摘要
目的总结腹腔镜根治性前列腺切除术中并发直肠损伤的处理经验。方法回顾性分析2015年1月至2018年10月浙江省人民医院行腹腔镜根治性前列腺切除术中并发直肠损伤的3例患者的临床资料。年龄69~79岁,平均74.3岁;体质指数25.6~28.6 kg/m2,平均27.1 kg/m2;术前PSA 5.7~74.1 ng/ml,平均32.7 ng/ml;前列腺体积55.2~80.3 ml,平均65.3 ml;术前TNM分期T1b^3aN0M0期;术前Gleason评分6~8分,平均7分。1例术前行新辅助内分泌治疗,1例术前3个月行前列腺钬激光剜除术。3例行腹腔镜根治性前列腺切除术过程中,1例在分离前列腺尖部时损伤直肠前壁,2例在分离狄氏筋膜时损伤直肠前壁。术中并发直肠损伤后,勿过多翻动检查创面,避免扩大损伤,找到正确层面先继续完成前列腺的切除,然后用大量稀释碘伏溶液反复冲洗创面,根据创口组织条件做创口修剪,用3-0可吸收线分3层(直肠黏膜层、直肠壁外层、狄氏筋膜后层)缝合,再用释碘伏和生理盐水冲洗创面后完成尿道吻合。结果手术时间138~210 min,平均166.7 min;直肠修补时间30~41 min,平均34.3 min。术中出血量110~215 ml,平均158.3 ml。术中破口长径1.0~1.5 cm,平均1.2 cm。术后恢复进食时间6~7 d,平均6.3 d;术后留置导尿管时间10~14 d,平均12.3 d。术后肿瘤病理分期T2~3bN0M0期;Gleason评分6~9分,平均7分;1例尖部阳性。3例术后均未出现直肠尿道瘘和腹腔感染。2例术后行辅助内分泌治疗。3例术后随访1年未出现生化复发。结论在良好的术前肠道准备、术中创口小且创缘较整齐的情况下,腹腔镜下一期3层缝合直肠破口可较好地修复根治性前列腺切除术中直肠损伤,且不需要回肠预防性造口。
Objective To report the experience of rectal injury during laparoscopic radical prostatectomy(LRP). Methods The clinical data for 3 patients with iatrogenic rectal injury in LRP in our hospital between January 2015 and October 2018 were retrospectively analyzed. The data of these three patients were as follows: age 69-79 year, mean 74.3 year;BMI 25.6-28.6 kg/m2, mean 27.1 kg/m2;preoperative PSA 5.7-74.1 ng/ml, mean 32.7 ng/ml;prostate volume 55.2-80.3 ml, mean 65.3 ml;preoperative TMN stage T1b-3aN0M0, preoperative Gleason score 6-8. One patient received neoadjuvant hormonal therapy;one patient did HoLEP three month before LRP. Surgical method: When rectal injury was noted, we continued our dissection between the correct layers until prostatectomy was completed. Then the wound in the rectum was thoroughly checked and irrigated with diluted povidone iodine. The wound was trimmed according to the wound condition, and the suture was conducted by absorbable silk at three layers: the rectal mucosa layer, the outer layer of the rectal wall, the posterior layer of the fascia. Then we rinsed the wound with iodophor and completed the urethral reconstruction. Results The operative time was 138-210 min, mean 166.7 min, and repair time was 30-41 min, mean 34.3 min. The intraoperative blood loss was 110-215 ml, mean 158.3 ml. Rectal injury occurred during prostatic apical dissection in 1 patients, during dissection of Denonvilliers fascia in 2 patient. The size of the lesions was 1.0-1.5 cm, mean 1.2 cm. All of the rectal injuries were recognized during the operation, and three-layered sutures were used for the primary repair. None of the cases required ileostomy procedure. Diet recovery time was 6-7 d, mean 6.3 d. The duration of transurethral catheter insertion was 10-14 d, mean 12.3 d. The pathological stage was T2~3bN0M0, pathological Gleason score 6-9, and 1 case surgical margin positivity in the apical region of the prostate. No case occurred urorectal fistulas.2 cases received adjuvant androgen deprivation therapy. Con
作者
王帅
张大宏
Wang Shuai;Zhang Dahong(Department of Urology, Zhejiang Provincial People's Hospital, People's Hospital of Hangzhou Medical College, Hangzhou 310014, China)
出处
《中华泌尿外科杂志》
CAS
CSCD
北大核心
2019年第8期592-595,共4页
Chinese Journal of Urology
基金
浙江省医药卫生科技项目(2016KYB009,2018KY263).
