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| 机器人辅助腹腔镜根治性前列腺切除术结合扩大盆腔淋巴结清扫术治疗极高危局部进展期前列腺癌疗效分析 |
| 潘家骅,邵晓光,朱寅杰,迟辰斐,钱弘阳,徐凡,王艳青,沙建军,董柏君,薛蔚* |
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(上海交通大学医学院附属仁济医院泌尿科, 上海 200127
*通信作者) |
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| 摘要: |
| 目的 观察机器人辅助腹腔镜根治性前列腺切除术（RARP）结合扩大盆腔淋巴结清扫术（ePLND）治疗极高危局部进展期前列腺癌的安全性及有效性，探讨新辅助内分泌治疗（NHT）及新辅助化学治疗联合内分泌治疗（NCHT）对术后病理特征的影响。方法 回顾性分析2015年10月至2019年3月我院收治的156例行RARP+ePLND治疗的极高危局部进展期前列腺癌患者的临床资料。记录并分析患者的初始前列腺特异抗原（PSA）、初始肿瘤TNM分期、Gleason评分、新辅助治疗方案、手术时间、术后血红蛋白下降幅度、围手术期并发症、住院时间及术后病理结果。结果 156例患者年龄为（67.9±6.9）岁，初始PSA为56.5（8.4~629.0）ng/mL，Gleason评分≥ 8分者占63.5%（99/156），临床分期≥ cT3者占95.5%（149/156），35.3%（55/156）的患者存在盆腔区域淋巴结转移；手术时间为（186.7±35.5）min，术后血红蛋白下降幅度为（18.8±9.9）g/L，住院时间为5（3~66）d；2例（1.3%）出现直肠损伤，3例（1.9%）在扩大淋巴结清扫过程中出现髂血管损伤；64.1%（100/156）的患者术后PSA下降至0.2 ng/mL以下，6.4%（10/156）的患者术后病理完全缓解（pT0），25.6%（40/156）的患者切缘阳性。51.3%（80/156）的患者出现病理降期，15.4%（24/156）的患者出现病理升期。35例确诊后未接受新辅助治疗而直接行RARP+ePLND（non-NT组），54例先接受4~6个周期NHT再行RARP+ePLND（NHT组），67例先接受4~6个周期NCHT再行RARP+ePLND（NCHT组）。NCHT组初始PSA和TNM分期高于NHT组和non-NT组（P均<0.01），但3组围手术期并发症发生率差异无统计学意义（P>0.05）。NHT组与NCHT组术后PSA达到根治水平以下的患者分别为72.2%（39/54）和82.1%（55/67），高于non-NT组的17.1%（6/35），3组间差异有统计学意义（P<0.01）。NHT组和NCHT组分别有57.4%（31/54）和68.7%（46/67）的患者出现病理降期，而non-NT组仅8.6%（3/35），3组间差异有统计学意义（P<0.01）。结论 RARP+ePLND治疗极高危局部进展期前列腺癌安全有效。术前新辅助治疗并不增加RARP+ePLND围手术期并发症，且可提高手术根治率、改善术后病理结果。 |
| 关键词: 前列腺肿瘤 极高危局部进展期前列腺癌 机器人手术 根治性前列腺切除术 扩大淋巴结清扫术 新辅助内分泌治疗 新辅助化学治疗 病理降期 |
| DOI：10.16781/j.0258-879x.2020.07.0737 |
| 投稿时间：2019-08-07修订日期：2020-02-13 |
| 基金项目:上海市科学技术委员会医学引导类科技项目（16411969800）. |
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| Robot-assisted laparoscopic radical prostatectomy combined with extended pelvic lymph node dissection in treating very high-risk locally advanced prostate cancer: an anlaysis of efficacy |
| PAN Jia-hua,SHAO Xiao-guang,ZHU Yin-jie,CHI Chen-fei,QIAN Hong-yang,XU Fan,WANG Yan-qing,SHA Jian-jun,DONG Bai-jun,XUE Wei* |
(Department of Urology, Renji Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200127, China
*Corresponding author) |
| Abstract: |
| Objective To study the safety and efficacy of robot-assisted laparoscopic radical prostatectomy (RARP) combined with expanded pelvic lymph node dissection (ePLND) in treating very high-risk locally advanced prostate cancer, and to explore the effects of neoadjuvant hormone therapy (NHT) and neoadjuvant chemotherapy combined with hormone therapy (NCHT) on postoperative pathological features. Methods The clinical data of 156 patients with very high-risk locally advanced prostate cancer who underwent RARP+ePLND between Oct. 2015 and Mar. 2019 were retrospectively analyzed. The initial prostate-specific antigen (PSA), initial tumor TNM stage, Gleason score, neoadjuvant regimen, operation time, decrease of postoperative hemoglobin, perioperative complications, length of hospital stay, and postoperative pathology were recorded. Results The mean age of the patients was (67.9±6.9) years, with a median initial PSA of 56.5 ng/mL (range 8.4-629.0 ng/mL). Patients with Gleason score ≥ 8 accounted for 63.5% (99/156), clinical stage ≥ cT3 accounted for 95.5% (149/156), and 35.3% (55/156) of the patients had pelvic regional lymph node metastasis. The average operation time was (186.7±35.5) min, the decrease of postoperative hemoglobin was (18.8±9.9) g/L, and the median hospital stay was 5 days (3-66 days). Two patients (1.3%) developed rectal injury and three patients (1.9%) developed vascular injury during extended lymphadenectomy. In 64.1% (100/156) of patients, PSA decreased to less than 0.2 ng/mL after RARP+ePLND, 6.4% (10/156) of patients had complete pathological remission (pT0), and 25.6% (40/156) of patients had positive margins. There were 51.3% (80/156) patients achieving pathological downstaging and 15.4% (24/156) patients having pathological upgrading. Thirty-five patients were treated with RARP+ePLND without neoadjuvant therapy (non-NT group), 54 patients underwent four to six cycles of NHT (NHT group), and 67 patients underwent four to six cycles of NCHT (NCHT group). The initial PSA and TNM stage in the NCHT group were significantly higher than those in NHT group and non-NT group (both P<0.01), but there was no significant difference in perioperative complications among the three groups. In the NHT group and NCHT group, the patients with complete PSA response were 72.2% (39/54) and 82.1% (55/67), respectively, which was significantly higher than 17.1% (6/35) in non-NT group (P<0.01). In addition, 57.4% (31/54) of patients in the NHT group and 68.7% (46/67) in NCHT group showed a decrease in pathological stage, compared with 8.6% (3/35) in non-NT group (P<0.01). Conclusion RARP+ePLND is safe and effective in the treatment of very high-risk locally advanced prostate cancer, and preoperative neoadjuvant therapy may gain higher surgical cure rate and more significant pathological downstaging effect without increasing perioperative complications. |
| Key words: prostatic neoplasms very high-risk locally advanced prostate cancer robotic surgical procedures radical prostatectomy extended lymphadenectomy neoadjuvant hormone therapy neoadjuvant chemotherapy pathological downstaging |
