欧美前列腺癌根治术新视点-2014.11 长春.ppt

New views in LaparoscopicRadical Prostatectomy Current Status In Pre-Robotic era Laparoscopic radical prostatectomy Remains a challenging operation Often easy and rarely very difficult Difficulty is mostly unpredicted and unpredictable Visible advantage Magnification in Visualisation - Better identification of structures - Avoids blind manoeuvres Dissection more precise Learning curve for LRP To achieve the plateau of 3.5 hours 40 to 60 cases necessary for skilled lap. Surgeon 80 to 100 cases for lap. na?ve surgeon First Obstacle to Radical Prostatectomy 前列腺癌根治术中出血的主要原因 “Uncorrected controlling of DVC” 75% of complications occur in the first 100 patients. Novel Technique for DVC 顺前列腺轮廓切断膀胱肌纤维。 从膀胱颈两侧游离，找到膀胱与前列腺交界处分离，更好保护尿道内括约肌。 神经【植物神经－NVB、体神经－阴部神经肌支】 肌肉组织【尿道长度，尿道内括约肌，粘膜】 血管【膀胱下A、V，副阴部A、V，阴部分支A、V】 支持结构【前列腺耻骨韧带】 “ 控尿神经”是一功能学名词，包括： 阴部神经—盆内支（肌支、控尿神经）—前列腺尖部以远0.3～0.8cm尿道两侧5 点和7 点——尿道括约肌中的横纹肌 盆丛—血管神经束—尿道括约肌中的平滑肌和尿道粘膜 REPLACE Single Needle Suturing 侧方前列腺周围筋膜 Kiyoshima等研究表明52％的患者存在前列腺包膜－前列腺筋膜－肛提肌筋膜的结构，而另外约半数患者存在不同程度的变异。 前列腺包膜与筋膜 发生融合 前列腺包膜缺如 前列腺筋膜缺如 保护神经血管束的措施 从尖部1点剪开盆筋膜和前列腺筋膜至前列腺包膜，在前列腺筋膜和前列腺包膜之间分离，用超声刀或Hem-o-Lok处理前列腺侧后韧带； 紧贴精囊切开D氏筋膜，紧贴前列腺包膜向两侧游离至1、11处点游离前列腺背侧； 离断前列腺尖部时注意对神经血管束的保护。 Data from this systematic review did not allow us to prove the superiority of any surgical approach in terms of functional and oncological outcomes. It is likely that the most critical issue is the selection of the best surgeon, rather than the surgical approach. Key Points A S E C * * * *