Laparoscopic radical prostatectomy with the Heilbronn technique: An analysis of the first 180 cases
Laparoscopic radical prostatectomy with the Heilbronn technique: An analysis of the first 180 cases
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DOI：
10.1016/s0022-5347(05)65514-0
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发表时间：
2001-12-01
影响因子：
6.6
通讯作者：
Rumpelt, HJ
中科院分区：
文献类型：
--
作者：
Rassweiler, J;Sentker, L;Rumpelt, HJ
目的：1998 年，Guillonneau 和 Vallancien 引入了腹腔镜根治性前列腺切除术，主要进入精囊。 1999 年，我们开发了一种不同的腹腔镜技术，类似于经典的耻骨后根治性前列腺切除术。我们重点关注前 1.80 名患者的早期结果和手术学习曲线。材料和方法：采用经腹膜方法立即进入 Retzius 空间。在内窥镜下缝合背静脉复合体后，切开尿道，并横切或不横切前列腺远端蒂。然后将顶端向腹侧拉，然后在膀胱颈切开，并经膀胱进入输精管和精囊。用5条间断内镜缝合完成尿道膀胱后壁吻合后，放置Foley导管，关闭膀胱颈并通过脐部切口提取标本。从1999年3月到2000年12月，我们进行了180例手术，其中3例针对pT1期肿瘤，88例pT2，82例pT3和7例pT4。术前平均 PSA 为 13.3 ng./ml。 （范围 1.4 至 148），平均样本重量 37.4 克。 （10 至 125），格里森评分中位数 6（3 至 9）。为了评估学习曲线，对 3 组（每组 60 名患者）进行了单独分析。对第 1 组（前 60 名患者）和第 3 组（最后 60 名患者）之间的差异进行统计显着差异分析。结果：平均手术时间为 271 分钟（范围 150 至 500），输血率为 31%。再干预率为4.4%，并发症发生率为18.8%。 92% 的患者在术后第 2 天不需要任何镇痛。16% 的患者发现切缘阳性。 pT2肿瘤的切缘阳性率为2.3%，pT3a为15%，pT3b为34%。中位随访 12 个月（范围 3 至 23 个月）后，9 名（5%）患者观察到前列腺特异性抗原复发。 83%的患者拔除导管后吻合口紧密，中位时间为7天（范围5至30天）。 3.3% 的患者因吻合口狭窄而必须采用激光切开术进行治疗。出院时，33% 的患者能够自控，6 个月后为 74%，12 个月后为 97%：学习曲线分析显示，手术时间（324 分钟与 265 分钟）、开放手术转换率（8.1% 对 1.7%）、并发症发生率（23.3% 对 11.7%）和延长导尿率（分别为 31.6% 对 10%）存在显着差异，-然而结论：腹腔镜根治性前列腺切除术需要丰富的腹腔镜专业知识和持续的学习曲线。发病率低，肿瘤控制与开放手术的结果相似，功能结果也有希望。该程序只能在经过充分培训和专业知识的专门中心进行。
Purpose: In 1998 Guillonneau and Vallancien introduced laparoscopic radical prostatectomy with primary access to the seminal vesicle. In 1999 we developed a different laparoscopic technique similar to the classic retropubic radical prostatectomy. We focus on early results and the learning curve of the procedure in the first 1.80 patients.Materials and Methods: A transperitoneal approach is used with immediate access to Retzius' space. After the dorsal vein complex is endoscopically sutured, the urethra is incised and distal pedicles of the prostate with or without the neurovascular bundle transected. The apex is then pulled ventrally followed with incision at the bladder neck, and transvesical access to vas deferens and seminal vesicle. After completing the posterior wall of the urethrovesical anastomosis with 5 interrupted endoscopic sutures, the Foley catheter is placed, bladder neck closed and specimen extracted via the umbilical incision. From March 1999 to December 2000 we have performed 180 procedures, including 3 for stage pT1 tumor, 88 pT2, 82 pT3 and 7 pT4. Mean preoperative PSA was 13.3 ng./ml. (.range 1.4 to 148), mean specimen weight 37.4 gm. (10 to 125) and median Gleason score 6 (3 to 9). For evaluation of the learning curve a separate analysis of 3 groups with 60 patients in each was done. Differences between groups 1 (first 60 patients) and 3 (last 60) were analyzed for statistically significant differences.Results: Mean operating time was 271 minutes (range 150 to 500) and transfusion rate 31%. The reintervention rate was 4.4% and complication rate 18.8%. Of the patients 92% did not require any analgesia on postoperative day 2. Positive margins were found in 16% of the patients. The rate of positive margins in pT2 tumors was 2.3%, pT3a 15% and pT3b 34%. After a median followup of 12 months (range 3 to 23) in 9 (5%) patients a prostate specific antigen relapse was observed. The anastomosis was tight after removal of the catheter in 83% of patients, with a median time of 7 days (range 5 to 30). An anastomotic stricture had to be treated with laser incision in 3.3% of patients. On discharge from the hospital 33% of patients were continent, after 6 months 74% and after 12 months 97%: Analysis of the learning curve revealed significant differences in operating time (324 versus 265 minutes), conversion rate to open surgery (8.1% versus 1.7%), complication rate (23.3% versus 11.7%) and rate of prolonged catheterization (31.6% versus 10%, respectively), -whereas the percentage of positive margins and continence rates showed no influence.Conclusions: Laparoscopic radical prostatectomy requires significant laparoscopic expertise with an ongoing learning curve. Morbidity is low, oncological control similar to results of open surgery and functional results are promising. The procedure should be performed only at dedicated centers with adequate training and expertise.