经纤维在前列腺尖部区域的空间分布在不同报道中并不一致。此外,很多泌尿外科医生在术中会发现前列腺体积改变对于膀胱颈部形态具有显著影响,特别是前列腺体积明显增大、腺体部分凸入膀胱者,膀胱颈部容易受到腺体挤压产生返折变形,术中很容易误伤膀胱三角区、导致颈口保留不足或前列腺腺体误切开等并发症。以上种种棘手而现实的问题都是每一个泌尿外科医生在手术中必然要面对的。正是因为对前列腺尖部及膀胱颈部解剖学研究的缺失,导致了 LRP术中如何保护重要的控尿及勃起相关功能结构缺乏客观具体的操作依据及技术规范,也使得外科医生在处理前列腺尖部结构、离断及重建膀胱颈部及尿道的过程中如同"盲人摸象"--由于缺乏精细的局部应用解剖学指导,只能凭经验、凭感觉甚至凭运气。以上种种问题的解决都依赖于对于前列腺周围结构特别是前列腺尖部及膀胱颈部精细的应用解剖学研究,而这正是本研究的目的所在。为此,本研究通过尸体解剖方法,以实际指导LRP术中科学实施控尿及性功能相关结构保留为目的,研究前列腺尖部及膀胱颈部区域相关结构的解剖学特点。[目的]1.测量尖部远端尿道与尿生殖膈的角度2.测量耻骨前列腺韧带的空间几何尺寸3.探究前逼尿肌围裙覆盖前列腺前表面的范围4.描述膀胱颈部形态特点及其向前列腺部尿道移行的特点[方法]1.与山东大学医学院解剖教研室合作,获取10%福尔马林固定男性尸体20具。截去所有尸体标本的双下肢,使用线锯对其中10具标本的骨盆进行正中矢状切开,暴露完整尿道并用红线标记,用量角器及直尺测量膜部(尖部远端尿道)穿过尿生殖膈的角度及长度。剥离膀胱及前列腺前方的脂肪组织,完全显露耻骨前列腺韧带的侧方,用直尺自耻骨端至前列腺端测量耻骨前列腺韧带的宽度。2.用线锯将另外10具标本的耻骨自耻骨联合外侧5cm处分别离断,用手术刀将盆腔脏器自盆壁完整剥离下来,避免损伤前列腺周围结构,观察膀胱颈与前列腺底的位置关系。用镊子清除耻骨后的疏松结缔组织,逐步钝性分离出逼尿肌围裙、耻骨前列腺韧带、背侧血管复合体等结构,描述或测量以上主要结构的几何形态及数据。[结果]1.尖部远端尿道穿过尿生殖膈的角度最大87.6°,最小70.3°,平均82.2±5.3°,前列腺尖部尿道(尖部远端尿道至盆膈)的长度为12.1 ±2.3mm。2.耻骨前列腺韧带耻骨端测得宽约7.5±1.3mm,中间宽约6.2±1.1mm,前列腺端宽约12.6 ±2.2mm,自耻骨端至前列腺端长约9.3 ±1.2mm。两条耻骨前列腺韧带耻骨端相距约10.7±1.8mm,前列腺端相距约12.8±2.6mm。3.逼尿肌围裙几乎覆盖前列腺全长,呈倒三角形分布,在前列腺底部分布范围约为10点至2点之间,在前列腺尖部分布范围约为11点至1点之间。其中间最厚,向两侧移行时逐渐变薄乃至消失。4.膀胱颈与前列腺底的接触面并非一个标准的平面,而是一个随膀胱颈向尿道移行逐渐向前列腺中央凹陷的曲面,其具体形态可能受前列腺体积影响---特别是对于前列腺体积较大、腺体向膀胱内凸出者。[结论]前列腺尖部及膀胱颈部结构复杂、精致,对LRP术后控尿及性功能恢复具有直接影响。对前列腺尖部远端后尿道长度、后尿道穿越盆底的角度、PPL几何尺寸的定量测量以及对膀胱颈部与前列腺基底交界曲面及其变异的定性描述,可以帮助术者对LRP术中控尿及性功能相关结构建立清晰的解剖图景,为LRP术中控尿及性功能保护技术的标准化及手术步骤的程序化提供基础性依据。[目的]将RELRP手术步骤分解、改良,建立技术规范化、步骤程序化的标准手术流程,保障手术安全、平滑其学习曲线并增强不同研究间数据的可比性。[资料与方法]对山东大学齐鲁医院泌尿外科2015年以来接受RELRP治疗患者手术过程录像,通过观摩手术过程并参阅相关文献,全面审视、梳理RELRP手术步骤,归纳提炼手术技巧及经验,实现RELRP操作技术标准化和操作步骤程序化。[结果]标准程序化RELRP可分解为21步(技术要点详见正文);1.摆手术体位2.手术野满毒铺巾3.留置尿管4.纯性扩张耻骨后腹膜外间隙5.建立腹腔镜操作通道及耻骨后腹膜外气腹6.置入腹腔镜,直视下建立双侧操作通道7.耻骨后间隙脂肪清理、止血,显露重要解剖标志8.清理盆腔淋己结9.显露并缝扎背侧血管复合体10.离断膀腕颈部11.切开狄氏筋膜并从前列腺后方游离达前列腺尖部12.剪断前列腺侧初带及耻骨前列腺初带13.离断前列腺尖部,完全游离前列腺并装袋14.直肠指检,排除直麻损伤15.吻合曰后方重建16.膀胱颈尿道吻合17.检测吻合口密闭性及手术止血18.顿合口前方悬吊19.留置创腔引流管20.取出标本21.缝合关闭切口,结束手术[结论]RELRP作为局限性前列腺癌的主流治疗术式之一在多数省级医院己经得到开展并积累了一定临床经验,但不同医疗中也甚至同一中也不同手术者之间在手术操作的技术细节、操作步骤的数量及顺序等方面存在较大差异,导致手术疗效差异较大、数据可比性欠佳,不利于循证医学的开展及大数据的挖掘。本研究通过观摩手术录像,结合论文第一部分中的解剖学研充成果,提炼手术共性及经验,将RELRP手术进行技术标准化、步骤程序化的整理,初步为RELRP建立了统一的操作流程和规范,保障了手术疗效和安全性,增强了不同研究之间数据的可比化进而有利于使用循证医学工具对RELRP技术做持续的优化和改良。同时,RELRP的标准程序化研究,可平滑该手术学习曲线,有利于该技术向县级及以下基层医院推广施行。[目的]量化比较、评价标准化RELRP(S-RELRP)的疗效和安全性。[研究对象及方法]研究对象:2015年10月到2016年10月,在山东大学齐鲁医院泌尿外科行RELRP手术的患者共45例,其中S-RELRP手术组20例、ns-RELRP手术组25例,所有患者前列腺癌诊断均由术前及术后病理证实。研究方法:回顾性收集并比较S-RELRP及ns-RELRP两组患者年龄、体重、术前PSA水平、术前Gleason评分、手术耗时、术中出血量、术后胃肠功能恢复时间、术后引流及住院天数、术后尿漏及琳己漏发生率、术后切缘阳性率、术后3个月的控尿情况、住院费用等数据。同时通过调查问卷的方式对术中医生及护士的工作负荷进巧比较。统计学分析使用SPSS.0软件完成,计量资料的对比使用独立样本的t检验,计数资料的对比根据数据特征分别采用X~2检验或Fisher精确概率法计算,定义P0.05为差异有统计学意义。[结果]所有手术均在全麻下实施,手术过程顺利,术中无术式改变。两组患者的基线数据,如年龄、体重、术前tPSA、术前巧SA/tPSA、术前Gleason评分等数据无显著差异(P0.05)。S-RELRP组患者平均手术用时218.25±20.47min,明显少于ns-RELRP组的254.20±40.25min(P=0.008)。S-RELRP组平均术中出血量130.00±57.12ml明显少于118-11组的194.00±113(1111=0.041),但两姐患者术中、术后巧未输血。S-RELRP组术后引流时间及术后住院时间分别文为7.20+2.14天和9.55+2.06天,显著短于ns-RELRP}D的9占2+3.11天和12.76+4.04天(P=0.028,P=0.033)。S-RELRP组顿合曰漏发生率0%(0/20)、淋巴漏5%(1/20),ns-RELRP吻合口漏4%(1/25)、淋巴漏16%(4/25),差异均无统计学意义(P=0.366,P=0.243)。S-RELRP组及ns-RELRP组切缘阳性率分别为5%(1/20)和8%(2/25),无显著差异(P=0.688)。术后3个月控尿率方面,S-RELRP组及ns-RELRP组分别为85%和56%,S-RELRP组明显占优(P=0.037)。S-RELRP组及ns-RELRP组术后3个月PSA阳性及达到生化复发水平者分别为10%、5%和24%、8%,均无显著差异(P=0.222,P=0.688)。S-RELRP组医生工作负荷明显更低(3.54+52 vs 4.09+0.54,P=0.025),而护±工作负荷则在两组间无显著差别(3.01+1.20 VS 3.13+0.83,P=0.732)[结论]S-RELRP具有手术耗时短、术中出血少、术后引流时间短、往院时间短、术后3个月控尿率高、医生工作负荷低等优点,而在术后吻合口漏、术后淋巴漏、术后胃麻恢复时间、术后切缘阳性率、术后PSA水平、住院总费用方面与ns-RELRP组相当。
[Abstract]:[background] anatomical studies are fundamental to surgery, as noted by the famous scholar Robert P.Myer: a surgeon familiar with the anatomy can make the patient less bleeding, better cutting edge, and more satisfactory in function preservation.1905 Hugh Hampton Young for the first time perineal radical prostatectomy, first Milin in 1947 The first case of radical prostatectomy for prostatectomy was presented in 1987 at Walsh in 1987. In 1992, the first case of peritoneal laparoscopic radical prostatectomy (LRP) was performed at Schuessler in 1992, and the first case of extraperitoneal laparoscopic radical prostatectomy (RELRP), Binder and Vall in 2000 was reported in 1997. Ancein first developed the robot assisted laparoscopic radical prostatectomy (RALRP). In China, because of the limited medical resources, especially the lack of medical equipment in the grass-roots hospitals at the county level below the county level, the RALRP operation has a unique advantage but it is still difficult to popularize, while the LRP operation is relatively low on medical equipment - in most of the county hospitals even developed. Laparoscopy in township hospitals in the region has been routinely equipped, which has led to LRP becoming the most mainstream surgical approach to the treatment of localized prostate cancer in China. In recent years, with the increase in the number of cases in the LRP operation and the accumulation of surgeons' experience, many specific surgical techniques and procedures have been improved and regulated by the academic community. More importantly, the anatomy of the prostate is further studied by anatomics, which provides the most fundamental theoretical support and practical guidance for the continuous evolution and evolution of the operation. However, the process of resection and reconstruction of LR P needs to take into account the maximization of the tumor resection and the minimization of the damage of the functional structure and the complexity of the procedure. The technical difficulty and the steep learning curve have been the most challenging operation in the Department of urology. There are still many questions about the local fine anatomy of the prostate and its surrounding structures. The classical anatomy textbooks and atlas are incompatible with the description or part of the detailed description of the fine structure of the prostate and surrounding the prostate and the surrounding structure. The theoretical requirements for guiding clinical surgery are not satisfied. The precise and precise qualitative description of the important structure of the bladder neck and the tip of the prostatic region is still blank. The prostate is located in the deep pelvic cavity with sophisticated fascia and neurovascular structures around it, and the bottom and the tip are related to complex urinary control. Structure. In recent years, the structure of the fasciae around the prostate and the prostatic ligament (PPL) and the dorsal vascular complex (DVC) are recognized at the qualitative level at home and abroad. However, there is still a lack of accurate measurements of the related structural parameters, especially for the fine anatomical measurements of the tip of the prostate and the neck of the bladder. Such as the apex of the prostate, the geometric space of the related structures is narrow, the interspecific / interindividual variation is large, and the anatomical study is difficult, but it is a subject that the urologist and anatomist must face and solve because of its anatomical structure and the successful operation of the surgery and the positive rate of the patients after the operation, the maintenance and recovery of the function and function of the urine control. It is closely related, and the latter has a direct impact on the patient's survival time and quality of life. For example, the maintenance of adequate urethral length and the maintenance of the physiological angles of the urethra into the genital diaphragms of the membrane contribute to the recovery of the urinary function of the patients after the operation, and to explore the dorsal vascular complex, the pubis prostatic ligament and the urethral transverse lines. The precise relative position relationship between the sphincter obviously helps to avoid the free PPL in the operation. The urethral transverse sphincter and the pelvic floor muscle are injured when DVC is ligation, and the condition of "anterior urethral suspension" is provided for the operation. The space position of the bundle (NVB) is located near the tip of the prostate and continues to move toward the distal end. How to maximize the protection of these nerve fibers during the operation is closely related to the recovery of the erectile and urinary function of the patients after radical prostatectomy, but the spatial distribution of these nerve fibers in the apex of the prostate is reported in different reports. In addition, a lot of urological surgeons will find that the volume change of the prostate has a significant influence on the shape of the bladder neck, especially the volume of the prostate, the gland part protruded into the bladder, the neck of the bladder is easily subject to the shape of the gland, and the bladder triangle is easily misunderstood during the operation, leading to the neck mouth. Complications such as insufficient retention or prostatic glandular incision. All of these difficult and practical problems are all inevitable in the operation of each urologist. It is the lack of anatomical study of the tip of the prostate and the neck of the bladder, which leads to the protection of important urinary and erectile related functional structures in LRP. The lack of objective specific operational basis and technical specifications made surgeons to handle the structure of the tip of the prostate, disconnect and reconstruct the neck and urethra of the bladder as "blind in the picture" - because of the lack of fine local applied anatomical guidance, only by experience, by feeling or even by luck. This is the purpose of this study for the fine applied anatomy of the surrounding prostatic structure, especially the apex of the prostate and the neck of the bladder. For this purpose, the purpose of this study was to guide the scientific implementation of the retention of urinary and sexual function related structures in LRP by autopsies, and to study the region of the prostatic tip and the neck region of the bladder. The anatomical characteristics of the related structures. [Objective]1. measurement of the spatial geometry of the prostatic ligament of the pubis 2. measured by the angle of the distal urethra and the genital diaphragm of the apex 3. to explore the scope of the anterior detrusor apron covering the anterior surface of the prostate (4.) to describe the morphological characteristics of the bladder neck and its characteristics to the prostatic urinary tract [method]1. with the Shandong University. The medical college's Department of anatomy and research worked together to obtain 20 formalin's fixed male cadavers, cut off the lower limbs of all the cadavers, and cut the pelvis in 10 of the 10 specimens by a line saw, exposed the intact urethra and marked with red lines, and measured the angle of the membrane (the distal end of the tip of the tip of the tip of the apex) and the angle of the genital diaphragm with a protractor and a ruler. The length, dissection of the adipose tissue in the front of the bladder and prostate, completely exposing the side of the pubic prostatic ligament, measuring the width of the prostatic ligament with a ruler from the end of the pubis to the prostatic end.2. with a wire saw to separate the pubic symphysis from the pubic symphysis and the lateral 5cm of the other 10 specimens. The pelvic organs are completely stripped from the pelvic wall with a scalpel. To avoid damage to the surrounding structure of the prostate, observe the position of the bladder neck and the base of the prostate. Remove the loose connective tissue after the pubis, gradually separate out the detrusor apron, the pubis prostatic ligament, the dorsal vascular complex and other structures, describe or measure the geometry and data of the main structure. [result]1. tip. The maximum angle of the distal urethra through the urogenital diaphragm was 87.6 degrees, the minimum 70.3 degree, and the average 82.2 + 5.3 degrees. The length of the prostatic urethra (the distal end of the tip of the urethra to the pelvic diaphragm) was 12.1 + 2.3mm.2. in the pubis of the pubis of the pubic symphysis. The width of the pubis of the pubic prostatic ligament was about 7.5 + 1.3mm, the middle width was 6.2 + 1.1mm, and the end of the proprost gland was about 12.6 + 2.2mm, from the pubis to the prostatic end. About 9.3 + 1.2mm. two pubic prostate ligaments are about 10.7 + 1.8mm, and the end of the prostate is approximately 12.8 + 2.6mm.3. detrusor aprons, which almost cover the total length of the prostate. The distribution of the prostate is about 10 to 2 at the bottom of the prostate. The range of the tip of the prostate is about 11 to 1. The contact surface of the.4. bladder neck and the base of the prostate is not a standard plane, but a curved surface that moves gradually to the central prostatic depression with the bladder neck to the urethra. The specific shape may be affected by the volume of the prostate - especially for the larger volume of the prostate. The glands protrude into the bladder. [Conclusion] the structure of the tip of the prostate and the neck of the bladder is complex and delicate. It has a direct effect on the urinary and sexual function recovery after LRP. The length of the posterior urethra, the angle of the posterior urethra through the pelvic floor, the quantitative measurement of the PPL geometry, and the qualitative description of the curved surface of the bladder neck and the anterior glandular basal junction and its variation. It can help the operator to set up a clear anatomical picture of the structure related to urinary and sexual function in LRP, and provide the basic basis for the standardization of the technique of urinary control and sexual function protection in LRP and the procedure of the operation. [Objective] to decompose and improve the procedure of RELRP operation, to establish the technical specification, and to ensure the procedure and procedure of the standard procedure. The operation was safe, the learning curve was smoothed and the comparability of data between different studies was enhanced. [data and methods] was used to videotape the operation process of RELRP patients in the Department of Urology of Qilu Hospital of Shandong University since 2015. The procedure was reviewed, the procedure of RELRP operation was combed and the surgical techniques were summarized. Experience, standardization of RELRP operation technology and procedure procedure. [results] standard programming RELRP can be decomposed into 21 steps (the main points of the technical points); 1. surgical position 2. operation field full poison paving towel 3. indwelling catheter 4. pure expansion of pubis retroperitoneal space gap 5. to establish laparoscope operation channel and pubis retroperitoneum pneumoperitoneum 6. into abdominal cavity A bilateral operation channel was set up to establish bilateral operation channel 7. after pubis clearance, fat cleaning, hemostasis, revealing important anatomical signs, 8. cleaning pelvic lymph nodes, 9. exposure, 9. of the dorsal lateral vascular complex, 10. dissection of the wrist neck and 11. dissection of the dieldron fascia, and from the rear of the prostate to the prostatic tip 12. to cut the prostatic lateral zone and the pubis prostatic zone 13 Disconnect the tip of the prostate, complete free prostate and bag 14. rectal examination, exclude 15. anastomosis, 16. bladder neck urethra anastomosis, 16. bladder neck urethral anastomosis 17., 18. tons of anastomotic closure and surgical hemostasis, 18. tons of anterior suspension 19. indwelling drainage tube 20. removed specimens 21. suture closure incision and end operation [Conclusion] One of the mainstream methods of prostatic cancer treatment in most provincial hospitals has been carried out and accumulated some clinical experience. However, there are significant differences in the technical details, the number and order of the operation procedures between the different operators in the same one and the same one in the same medium, which leads to the large difference in the operation effect. Poor comparability is not conducive to the development of evidence-based medicine and the mining of large data. This study, through the observation of surgical video, combined with the results of the anatomic study in the first part of the paper, abstracts the common and experience of the operation, standardizing the operation of the RELRP and arranging the procedure procedure, and initially establishes a unified operation process and standard for the RELRP. The effectiveness and safety of the operation have been ensured, and the comparability of data between different studies is enhanced and the RELRP technology is optimized and improved by using evidence-based medicine tools. Meanwhile, the standard programming study of RELRP can smooth the learning curve of the operation, which is beneficial to the implementation of the technology to the county and below grass-roots hospitals. Quantitative comparison, evaluation of the efficacy and safety of standardized RELRP (S-RELRP). [object and method]: from October 2015 to October 2016, 45 patients underwent RELRP surgery in Department of Urology, Qilu Hospital of Shandong University, including 20 cases of S-RELRP operation group and 25 cases of ns-RELRP operation group. All the diagnosis of prostate cancer were all before and after operation. Post pathology confirmation. Research methods: retrospective collection and comparison of S-RELRP and ns-RELRP two groups of patients age, weight, preoperative PSA level, preoperative Gleason score, operation time, intraoperative bleeding, postoperative gastrointestinal function recovery time, postoperative drainage and hospital days, postoperative urinary leakage and the incidence of urinary leakage, postoperative margin positive rate, 3 months after the operation of urinary control. The data of hospitalization expenses and hospitalization expenses were compared.
【学位授予单位】：山东大学
【学位级别】：博士
【学位授予年份】：2017
【分类号】：R737.25

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