机器人辅助与普通腹腔镜根治性膀胱切除术+原位回肠新膀胱术后性功能的对比研究  

A comparative study of sexual function preservation after robot-assisted and laparoscopic radical cystectomy and orthotopic bladder reconstruction

作　　者：王莉萍[1] 王帅[1] 祁小龙[1] 沃奇军[1] 白宇晨 张大宏[1] Wang Liping;Wang Shuai;Qi Xiaolong;Wo Qijun;Bai Yucheng;Zhang Dahong(Department of Urology,Zhejiang Provincial People’s Hospital,People’s Hospital of Hangzhou Medical College,Hangzhou 310014,China)

机构地区：[1]浙江省人民医院杭州医学院附属人民医院泌尿外科,杭州310014

出　　处：《中华泌尿外科杂志》2020年第5期356-361,共6页Chinese Journal of Urology

基　　金：浙江省医药卫生科技项目(2016KYA008);浙江省科技厅公益技术研究计划/社会发展项目(LGF18H050004)。

摘　　要：目的探讨机器人辅助与普通腹腔镜根治性膀胱切除术+原位回肠新膀胱对膀胱癌患者术后性功能的影响。方法回顾性分析2014年1月至2019年1月浙江省人民医院行腹腔镜根治性膀胱切除术+原位回肠新膀胱的84例男性患者的临床资料。84例经膀胱镜活检或诊断性电切病理确诊为高级别尿路上皮癌,且后尿道及膀胱颈口活检未见肿瘤侵犯。术前国际勃起功能评分(IIEF-5)均≥21分。84例术前PSA均<4.0 ng/ml,直肠指检均正常,经直肠超声、MRI检查均未见前列腺结节,均排除前列腺癌可能。84例手术均由同一医疗团队施行。45例行机器人辅助腹腔镜根治性膀胱切除术(RARC组),39例行普通腹腔镜根治性膀胱切除术(LRC组)。RARC组45例,年龄53(50~67)岁;肿瘤临床分期为cT1期10例,cT2期21例,cT3期14例。LRC组39例,年龄56(52~65)岁;肿瘤临床分期为cT1期6例,cT2期23例,cT3期10例。RARC组与保护性功能有关的主要手术步骤:①探查腹腔脏器,显露盆腔,观察髂血管和输尿管,在输尿管髂血管交叉处旁开l^2 cm打开腹膜,沿髂外动静脉及闭孔神经周围行标准或扩大盆腔淋巴结清扫。本研究遵循无明显可疑淋巴结转移者按标准范围切除两侧盆腔淋巴结,尽可能保护盆底的神经。②用机器人第3臂将膀胱提起,观察到隆起的精囊和输精管壶腹部后在该处打开腹膜,向两侧与已经打开的腹膜连通,沿输精管和精囊游离,交替提起输精管和精囊,打开狄氏筋膜,暴露前列腺后方。观察脐正中韧带,第3臂向下牵拉帮助暴露,打开腹膜至耻骨后,显露前列腺区。继续向下游离膀胱前间隙直到暴露盆筋膜和耻骨前列腺韧带。用Hem-o-1ok结扎两侧膀胱侧韧带并离断,于筋膜内层面切除膀胱前列腺,保留两侧血管神经束至前列腺尖部,暴露尿道,拔除导尿管后,于前列腺尖部用Hem-o-lok夹闭尿道并离断,创面彻底止血,取少量远端尿道组织送快速�Objective To Investigate the postoperative sexual function outcomes in patients with bladder cancer who underwent robot-assisted radical cystectomy(RARC)or laparoscopic radical cystectomy(LRC)followed by orthotopic neobladder reconstruction.Methods We performed a retrospective review of 84 bladder cancer patients having undergone laparoscopic radical cystectomy(LRC)and robotic-assisted radical cystectomy(RARC)with≥21 IIEF-5 in our institution from Jan 2014 to Jan 2019.All of them were diagnosed as high grade urothelial carcinoma by biopsy or TURBT.Biopsy of the posterior urethra and bladder neck reveal negative result of tumor invasion.Their PSA level was less than 4.0 ng/ml with negative result of DRE.All patients undergone laparoscopic radical cystectomy and orthotopic neobladder reconstruction by one medical team.45 patients underwent robotic assistant radical cystectomy(RARC group),and the rest of patients 39 were treated with laparoscopic radical cystectomy(LRC group).In RARC group,the mean age were 53 years old(ranging 50-67 years old)and clinical stage of the tumor was cT1 in 10 patients,cT2 in 21 patients and cT3 in 14 patients.In the LRC group,the mean age were 56 years old(ranging52-65 years old)and the clinical staging of the tumors was 6 patients in cT1,23 patients in the cT2 and 12 patients in the cT3.The RARC group paid special attention to the protective function of the following surgical details:①To detect the abdominal organs,reveal the pelvic cavity,observe the blood vessels and ureter,open the perinatal membrane next to the cross of the ureter,along the outer venous veins and closed-hole nerves around the standard or expand the pelvic lymph node cleaning.In this study,the patients who did not have obvious suspected lymph node metastasis were removed within the standard range of the pelvic lymph nodes on both sidesin order to protect the nerves at the pelvic floor as much as possible.②With the robot 3rd arm lifting the bladder,the peritoneum was opened at the site of seminal vesicle and am

关 键 词：膀胱肿瘤 膀胱癌 机器人辅助腹腔镜手术 根治性膀胱切除术 性功能 

分 类 号：R737.14[医药卫生—肿瘤]