保留尿道的机器人辅助简单前列腺切除术

Urethral-sparing Robot-assisted Simple Prostatectomy:An Innovative Technique to Preserve Ejaculatory FunctionOvercoming the Limitation of the Standard Millin Approach

保留尿道的机器人辅助简单前列腺切除术：一种保留射精功能的创新技术，克服了标准Millin前列腺切除术的局限性

Lower urinary tract symptoms (LUTS) are often related to benign prostatic obstruction (BPO), and when prostate volume is >80-100 ml, simple prostatectomy (SP) might represent a valid alternative to transurethral techniques.

下尿路症状（LUTS）通常与良性前列腺梗阻（BPO）相关，当前列腺体积>80-100 ml时，简单前列腺切除术（SP）可能是经尿道技术的有效替代方法。

Open surgery is the gold standard approach for SP, but in recent years, minimally invasive techniques have been attempted worldwide, with interesting results.

开放式是SP的金标准，但近年来，全世界都在尝试微创技术，并取得了有趣的结果。

In 2008, Sotelo et al described, for the first time, robot-assisted simple prostatectomy (RASP). RASP appears to be attractive when compared with open SP, as RASP offers less blood loss and a shorter hospital stay.

2008年，Sotelo等人首次描述了机器人辅助的简单前列腺切除术（RASP）。与开放式SP相比，RASP似乎更有吸引力，因为RASP的失血量更少，住院时间更短。

Despite recent technical innovations, several postoperative problems are still unresolved. Among them, retrograde ejaculation is one of the most frequent problems, with a major impact on patients' quality of life.

虽然技术在不断创新，但一些术后问题仍未解决。其中，逆行射精是最常见的问题之一，严重影响患者的生活质量。

To prevent this unwanted adverse event, the ejaculatory- sparing approach has gained popularity.We present our technique of urethral-sparingRASP(usRASP), performed in a series of patients with large benign prostatic hyperplasia (BPH) in a high-volume robotic surgery center.

为了避免这种不良事件，医学界开始研究保留射精功能的方法。本文展示了我们在一项大容量机器人手术中心对良性前列腺增生（BPH）患者进行的保留尿道的RASP（usRASP）技术。

All adenomectomies were performed by a single, highly experienced,surgeon using a da Vinci Si or XI Surgical System (Intuitive Surgical,Sunnyvale, CA, USA).

所有腺体切除术均由一位经验丰富的外科医生使用da Vinci Si或XI手术系统进行。

Under general anesthesia, the patient is prepared and positioned in a slight (27°) Trendelenburg position. Pneumoperitoneum is achieved using a Veress needle inserted in the periumbilical area.

在全身麻醉下，患者采取轻微（27°）特伦德伦伯卧位。将气腹针插入脐周区域建立气腹。

Six ports (12 mm port for the optic for SI or 8 mm for XI, three 8 mm ports for robotic instruments, and 10 and 5 mm ports for the assistant) are placed in a classical fan configuration. Finally, the robot is docked.

放置六个套管（一个用于放摄像头的12 mm套管[da Vinci Si系统]或8 mm套管[XI系统]、三个用于机械臂的8mm套管以及供助手操作的10 mm和5mm套管）。最后，机器人就位。

After the parietal peritoneum is incised to gain access to the retropubic space and prostate defatting is performed, a transversal anterolateral incision is made halfway between the dorsal venous complex and the bladder neck (Fig. 1A). The cleavage plane between the surgical capsule and the adenoma is identified anteriorly, and gently dissected at the prostate apex bilaterally (Fig. 1B).

切开壁腹膜，暴露耻骨后间隙，分离前列腺表面的脂肪组织，在背静脉复合体和膀胱颈的中间位置进行横向前外侧切开（图 1A）。识别手术包膜和腺体之间的剥离平面，并在双侧向前列腺尖部轻轻剥离（图 1B）。

Fig. 1 - (A) A transversal anterolateral incision is made halfway between the dorsal venous complex and the bladder neck, done according to Millin. (B) The median face of the adenoma was dissected gently form the urethra.

图1. （A）按照Millin法，在背静脉复合体和膀胱颈中间进行横向前外侧切开。（B）从尿道轻轻剥离腺体的正中面。

Adenoma enucleation is performed following the avascular plane of the surgical capsule, starting from the left lobe. The dissection proceeds anteriorly from the prostate's apex bilaterally to the left lateral face of the adenoma, then cranially at the bladder neck. Bipolar forceps are used to control possible bleeding from perforating blood vessels.

在手术包膜的无血管平面之后剥离腺体，从左叶开始。从前列腺尖部两侧向前剥离，剥离至腺体的左侧面，然后至膀胱颈。双极钳用于控制血管穿孔可能导致的出血。

It is useful to emphasize that, in order to avoid straying into the capsular plane, the entire dissection must tightly adhere to the adenoma's surface.

需要强调的是，为了避免误入包膜平面，剥离的整个过程都必须紧贴腺体表面进行。

At the end of this step, the left lobe is mobilized, except for its medial portion, which is still anchored to the urethra. Subsequently, a median longitudinal incision is made at the anterior commissure. The urethra is medialized by the assistance of a suction device and gently dissected from the left lobe of the adenoma.

剥离至此，左叶除了内侧部分仍与尿道相连，其他部分均已剥离。随后，在前连合处进行正中纵向切开。在抽吸装置的帮助下将尿道向中间移动，并将腺体的左叶从尿道轻轻剥离。

Often, especially in cases of large adenomas, the left lobe is in continuity with the right lobe, posteriorly to the urethra. In these cases, an incision of the adenoma is needed, and if the posterior tissue is abundant, it can be removed separately.

通常，尤其是在腺体较大的情况下，左叶与右叶相连，位于尿道后方。在这些情况下，需要切开腺体，如果后部组织丰富，可以单独切除。

Finally, the posterior aspect of the surgical capsule is reached with a caudocranial dissection. The left lobe is then removed.

最后，从头到尾剥离，直至手术包膜的后部，左叶成功切除。

The procedure is repeated for the right lobe.

右叶的切除重复上述步骤。

After the removal of the adenoma (Fig. 2A and 2B), a hydrodistension test is performed, filling the bladder with 150 ml of saline solution, in order to verify urethral and bladder integrity.

切除腺体后（图2A和2B），进行膀胱水扩张检查，用150 ml盐水溶液填充膀胱，以验证尿道和膀胱的完整性。

Fig. 2 - (A) At the end of the extirpative phase, the adenoma was removed and the urethra was spared inside the prostatic lodge. (B) As shown, the urethra and ejaculatory ducts were preserved.

图2（A）最终，腺体切除，尿道留在前列腺腔内。（B）如图所示，保留了尿道和射精管。

Any perforation is sutured with a 4-0 absorbable monofilament. Any bleeding is controlled; eventually, a thrombin gelatin hemostatic matrix is injected at the prostatic lodge to facilitate hemostasis. Finally, the prostatic capsule is closed with a running two-layer 3/0 barbed suture.

使用4-0可吸收缝合线缝合穿孔，控制出血。将凝血酶明胶基质注射到前列腺处以促进止血。最后，通过3/0倒刺缝线两层连续缝合来闭合前列腺包膜。

In the presence of a median lobe, after the two lateral lobes are removed, a 2 cm median longitudinal incision is made at the anterior face of the bladder, previously filled with 150 ml of saline solution. A transversal incision at the mucosa covering the median lobe isperformed (Fig. 3). The third lobe is then exposed, and using upward traction from behind the bladder neck, it is progressively dissected and then resected. Then, the previously incised mucosa is sutured with a barbed running suture.

在存在中叶增生的情况下，切除两个侧叶后，预先在膀胱内填充150 ml盐水溶液，然后在膀胱前面建立一个2 cm的正中纵向切口。横向切开中叶黏膜（图 3）。然后暴露第三叶，从膀胱颈后面向上牵引，逐渐剥离，然后切除。通过倒刺缝线连续缝合来闭合先前切开的黏膜。

Fig. 3 - In case of a medianlobe not manageable with transcapsular approach, an incision of the bladder wall is needed in order to reach it. A transversal incision at the level of mucosa covering the median lobe is then performed, and the third lobe is exposed with an upward traction from behind the bladder neck. With this traction, it is progressively dissected.

图3. 如果经包膜入路无法移除中叶，则需要切开膀胱壁才能触及包膜。横向切开中叶黏膜，暴露第三叶，从膀胱颈后面向上牵引，逐渐剥离。

During this phase, there is the risk of detaching the urethra from the median lobe, which can be damaged.

在此阶段，存在尿道与中叶分离的风险，尿道可能会受损。

If this occurs, the urethral-sparing approach is not applicable, and then the whole urethra has to be removed and "trigonization" performed.

如果发生这种情况，则不适合保留尿道，必须切除整个尿道，并将膀胱三角的黏膜游离边缘向下与尿道和包膜后部吻合。

Finally, the bladder wall is sutured with a two-layer 3/0 barbed running suture.

最后，使用3/0倒刺缝线连续双层缝合膀胱壁。