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目的:探讨盆腔淋巴结清扫在根治性前列腺切除术中的意义。方法:对266例接受前列腺癌根治性切除及盆腔淋巴结清扫的患者的临床资料进行回顾性分析。患者术前均诊断为局限性前列腺癌,平均年龄(66.5±5.5)(58~82)岁。高危者68例,中危者155例,低危者43例。130例行耻骨后根治性前列腺切除术(retropubic radical prostatectomy,RRP),33例行腹腔镜根治性前列腺切除术(laparoscopic radical prostatectomy,LRP),103例行达芬奇机器人辅助腹腔镜根治性前列腺切除术(robot assisted laparoscopic radical prostatectomy,RALRP)。其中标准盆腔淋巴结清扫(standard pelvic lymph node dissection,sPLND)者181例,扩大盆腔淋巴结清扫(extended pelvic lymph node dissection,ePLND)者85例。标准盆腔淋巴结清扫范围包括双侧闭孔及髂外淋巴结,扩大盆腔淋巴结清扫在标准盆腔淋巴结清扫的基础上尚切除髂内淋巴结及髂总淋巴结。淋巴结阳性患者术后均予辅助性内分泌治疗。结果:手术时间(operating time,OT)sPLND组(12.6±0.2)min,ePLND组(30.6±2.1)min(P=0.0012);平均失血量(estimated blood loss,EBL)sPLND组(25.7±5.5)ml,ePLND组(60.2±8.3)ml(P=0.0021);清扫淋巴结数目sPLND组(9.0±2.3)枚,阳性病例率8.3%,ePLND组(26.2±5.8)枚,阳性病例率17.6%(P=0.024)。术后平均住院天数(hospital stay,HS)sPLND组(7.8±0.2)d,ePLND组(9.8±0.4)d(P=0.11)。sPLND组11例(6.1%)出现淋巴清扫术后相关并发症,ePLND组11例(12.9%)出现淋巴清扫术后相关并发症(P=0.058)。在sPLND组和ePLND组分别计算低危组、中危组和高危组的手术时间、失血量、住院天数和并发症比率,其差异无统计学意义。在85例ePLND中,手术时间在RRP组、LRP组、RALRP组分别为(28.8±0.4)min、(47.8±0.9)min和(26.5±0.3)min(P=0.06);失血量在RRP组、LRP组、RALRP组分别为(30.3±2.5)ml、(62.7±5.2)ml和(38.1±3.7)ml(P=0.11);术后住院天数在RRP组、LRP组、RALRP组分别为(10.2±0.8)d、(8.8±0.5)d和(7.5±0.3)d(P=0.51)。结论:盆腔淋巴结清扫可以对前列腺癌提供精确的分期,同sPLND相比,ePLND耗时、失血量较多,但能获取更多的淋巴结,并发症也较多。低危前列腺癌患者,不必常规行淋巴结清扫,中危和高危患者,sPLND和ePLND均可选择,但推荐对高危患者行ePLND。是淋巴结清扫的范围,而不是危险度影响了手术的难度。以不同的手术方式行ePLND,机器人手术和开放手术具有一定的优势。淋巴结清扫的范围对患者预后的影响尚需长期随访。
Objective: To investigate the significance of pelvic lymph node dissection in radical prostatectomy. Methods: The clinical data of 266 patients undergoing radical resection of prostate cancer and pelvic lymph node dissection were analyzed retrospectively. Patients were diagnosed with localized prostate cancer preoperatively, with an average age of (66.5 ± 5.5) (58-82) years. 68 cases of high risk, 155 cases of moderate risk, 43 cases of low risk. 130 cases underwent retropubic radical prostatectomy (RRP), 33 cases underwent laparoscopic radical prostatectomy (LRP) and 103 cases underwent laparoscopic radical prostatectomy Robot assisted laparoscopic radical prostatectomy (RALRP). One hundred and eighty-one patients with standard pelvic lymph node dissection (sPLND) and 85 patients with extended pelvic lymph node dissection (ePLND). Standard pelvic lymph node dissection, including bilateral obturator and external iliac lymph nodes, expanding pelvic lymph node dissection in the standard pelvic lymph node dissection is still based on the removal of the internal iliac lymph nodes and common iliac lymph nodes. Patients with lymph node-positive postoperative adjuvant endocrine therapy. Results: In the sPLND group (20.6 ± 0.2) min, ePLND group (P = 0.0012), and mean blood loss (sPLND) group (sPLND 25.7 ± 5.5) ml, ePLND group (60.2 ± 8.3) ml (P = 0.0021). The number of lymph nodes in sPLND group was 9.0 ± 2.3, the positive rate was 8.3% and the ePLND group was 26.2 ± 5.8. The positive rate was 17.6% = 0.024). The mean postoperative hospital stay (sPLND) sPLND (7.8 ± 0.2) d and ePLND (9.8 ± 0.4) d (P = 0.11) patients were significantly higher than those in the ePLND group. Eleven patients (6.1%) in the sPLND group had postoperative complications related to lymphadenectomy and 11 (12.9%) patients in the ePLND group had complications related to lymphadenectomy (P = 0.058). There was no significant difference between the sPLND group and the ePLND group in calculating the operation time, blood loss, length of stay and complication rate in the low-risk group, the middle-risk group and the high-risk group respectively. In 85 patients with ePLND, the operative time was (28.8 ± 0.4) min, (47.8 ± 0.9) min and (26.5 ± 0.3) min in RRP group, LRP group and RALRP group respectively (P = 0.06) (30.3 ± 2.5) ml, (62.7 ± 5.2) ml and (38.1 ± 3.7) ml respectively in the LRP group and the RALRP group (P = 0.11). The postoperative hospital stay in the RRP group, the LRP group and the RALRP group were 10.2 ± 0.8) d, (8.8 ± 0.5) d and (7.5 ± 0.3) d (P = 0.51). Conclusions: Pelvic lymph node dissection can provide accurate staging for prostate cancer. Compared with sPLND, ePLND is time-consuming and has more blood loss, but more lymph nodes can be obtained with more complications. Patients with low-risk prostate cancer do not routinely undergo lymph node dissection, and sPLND and ePLND are available in moderate-to-high-risk patients, but ePLND is recommended for high-risk patients. Is the scope of lymph node dissection, rather than the degree of risk affect the operation of the difficulty. With different surgical methods ePLND, robotic surgery and open surgery has some advantages. The extent of lymph node dissection on the prognosis of patients still need long-term follow-up.