80岁及以上前列腺癌患者行腹腔镜前列腺根治性切除术围手术期参数及预后

doi:10.19723/j.issn.1671-167X.2018.05.010

摘要/Abstract

摘要： 目的：分析北京大学第三医院泌尿外科收治的超高龄（≥80岁）前列腺癌患者的围手术期参数、术后控尿功能恢复及肿瘤学预后，探讨中国人群超高龄前列腺癌患者接受腹腔镜前列腺根治性切除术治疗的安全性和有效性。方法：选择2007年1月至2016年12月于北京大学第三医院因前列腺腺癌行腹腔镜前列腺根治性切除术的超高龄（≥80岁）患者进行回顾性分析，纳入标准为患者年龄≥80岁，经组织病理学检查确诊为前列腺腺癌，临床资料齐备。所有患者均经腹膜外途径行腹腔镜前列腺根治性切除术，收集患者临床资料、围手术期参数、术后病理资料等。术后3个月、6个月和1年对患者控尿功能恢复情况进行随访，定期检测血清前列腺特异性抗原（prostate specific antigen, PSA）水平，将生化复发定义为连续两次血清PSA水平大于0.2 μg/L者，应用Kaplan-Meier生存曲线分析患者无生化复发生存率和总生存率，多因素COX回归分析影响超高龄前列腺癌患者术后生化复发的危险因素。结果：所有51例患者年龄（81.6±1.6）岁，穿刺前PSA (15.19±13.68) μg/L，穿刺Gleason评分为6分、7分和≥8分者分别为14例（27.5%）、19例（37.3%）和18例（35.3%），临床分期为T1、T2和T3期者分别为6例（11.8%）、31例（60.8%）和14例（27.5%），ASA分级Ⅰ级者6例，Ⅱ级者45例。所有患者均完成手术，手术时间（189.6±69.1） min，手术出血量（169.9±163.5） mL，11例（21.6%）患者发生围手术期并发症。通过超高龄前列腺癌患者腹腔镜前列腺根治性切除术(laparoscopic radical prostatectomy，LRP)术后的大体标本病理进行分析，术后病理分期T2期者29例（56.9%），T3期22例者（43.1%），其中包膜侵犯者18例（35.3%），精囊侵犯者4例（7.8%）；大体病理Gleason评分6分、7分和≥8分者分别为8例（15.7%）、21例（41.1%）和22例（43.1%），术后病理切缘阳性者14例（27.5%）。截止2017年10月术后随访10~118个月，中位随访时间42个月，术后3个月、6个月和1年超高龄前列腺癌患者行LRP术后的尿控率分别为64.7%(33/51)、82.4%(42/51)和 92.2%(47/51)。在随访过程中，12例（23.5%）超高龄前列腺癌患者LRP术后出现生化复发，平均生化复发时间为40.9个月；4例（7.8%）患者在随访过程中死亡，其中1例（2.0%）患者因前列腺癌进展死亡,3例（5.9%）患者因其他疾病死亡。经多因素COX回归分析，影响超高龄前列腺癌患者术后生化复发的危险因素主要为高PSA水平（P=0.019）、病理分期≥T3期（P =0.017）和切缘阳性（P =0.020）。结论：对选择恰当的超高龄前列腺癌患者施行腹腔镜前列腺根治性切除术是可行的，并且远期肿瘤控制情况良好，高PSA水平、病理分期≥T3期和切缘阳性可能是超高龄前列腺癌患者术后生化复发的独立危险因素，但此结论尚需大样本量的前瞻性临床研究证实。

关键词: 前列腺恶性肿瘤, 前列腺切除术, 超高龄

Abstract: Objective： To assess the perioperative outcome, continence recovery and oncologic outcome of Chinese patients aged 80 years or older treated with radical prostatectomy for prostate cancer. Methods: We retrospectively evaluated the octogenarian patients who recieved biopsy for prostatic carcinoma and underwent laparoscopic radical prostatectomy from 2007 to 2016. We collected the data of clinical variables, perioperative parameters and postoperative pathological results for the octogenarian patients. We recorded and analyzed the recovery of urinary continence of the patients 3 months, 6 months and 1 year after surgery. Biochemical progression was defined as postoperative prostate specific antigen (PSA) greater than 2 μg/L for 2 times. We evaluated the non-biochemical recurrence survival rate and overall survival rate by Kaplan-Meier survival curve analysis for the patients aged 80 years or older. Multivariable COX regression analyses were used for evaluating the influence factors of biochemical recurrence after laparoscopic radical prostatectomy. Results: For all the 51 patients, the average age was (81.6±1.6) years,and prebiopsy PSA was (15.19±13.68) μg/L. There were 14 cases (27.5%), 19 cases (37.3%) and 18 cases (35.3%) for biopsy Gleason score 6, 7 and ≥8. There were 6 patients(11.8%) with clinical stage T1, 31 patients (60.8%) with clinical stage T2 and 14 patients (27.5%) with clinical stage T3.According to American Society of Anesthesiologists (ASA) classification, grade Ⅰ was in 6 patients and grade Ⅱ in 45 patients. All the octogenarian patients received extra-peritoneal laparoscopic radical prostatectomy. The average operation time was (189.6±69.1) min, the estimated blood volume was (169.9±163.5) mL, and 11 patients (21.6%) had perioperative complications. There were 29 cases (56.9%) and 22 cases (43.1%) staged for pT2 and pT3 based on postoperative pathological test. Of the pT3 patients, 18 (35.3%) and 4 (7.8%) were pT3a and pT3b.Eight cases (15.7%) presented Gleason score 6,21 cases (41.1%) 7 and 22 cases(43.1%) ≥8. Fourteen cases were positive surgical margin patients after surgery. Overall, the median follow up was 42 months. The continence rate of the octogenarian patients was 64.7%, 82.4% and 92.2% for 3 months, 6 months and 12 months after the surgery. Twelve cases (23.5%) had biochemical recurrence and 4 cases (7.8%) died in the follow up. There was 1 patient who died of prostate cancer progression and 3 died for other reasons. PSA (P=0.019), pT≥T3 (P=0.017) and positive surgical margin (P=0.020) were independent risk factors for biochemical recurrence of the octogenarian prostate cancer patients according to multivariable COX regression analysis. Conclusion: For well selected octogenarian prostate cancer patients, laparoscopic radical prostatectomy was a feasible treatment option. Octogenarian patients who received laparoscopic radical prostatectomy showed good oncologic outcome. PSA, pT≥T3 and positive surgical margin were independent risk factors for biochemical recurrence of octogenarian prostate cancer patients.

Key words: Prostatic neoplasm, Prostatectomy, Octogenarians

中图分类号:

R699.8

张帆，张树栋，肖春雷，黄毅，马潞林. 80岁及以上前列腺癌患者行腹腔镜前列腺根治性切除术围手术期参数及预后[J]. 北京大学学报(医学版), 2018, 50(5): 822-827.

ZHANG Fan, ZHANG Shu-dong, XIAO Chun-lei, HUANG Yi, MA Lu-lin. Perioperative parameters and prognosis analysis of patients aged 80 years or older treated with radical prostatectomy for prostate cancer[J]. Journal of Peking University(Health Sciences), 2018, 50(5): 822-827.

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