發(fā)布時(shí)間：2018-05-28 23:59

  本文選題：前列腺癌根治術(shù) + 前列腺尖部��； 參考：《山東大學(xué)》2017年博士論文

【摘要】：[研究背景]解剖學(xué)研究對(duì)于外科手術(shù)具有根本性的意義,正如著名學(xué)者Robert P.Myer所指出的:一個(gè)熟悉解剖的外科醫(yī)師,能讓患者出血更少、切緣更好、功能保存更滿意。1905年Hugh Hampton Young首次開(kāi)展經(jīng)會(huì)陰途徑前列腺癌根治術(shù),1947年Milin首次描述恥骨后途徑前列腺癌根治術(shù),1987年Walsh正式提出了解剖性前列腺根治切除的概念,1992年Schuessler開(kāi)展第一例經(jīng)腹腔途徑腹腔鏡前列腺癌根治術(shù)(LRP),1997年Raboy報(bào)道了首例經(jīng)腹膜外途徑腹腔鏡前列腺癌根治術(shù)(RELRP),2000年Binder及Vallancein首次開(kāi)展機(jī)器人輔助腹腔鏡前列腺癌根治術(shù)(RALRP)。在國(guó)內(nèi),由于醫(yī)療資源有限,特別是縣級(jí)以下基層醫(yī)院醫(yī)療器械配置不足,RALRP手術(shù)雖然獨(dú)具優(yōu)勢(shì)但尚難以普及,而LRP手術(shù)對(duì)醫(yī)療設(shè)備要求相對(duì)較低---在國(guó)內(nèi)多數(shù)縣級(jí)醫(yī)院甚至發(fā)達(dá)地區(qū)的鄉(xiāng)鎮(zhèn)醫(yī)院腹腔鏡已經(jīng)是常規(guī)配備,這導(dǎo)致了 LRP逐漸成為了目前國(guó)內(nèi)治療局限性前列腺癌最主流的手術(shù)方式。近年來(lái),隨著LRP手術(shù)開(kāi)展例數(shù)的增加和外科醫(yī)生手術(shù)經(jīng)驗(yàn)的積累,學(xué)界改良和規(guī)范了許多具體的手術(shù)操作技巧和步驟。更重要的是,解剖學(xué)者對(duì)于前列腺周圍解剖結(jié)構(gòu)的研究不斷深入,為該術(shù)式的持續(xù)進(jìn)化和演進(jìn)提供了最根本的理論支撐和實(shí)踐指導(dǎo)。但LR P手術(shù)兼具切除和重建的過(guò)程,需要兼顧腫瘤切除的最大化及功能結(jié)構(gòu)損傷的最小化,手術(shù)步驟繁復(fù)、技術(shù)難度大、學(xué)習(xí)曲線陡峭漫長(zhǎng),一直是泌尿外科最具挑戰(zhàn)性的手術(shù)。目前對(duì)前列腺及周圍結(jié)構(gòu)的局部精細(xì)解剖尚存較多疑問(wèn),經(jīng)典的解剖學(xué)教科書(shū)及圖譜對(duì)于前列腺及周圍精細(xì)結(jié)構(gòu)缺乏詳盡的描述甚至部分描述間相互矛盾,遠(yuǎn)遠(yuǎn)不能滿足指導(dǎo)臨床手術(shù)的理論需求。特別是對(duì)于膀胱頸部及前列腺尖部區(qū)域重要結(jié)構(gòu)的精細(xì)測(cè)量數(shù)據(jù)甚至精確定性描述均尚屬空白。前列腺位于盆腔深部,其周圍有精密復(fù)雜的筋膜及神經(jīng)血管結(jié)構(gòu),其底部及尖部則有復(fù)雜的控尿相關(guān)結(jié)構(gòu)。近年來(lái)國(guó)內(nèi)外對(duì)于前列腺周圍的筋膜結(jié)構(gòu)以及恥骨前列腺韌帶(PPL)、背血管復(fù)合體(DVC)在總體性的定性層面上有所認(rèn)識(shí),但仍缺乏對(duì)相關(guān)結(jié)構(gòu)參數(shù)的精確測(cè)量數(shù)據(jù),特別是對(duì)于前列腺尖部及膀胱頸部的精細(xì)解剖測(cè)量目前基本尚屬空白。如前列腺尖部,相關(guān)結(jié)構(gòu)幾何空間狹小、人種間/個(gè)體間變異大,解剖研究難度很大,但又是泌尿外科醫(yī)生和解剖學(xué)者必須面對(duì)和解決的課題,因?yàn)槠浣馄式Y(jié)構(gòu)與手術(shù)的順利進(jìn)行和術(shù)后病人切緣陽(yáng)性率、控尿功能及性功能的保持和恢復(fù)密切相關(guān),而后者又直接影響到病人的術(shù)后生存時(shí)間及生活質(zhì)量。例如,術(shù)中保持足夠的尖部尿道長(zhǎng)度以及及維持膜部尿道進(jìn)入尿生殖膈的生理角度有助于術(shù)后患者控尿功能的恢復(fù),而探究背血管復(fù)合體、恥骨前列腺韌帶及尿道橫紋括約肌之間精確的相對(duì)位置關(guān)系顯然有助于避免術(shù)中游離PPL、縫扎DVC時(shí)誤傷尿道橫紋括約肌及盆底肌群,并為術(shù)中進(jìn)行"尿道前方懸吊"提供條件。再如,膜部尿道四周均有大量神經(jīng)纖維出現(xiàn),其很有可能是走行于前列腺后外側(cè)的神經(jīng)血管束(NVB)在靠近前列腺尖部并繼續(xù)向遠(yuǎn)端走行過(guò)程中的空間位置二次分布,術(shù)中如何最大限度地保護(hù)這些神經(jīng)纖維與前列腺癌根治術(shù)后患者勃起及控尿功能的恢復(fù)密切相關(guān),但這些神經(jīng)纖維在前列腺尖部區(qū)域的空間分布在不同報(bào)道中并不一致。此外,很多泌尿外科醫(yī)生在術(shù)中會(huì)發(fā)現(xiàn)前列腺體積改變對(duì)于膀胱頸部形態(tài)具有顯著影響,特別是前列腺體積明顯增大、腺體部分凸入膀胱者,膀胱頸部容易受到腺體擠壓產(chǎn)生返折變形,術(shù)中很容易誤傷膀胱三角區(qū)、導(dǎo)致頸口保留不足或前列腺腺體誤切開(kāi)等并發(fā)癥。以上種種棘手而現(xiàn)實(shí)的問(wèn)題都是每一個(gè)泌尿外科醫(yī)生在手術(shù)中必然要面對(duì)的。正是因?yàn)閷?duì)前列腺尖部及膀胱頸部解剖學(xué)研究的缺失,導(dǎo)致了 LRP術(shù)中如何保護(hù)重要的控尿及勃起相關(guān)功能結(jié)構(gòu)缺乏客觀具體的操作依據(jù)及技術(shù)規(guī)范,也使得外科醫(yī)生在處理前列腺尖部結(jié)構(gòu)、離斷及重建膀胱頸部及尿道的過(guò)程中如同"盲人摸象"--由于缺乏精細(xì)的局部應(yīng)用解剖學(xué)指導(dǎo),只能憑經(jīng)驗(yàn)、憑感覺(jué)甚至憑運(yùn)氣。以上種種問(wèn)題的解決都依賴于對(duì)于前列腺周圍結(jié)構(gòu)特別是前列腺尖部及膀胱頸部精細(xì)的應(yīng)用解剖學(xué)研究,而這正是本研究的目的所在。為此,本研究通過(guò)尸體解剖方法,以實(shí)際指導(dǎo)LRP術(shù)中科學(xué)實(shí)施控尿及性功能相關(guān)結(jié)構(gòu)保留為目的,研究前列腺尖部及膀胱頸部區(qū)域相關(guān)結(jié)構(gòu)的解剖學(xué)特點(diǎn)。[目的]1.測(cè)量尖部遠(yuǎn)端尿道與尿生殖膈的角度2.測(cè)量恥骨前列腺韌帶的空間幾何尺寸3.探究前逼尿肌圍裙覆蓋前列腺前表面的范圍4.描述膀胱頸部形態(tài)特點(diǎn)及其向前列腺部尿道移行的特點(diǎn)[方法]1.與山東大學(xué)醫(yī)學(xué)院解剖教研室合作,獲取10%福爾馬林固定男性尸體20具。截去所有尸體標(biāo)本的雙下肢,使用線鋸對(duì)其中10具標(biāo)本的骨盆進(jìn)行正中矢狀切開(kāi),暴露完整尿道并用紅線標(biāo)記,用量角器及直尺測(cè)量膜部(尖部遠(yuǎn)端尿道)穿過(guò)尿生殖膈的角度及長(zhǎng)度。剝離膀胱及前列腺前方的脂肪組織,完全顯露恥骨前列腺韌帶的側(cè)方,用直尺自恥骨端至前列腺端測(cè)量恥骨前列腺韌帶的寬度。2.用線鋸將另外10具標(biāo)本的恥骨自恥骨聯(lián)合外側(cè)5cm處分別離斷,用手術(shù)刀將盆腔臟器自盆壁完整剝離下來(lái),避免損傷前列腺周圍結(jié)構(gòu),觀察膀胱頸與前列腺底的位置關(guān)系。用鑷子清除恥骨后的疏松結(jié)締組織,逐步鈍性分離出逼尿肌圍裙、恥骨前列腺韌帶、背側(cè)血管復(fù)合體等結(jié)構(gòu),描述或測(cè)量以上主要結(jié)構(gòu)的幾何形態(tài)及數(shù)據(jù)。[結(jié)果]1.尖部遠(yuǎn)端尿道穿過(guò)尿生殖膈的角度最大87.6°,最小70.3°,平均82.2±5.3°,前列腺尖部尿道(尖部遠(yuǎn)端尿道至盆膈)的長(zhǎng)度為12.1 ±2.3mm。2.恥骨前列腺韌帶恥骨端測(cè)得寬約7.5±1.3mm,中間寬約6.2±1.1mm,前列腺端寬約12.6 ±2.2mm,自恥骨端至前列腺端長(zhǎng)約9.3 ±1.2mm。兩條恥骨前列腺韌帶恥骨端相距約10.7±1.8mm,前列腺端相距約12.8±2.6mm。3.逼尿肌圍裙幾乎覆蓋前列腺全長(zhǎng),呈倒三角形分布,在前列腺底部分布范圍約為10點(diǎn)至2點(diǎn)之間,在前列腺尖部分布范圍約為11點(diǎn)至1點(diǎn)之間。其中間最厚,向兩側(cè)移行時(shí)逐漸變薄乃至消失。4.膀胱頸與前列腺底的接觸面并非一個(gè)標(biāo)準(zhǔn)的平面,而是一個(gè)隨膀胱頸向尿道移行逐漸向前列腺中央凹陷的曲面,其具體形態(tài)可能受前列腺體積影響---特別是對(duì)于前列腺體積較大、腺體向膀胱內(nèi)凸出者。[結(jié)論]前列腺尖部及膀胱頸部結(jié)構(gòu)復(fù)雜、精致,對(duì)LRP術(shù)后控尿及性功能恢復(fù)具有直接影響。對(duì)前列腺尖部遠(yuǎn)端后尿道長(zhǎng)度、后尿道穿越盆底的角度、PPL幾何尺寸的定量測(cè)量以及對(duì)膀胱頸部與前列腺基底交界曲面及其變異的定性描述,可以幫助術(shù)者對(duì)LRP術(shù)中控尿及性功能相關(guān)結(jié)構(gòu)建立清晰的解剖圖景,為L(zhǎng)RP術(shù)中控尿及性功能保護(hù)技術(shù)的標(biāo)準(zhǔn)化及手術(shù)步驟的程序化提供基礎(chǔ)性依據(jù)。[目的]將RELRP手術(shù)步驟分解、改良,建立技術(shù)規(guī)范化、步驟程序化的標(biāo)準(zhǔn)手術(shù)流程,保障手術(shù)安全、平滑其學(xué)習(xí)曲線并增強(qiáng)不同研究間數(shù)據(jù)的可比性。[資料與方法]對(duì)山東大學(xué)齊魯醫(yī)院泌尿外科2015年以來(lái)接受RELRP治療患者手術(shù)過(guò)程錄像,通過(guò)觀摩手術(shù)過(guò)程并參閱相關(guān)文獻(xiàn),全面審視、梳理RELRP手術(shù)步驟,歸納提煉手術(shù)技巧及經(jīng)驗(yàn),實(shí)現(xiàn)RELRP操作技術(shù)標(biāo)準(zhǔn)化和操作步驟程序化。[結(jié)果]標(biāo)準(zhǔn)程序化RELRP可分解為21步(技術(shù)要點(diǎn)詳見(jiàn)正文);1.擺手術(shù)體位2.手術(shù)野滿毒鋪巾3.留置尿管4.純性擴(kuò)張恥骨后腹膜外間隙5.建立腹腔鏡操作通道及恥骨后腹膜外氣腹6.置入腹腔鏡,直視下建立雙側(cè)操作通道7.恥骨后間隙脂肪清理、止血,顯露重要解剖標(biāo)志8.清理盆腔淋己結(jié)9.顯露并縫扎背側(cè)血管復(fù)合體10.離斷膀腕頸部11.切開(kāi)狄氏筋膜并從前列腺后方游離達(dá)前列腺尖部12.剪斷前列腺側(cè)初帶及恥骨前列腺初帶13.離斷前列腺尖部,完全游離前列腺并裝袋14.直腸指檢,排除直麻損傷15.吻合曰后方重建16.膀胱頸尿道吻合17.檢測(cè)吻合口密閉性及手術(shù)止血18.頓合口前方懸吊19.留置創(chuàng)腔引流管20.取出標(biāo)本21.縫合關(guān)閉切口,結(jié)束手術(shù)[結(jié)論]RELRP作為局限性前列腺癌的主流治療術(shù)式之一在多數(shù)省級(jí)醫(yī)院己經(jīng)得到開(kāi)展并積累了一定臨床經(jīng)驗(yàn),但不同醫(yī)療中也甚至同一中也不同手術(shù)者之間在手術(shù)操作的技術(shù)細(xì)節(jié)、操作步驟的數(shù)量及順序等方面存在較大差異,導(dǎo)致手術(shù)療效差異較大、數(shù)據(jù)可比性欠佳,不利于循證醫(yī)學(xué)的開(kāi)展及大數(shù)據(jù)的挖掘。本研究通過(guò)觀摩手術(shù)錄像,結(jié)合論文第一部分中的解剖學(xué)研充成果,提煉手術(shù)共性及經(jīng)驗(yàn),將RELRP手術(shù)進(jìn)行技術(shù)標(biāo)準(zhǔn)化、步驟程序化的整理,初步為RELRP建立了統(tǒng)一的操作流程和規(guī)范,保障了手術(shù)療效和安全性,增強(qiáng)了不同研究之間數(shù)據(jù)的可比化進(jìn)而有利于使用循證醫(yī)學(xué)工具對(duì)RELRP技術(shù)做持續(xù)的優(yōu)化和改良。同時(shí),RELRP的標(biāo)準(zhǔn)程序化研究,可平滑該手術(shù)學(xué)習(xí)曲線,有利于該技術(shù)向縣級(jí)及以下基層醫(yī)院推廣施行。[目的]量化比較、評(píng)價(jià)標(biāo)準(zhǔn)化RELRP(S-RELRP)的療效和安全性。[研究對(duì)象及方法]研究對(duì)象:2015年10月到2016年10月,在山東大學(xué)齊魯醫(yī)院泌尿外科行RELRP手術(shù)的患者共45例,其中S-RELRP手術(shù)組20例、ns-RELRP手術(shù)組25例,所有患者前列腺癌診斷均由術(shù)前及術(shù)后病理證實(shí)。研究方法:回顧性收集并比較S-RELRP及ns-RELRP兩組患者年齡、體重、術(shù)前PSA水平、術(shù)前Gleason評(píng)分、手術(shù)耗時(shí)、術(shù)中出血量、術(shù)后胃腸功能恢復(fù)時(shí)間、術(shù)后引流及住院天數(shù)、術(shù)后尿漏及琳己漏發(fā)生率、術(shù)后切緣陽(yáng)性率、術(shù)后3個(gè)月的控尿情況、住院費(fèi)用等數(shù)據(jù)。同時(shí)通過(guò)調(diào)查問(wèn)卷的方式對(duì)術(shù)中醫(yī)生及護(hù)士的工作負(fù)荷進(jìn)巧比較。統(tǒng)計(jì)學(xué)分析使用SPSS.0軟件完成,計(jì)量資料的對(duì)比使用獨(dú)立樣本的t檢驗(yàn),計(jì)數(shù)資料的對(duì)比根據(jù)數(shù)據(jù)特征分別采用X~2檢驗(yàn)或Fisher精確概率法計(jì)算,定義P0.05為差異有統(tǒng)計(jì)學(xué)意義。[結(jié)果]所有手術(shù)均在全麻下實(shí)施,手術(shù)過(guò)程順利,術(shù)中無(wú)術(shù)式改變。兩組患者的基線數(shù)據(jù),如年齡、體重、術(shù)前tPSA、術(shù)前巧SA/tPSA、術(shù)前Gleason評(píng)分等數(shù)據(jù)無(wú)顯著差異(P0.05)。S-RELRP組患者平均手術(shù)用時(shí)218.25±20.47min,明顯少于ns-RELRP組的254.20±40.25min(P=0.008)。S-RELRP組平均術(shù)中出血量130.00±57.12ml明顯少于118-11組的194.00±113(1111=0.041),但兩姐患者術(shù)中、術(shù)后巧未輸血。S-RELRP組術(shù)后引流時(shí)間及術(shù)后住院時(shí)間分別文為7.20+2.14天和9.55+2.06天,顯著短于ns-RELRP}D的9占2+3.11天和12.76+4.04天(P=0.028,P=0.033)。S-RELRP組頓合曰漏發(fā)生率0%(0/20)、淋巴漏5%(1/20),ns-RELRP吻合口漏4%(1/25)、淋巴漏16%(4/25),差異均無(wú)統(tǒng)計(jì)學(xué)意義(P=0.366,P=0.243)。S-RELRP組及ns-RELRP組切緣陽(yáng)性率分別為5%(1/20)和8%(2/25),無(wú)顯著差異(P=0.688)。術(shù)后3個(gè)月控尿率方面,S-RELRP組及ns-RELRP組分別為85%和56%,S-RELRP組明顯占優(yōu)(P=0.037)。S-RELRP組及ns-RELRP組術(shù)后3個(gè)月PSA陽(yáng)性及達(dá)到生化復(fù)發(fā)水平者分別為10%、5%和24%、8%,均無(wú)顯著差異(P=0.222,P=0.688)。S-RELRP組醫(yī)生工作負(fù)荷明顯更低(3.54+52 vs 4.09+0.54,P=0.025),而護(hù)±工作負(fù)荷則在兩組間無(wú)顯著差別(3.01+1.20 VS 3.13+0.83,P=0.732)[結(jié)論]S-RELRP具有手術(shù)耗時(shí)短、術(shù)中出血少、術(shù)后引流時(shí)間短、往院時(shí)間短、術(shù)后3個(gè)月控尿率高、醫(yī)生工作負(fù)荷低等優(yōu)點(diǎn),而在術(shù)后吻合口漏、術(shù)后淋巴漏、術(shù)后胃麻恢復(fù)時(shí)間、術(shù)后切緣陽(yáng)性率、術(shù)后PSA水平、住院總費(fèi)用方面與ns-RELRP組相當(dāng)。
[Abstract]:[background] anatomical studies are fundamental to surgery, as noted by the famous scholar Robert P.Myer: a surgeon familiar with the anatomy can make the patient less bleeding, better cutting edge, and more satisfactory in function preservation.1905 Hugh Hampton Young for the first time perineal radical prostatectomy, first Milin in 1947 The first case of radical prostatectomy for prostatectomy was presented in 1987 at Walsh in 1987. In 1992, the first case of peritoneal laparoscopic radical prostatectomy (LRP) was performed at Schuessler in 1992, and the first case of extraperitoneal laparoscopic radical prostatectomy (RELRP), Binder and Vall in 2000 was reported in 1997. Ancein first developed the robot assisted laparoscopic radical prostatectomy (RALRP). In China, because of the limited medical resources, especially the lack of medical equipment in the grass-roots hospitals at the county level below the county level, the RALRP operation has a unique advantage but it is still difficult to popularize, while the LRP operation is relatively low on medical equipment - in most of the county hospitals even developed. Laparoscopy in township hospitals in the region has been routinely equipped, which has led to LRP becoming the most mainstream surgical approach to the treatment of localized prostate cancer in China. In recent years, with the increase in the number of cases in the LRP operation and the accumulation of surgeons' experience, many specific surgical techniques and procedures have been improved and regulated by the academic community. More importantly, the anatomy of the prostate is further studied by anatomics, which provides the most fundamental theoretical support and practical guidance for the continuous evolution and evolution of the operation. However, the process of resection and reconstruction of LR P needs to take into account the maximization of the tumor resection and the minimization of the damage of the functional structure and the complexity of the procedure. The technical difficulty and the steep learning curve have been the most challenging operation in the Department of urology. There are still many questions about the local fine anatomy of the prostate and its surrounding structures. The classical anatomy textbooks and atlas are incompatible with the description or part of the detailed description of the fine structure of the prostate and surrounding the prostate and the surrounding structure. The theoretical requirements for guiding clinical surgery are not satisfied. The precise and precise qualitative description of the important structure of the bladder neck and the tip of the prostatic region is still blank. The prostate is located in the deep pelvic cavity with sophisticated fascia and neurovascular structures around it, and the bottom and the tip are related to complex urinary control. Structure. In recent years, the structure of the fasciae around the prostate and the prostatic ligament (PPL) and the dorsal vascular complex (DVC) are recognized at the qualitative level at home and abroad. However, there is still a lack of accurate measurements of the related structural parameters, especially for the fine anatomical measurements of the tip of the prostate and the neck of the bladder. Such as the apex of the prostate, the geometric space of the related structures is narrow, the interspecific / interindividual variation is large, and the anatomical study is difficult, but it is a subject that the urologist and anatomist must face and solve because of its anatomical structure and the successful operation of the surgery and the positive rate of the patients after the operation, the maintenance and recovery of the function and function of the urine control. It is closely related, and the latter has a direct impact on the patient's survival time and quality of life. For example, the maintenance of adequate urethral length and the maintenance of the physiological angles of the urethra into the genital diaphragms of the membrane contribute to the recovery of the urinary function of the patients after the operation, and to explore the dorsal vascular complex, the pubis prostatic ligament and the urethral transverse lines. The precise relative position relationship between the sphincter obviously helps to avoid the free PPL in the operation. The urethral transverse sphincter and the pelvic floor muscle are injured when DVC is ligation, and the condition of "anterior urethral suspension" is provided for the operation. The space position of the bundle (NVB) is located near the tip of the prostate and continues to move toward the distal end. How to maximize the protection of these nerve fibers during the operation is closely related to the recovery of the erectile and urinary function of the patients after radical prostatectomy, but the spatial distribution of these nerve fibers in the apex of the prostate is reported in different reports. In addition, a lot of urological surgeons will find that the volume change of the prostate has a significant influence on the shape of the bladder neck, especially the volume of the prostate, the gland part protruded into the bladder, the neck of the bladder is easily subject to the shape of the gland, and the bladder triangle is easily misunderstood during the operation, leading to the neck mouth. Complications such as insufficient retention or prostatic glandular incision. All of these difficult and practical problems are all inevitable in the operation of each urologist. It is the lack of anatomical study of the tip of the prostate and the neck of the bladder, which leads to the protection of important urinary and erectile related functional structures in LRP. The lack of objective specific operational basis and technical specifications made surgeons to handle the structure of the tip of the prostate, disconnect and reconstruct the neck and urethra of the bladder as "blind in the picture" - because of the lack of fine local applied anatomical guidance, only by experience, by feeling or even by luck. This is the purpose of this study for the fine applied anatomy of the surrounding prostatic structure, especially the apex of the prostate and the neck of the bladder. For this purpose, the purpose of this study was to guide the scientific implementation of the retention of urinary and sexual function related structures in LRP by autopsies, and to study the region of the prostatic tip and the neck region of the bladder. The anatomical characteristics of the related structures. [Objective]1. measurement of the spatial geometry of the prostatic ligament of the pubis 2. measured by the angle of the distal urethra and the genital diaphragm of the apex 3. to explore the scope of the anterior detrusor apron covering the anterior surface of the prostate (4.) to describe the morphological characteristics of the bladder neck and its characteristics to the prostatic urinary tract [method]1. with the Shandong University. The medical college's Department of anatomy and research worked together to obtain 20 formalin's fixed male cadavers, cut off the lower limbs of all the cadavers, and cut the pelvis in 10 of the 10 specimens by a line saw, exposed the intact urethra and marked with red lines, and measured the angle of the membrane (the distal end of the tip of the tip of the tip of the apex) and the angle of the genital diaphragm with a protractor and a ruler. The length, dissection of the adipose tissue in the front of the bladder and prostate, completely exposing the side of the pubic prostatic ligament, measuring the width of the prostatic ligament with a ruler from the end of the pubis to the prostatic end.2. with a wire saw to separate the pubic symphysis from the pubic symphysis and the lateral 5cm of the other 10 specimens. The pelvic organs are completely stripped from the pelvic wall with a scalpel. To avoid damage to the surrounding structure of the prostate, observe the position of the bladder neck and the base of the prostate. Remove the loose connective tissue after the pubis, gradually separate out the detrusor apron, the pubis prostatic ligament, the dorsal vascular complex and other structures, describe or measure the geometry and data of the main structure. [result]1. tip. The maximum angle of the distal urethra through the urogenital diaphragm was 87.6 degrees, the minimum 70.3 degree, and the average 82.2 + 5.3 degrees. The length of the prostatic urethra (the distal end of the tip of the urethra to the pelvic diaphragm) was 12.1 + 2.3mm.2. in the pubis of the pubis of the pubic symphysis. The width of the pubis of the pubic prostatic ligament was about 7.5 + 1.3mm, the middle width was 6.2 + 1.1mm, and the end of the proprost gland was about 12.6 + 2.2mm, from the pubis to the prostatic end. About 9.3 + 1.2mm. two pubic prostate ligaments are about 10.7 + 1.8mm, and the end of the prostate is approximately 12.8 + 2.6mm.3. detrusor aprons, which almost cover the total length of the prostate. The distribution of the prostate is about 10 to 2 at the bottom of the prostate. The range of the tip of the prostate is about 11 to 1. The contact surface of the.4. bladder neck and the base of the prostate is not a standard plane, but a curved surface that moves gradually to the central prostatic depression with the bladder neck to the urethra. The specific shape may be affected by the volume of the prostate - especially for the larger volume of the prostate. The glands protrude into the bladder. [Conclusion] the structure of the tip of the prostate and the neck of the bladder is complex and delicate. It has a direct effect on the urinary and sexual function recovery after LRP. The length of the posterior urethra, the angle of the posterior urethra through the pelvic floor, the quantitative measurement of the PPL geometry, and the qualitative description of the curved surface of the bladder neck and the anterior glandular basal junction and its variation. It can help the operator to set up a clear anatomical picture of the structure related to urinary and sexual function in LRP, and provide the basic basis for the standardization of the technique of urinary control and sexual function protection in LRP and the procedure of the operation. [Objective] to decompose and improve the procedure of RELRP operation, to establish the technical specification, and to ensure the procedure and procedure of the standard procedure. The operation was safe, the learning curve was smoothed and the comparability of data between different studies was enhanced. [data and methods] was used to videotape the operation process of RELRP patients in the Department of Urology of Qilu Hospital of Shandong University since 2015. The procedure was reviewed, the procedure of RELRP operation was combed and the surgical techniques were summarized. Experience, standardization of RELRP operation technology and procedure procedure. [results] standard programming RELRP can be decomposed into 21 steps (the main points of the technical points); 1. surgical position 2. operation field full poison paving towel 3. indwelling catheter 4. pure expansion of pubis retroperitoneal space gap 5. to establish laparoscope operation channel and pubis retroperitoneum pneumoperitoneum 6. into abdominal cavity A bilateral operation channel was set up to establish bilateral operation channel 7. after pubis clearance, fat cleaning, hemostasis, revealing important anatomical signs, 8. cleaning pelvic lymph nodes, 9. exposure, 9. of the dorsal lateral vascular complex, 10. dissection of the wrist neck and 11. dissection of the dieldron fascia, and from the rear of the prostate to the prostatic tip 12. to cut the prostatic lateral zone and the pubis prostatic zone 13 Disconnect the tip of the prostate, complete free prostate and bag 14. rectal examination, exclude 15. anastomosis, 16. bladder neck urethra anastomosis, 16. bladder neck urethral anastomosis 17., 18. tons of anastomotic closure and surgical hemostasis, 18. tons of anterior suspension 19. indwelling drainage tube 20. removed specimens 21. suture closure incision and end operation [Conclusion] One of the mainstream methods of prostatic cancer treatment in most provincial hospitals has been carried out and accumulated some clinical experience. However, there are significant differences in the technical details, the number and order of the operation procedures between the different operators in the same one and the same one in the same medium, which leads to the large difference in the operation effect. Poor comparability is not conducive to the development of evidence-based medicine and the mining of large data. This study, through the observation of surgical video, combined with the results of the anatomic study in the first part of the paper, abstracts the common and experience of the operation, standardizing the operation of the RELRP and arranging the procedure procedure, and initially establishes a unified operation process and standard for the RELRP. The effectiveness and safety of the operation have been ensured, and the comparability of data between different studies is enhanced and the RELRP technology is optimized and improved by using evidence-based medicine tools. Meanwhile, the standard programming study of RELRP can smooth the learning curve of the operation, which is beneficial to the implementation of the technology to the county and below grass-roots hospitals. Quantitative comparison, evaluation of the efficacy and safety of standardized RELRP (S-RELRP). [object and method]: from October 2015 to October 2016, 45 patients underwent RELRP surgery in Department of Urology, Qilu Hospital of Shandong University, including 20 cases of S-RELRP operation group and 25 cases of ns-RELRP operation group. All the diagnosis of prostate cancer were all before and after operation. Post pathology confirmation. Research methods: retrospective collection and comparison of S-RELRP and ns-RELRP two groups of patients age, weight, preoperative PSA level, preoperative Gleason score, operation time, intraoperative bleeding, postoperative gastrointestinal function recovery time, postoperative drainage and hospital days, postoperative urinary leakage and the incidence of urinary leakage, postoperative margin positive rate, 3 months after the operation of urinary control. The data of hospitalization expenses and hospitalization expenses were compared.
【學(xué)位授予單位】：山東大學(xué)
【學(xué)位級(jí)別】：博士
【學(xué)位授予年份】：2017
【分類號(hào)】：R737.25

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1 盧華;恥骨后腹膜外途徑腹腔鏡前列腺癌根治術(shù)（RELRP）相關(guān)解剖及手術(shù)標(biāo)準(zhǔn)程序化研究[D];山東大學(xué);2017年

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本文編號(hào)：1948700