机器人辅助前列腺癌根治术后患者的控尿恢复时间

doi:10.19723/j.issn.1671-167X.2021.04.013

摘要/Abstract

摘要：

目的: 探讨机器人辅助前列腺癌根治术后控尿恢复时间及影响控尿恢复的危险因素。方法: 2019年1月至2021年1月,前瞻性收集北京大学第一医院泌尿外科单一术者行机器人辅助下前列腺癌根治及尿道周围全重建术的患者资料,纳入临床分期为cT1~T3、cN0、cM0的局限性前列腺癌患者。对于高危患者,常规行双侧盆腔淋巴结清扫。记录患者拔除尿管之后48 h、1周、4周、12周、24周后的控尿情况及相应时间节点的国际前列腺症状评分(international prostatic symptoms score,IPSS)和膀胱过度活动症状评分(overactive bladder symptom score,OABSS)。将24 h使用尿垫≤1片或24 h漏尿量≤20 g定义为完全自主控尿,记录患者拔除尿管之后至达到完全自主控尿的时间,并分析影响控尿恢复时间的危险因素。结果: 共有166例患者纳入本研究,入组患者平均年龄(66.2±6.7)岁,中位前列腺特异抗原(prostate specific antigen, PSA) 8.51 μg/L(4.69~13.20 μg/L)。共59例(35.5%)行双侧淋巴清扫,28例(16.9%)行保留性神经的手术。术后病理情况:pT1期1例(0.6%),pT2期77例(46.4%),pT3期86例(51.8%),28例患者切缘阳性(16.9%)。在所有行淋巴结清扫的患者中,有7例(11.9%)发现淋巴结转移。控尿情况:患者恢复控尿的中位时间为1周,65例(39.2%)患者在拔除尿管48 h之内即实现控尿,32例(19.3%)于术后1周内恢复控尿,34例(20.5%)于术后4周内恢复控尿,24例(14.5%)于术后12周内恢复控尿,9例(5.4%)术后24周内恢复控尿,有2例(1.2%)在术后24周时仍未恢复控尿。在拔除尿管后48 h、1周、4周、12周及24周时控尿率分别为39.2%、58.4%、78.9%、93.4%和98.8%。单因素COX回归分析显示,患者是否合并糖尿病是影响控尿恢复时间的危险因素(OR=1.589,95%CI:1.025~2.462,P=0.038)。在拔除尿管后48 h、4周、12周和24周时能够控尿组患者的平均OABSS均显著低于不能控尿组。结论: 机器人前列腺癌根治术后患者能够获得满意的早期控尿,糖尿病是影响术后控尿恢复时间的危险因素,拔除尿管后膀胱过度活动症状与能否控尿存在相关性。

关键词: 前列腺切除术, 机器人手术, 尿失禁

Abstract:

Objective: To evaluate urinary continence recovery time and risk factors of urinary continence recovery after robot-assisted laparoscopic radical prostatectomy (RARP). Methods: From January 2019 to January 2021, a consecutive series of patients with localized prostate cancer (cT1-T3, cN0, cM0) were prospectively collected. RARP with total anatomical reconstruction was performed in all the cases by an experienced surgeon. Lymph node dissection was performed if the patient was in high-risk group according to the D’Amico risk classification. The primary endpoint was urinary continence recovery time after catheter removal. Postoperative and pathological variables were analyzed. Continence was rigo-rously analyzed 48 hours, 1 week, 4 weeks, 12 weeks, and 24 weeks after catheter removal. Continence was evaluated by recording diaper pads used per day, and all the patients were instructed to perform the 24-hour pad weight test until full recovery of urinary continence. The patient was defined as continent if no more than one safety pad were needed per day, or no more than 20-gram urine leakage on the 24-hour pad weight test. Time from catheter removal to full recovery of urinary continence was recorded, and risk factors influencing continence recovery time evaluated. Results: In total, 166 patients were analyzed. The mean age of the enrolled patients was 66.2 years, and the median prostate specific antigen (PSA) was 8.51 μg/L. A total of 59 patients (35.5%) had bilateral lymphatic dissection, and 28 (16.9%) underwent neurovascular bundle (NVB) preservation surgery. Postoperative pathology results showed that stage pT1 in 1 case (0.6%), stage pT2 in 77 cases (46.4%), stage pT3 in 86 cases (51.8%), and positive margins in 28 patients (16.9%). Among patients who underwent lymph node dissection, lymph node metastasis was found in 7 cases (11.9%). Median continence recovery time was one week. The number of the continent patients at the end of 48 hours, 1 week, 4 weeks, 12 weeks, and 24 weeks were 65 (39.2%), 32 (19.3%), 34 (20.5%), 24 (14.5%), and 9 (5.4%). Two patients remained incontinent 24 weeks after catheter removal. The continence rates after catheter removal at the end of 48 hours, 1 week, 4 weeks, 12 weeks, and 24 weeks were 39.2%, 58.4%, 78.9%, 93.4%, and 98.8%, respectively. Univariate COX analysis revealed that diabetes appeared to influence continence recovery time (OR=1.589, 95%CI: 1.025-2.462,P=0.038). At the end of 48 hours, 4 weeks, 12 weeks, and 24 weeks after catheter removal, the mean OABSS score of the continent group was significantly lower than that of the incontinent group. Conclusion: RARP showed promising results in the recovery of urinary continence. Diabetes was a risk factor influencing continence recovery time. Bladder overactive symptoms play an important role in the recovery of continence after RARP.

Key words: Prostatectomy, Robotic surgical procedures, Urinary incontinence

中图分类号:

R737.25

郝瀚,刘越,陈宇珂,司龙妹,张萌,范宇,张中元,唐琦,张雷,吴士良,宋毅,林健,赵峥,谌诚,虞巍,韩文科. 机器人辅助前列腺癌根治术后患者的控尿恢复时间[J]. 北京大学学报（医学版）, 2021, 53(4): 697-703.

HAO Han,LIU Yue,CHEN Yu-ke,SI Long-mei,ZHANG Meng,FAN Yu,ZHANG Zhong-yuan,TANG Qi,ZHANG Lei,WU Shi-liang,SONG Yi,LIN Jian,ZHAO Zheng,SHEN Cheng,YU Wei,HAN Wen-ke. Evaluating continence recovery time after robot-assisted radical prostatectomy[J]. Journal of Peking University (Health Sciences), 2021, 53(4): 697-703.

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Pathological findings	Data
Positive margins, n(%)	28 (16.9)
Stage, n(%)
pT1	1 (0.6)
pT2	77 (46.4)
pT3	86 (51.8)
pT3a	54 (32.5)
pT3b	32 (19.3)
Gleason score, n(%)
2-6	12 (7.2)
7	102 (61.4)
8-10	50 (30.1)

Time after catheter removal	Leakage weights/g, M (P₂₅,P₇₅)	Pads usage, M (P₂₅,P₇₅)
48 hours	150 (21, 500)	2 (1, 4)
1 weeks	50 (10, 200)	1 (1, 3)
4 weeks	15 (3, 93)	1 (0, 2)
12 weeks	3 (0, 10)	0 (0, 1)
24 weeks	1 (0, 9)	0 (0, 1)

Items	OR (95%CI)	P
Age	0.998 (0.975-1.021)	0.860
BMI	0.969 (0.925-1.016)	0.191
Diabetes	1.589 (1.025-2.462)	0.038
Prostate volume	1.005 (0.997-1.013)	0.218
PSA	1.007 (0.992-1.022)	0.374
NVB preservation	0.803 (0.532-1.211)	0.295
Lymph node dissection	0.873 (0.632-1.206)	0.410
Positive margin	1.099 (0.729-1.655)	0.653
IPSS score	1.016 (0.997-1.036)	0.107
OABSS score	1.004 (0.945-1.066)	0.903