達文西機器手臂輔助腹腔鏡根除性攝護腺切除術使用於疑似攝護腺癌50例病患之經驗-是否是機器手臂手術新的適應症？
歐宴泉1、楊晨洸1、張光喜2、王約翰 3、熊小澐4
臺中榮民總醫院外科部泌尿外科1，研究部2，病理部3，放射線部4
”robotic-assisted laparoscopic radical prostatectomy for preoperativelysuspicious prostate cancer patients in experience of 50 cases- is a novel indication for robotic surgery?"
Yen-Chuan Ou, M.D., Ph.D. 1, Chun-Kuang Yang, M.D. 1, Kuangh-Si Chang, 2 John Wang, M.D. 3, Siu-Wan Hung, M.D.4
Division of Urology, Department of Surgery1, Department of Research, 2 Department of Pathology3, Department of Radiation4,
Taichung Veterans General Hospital, Taichung, Taiwan
INTRODUCTION AND OBJECTIVES：To report the experience of 50 cases of robotic-assisted laparoscopic radical prostatectomy (RALP) by single surgeon (YCOU) for suspicious prostate cancer preoperatively.
METHODS：Prostate cancer was suspected and RALP was performed in 50 cases from Feb. 2012 to March 2015. The mean age was 64.21-year-old. The PSA level range 2.5-75 ng/dl (mean: 15) preoperatively. Transrectalsonoguiding biopsy (TRUS) of prostate was done in 41 (82%) cases (once: 26 cases, twice: 12 cases, thrice: 2 cases and four times: one case) and 9 (18%) cases didn’t receive biopsy preoperatively. TRUS pathology revealed prostatic intraepithelial neoplasia (PIN) in 5 cases (high grade: 3, low grade: 2), atypical hyperplasia in one case and nodular hyperplasia (with or without inflammation) in 35 cases. All patients have lower urinary tract symptom(LUTS). MRI was performed in 45 cases and showed prostate index (PI)-Rad grade III in 36 cases and PI-Rad grade IV in 9 cases. Patients with full understanding signed informed consent for robotic radical prostatectomy before operation after discussion with operator.
RESULTS：Operation parameters included console time 112.6 min, blood loss 92.6 ml and the mean prostate volume was 63.69 ml. No blood transfusion in all patients. Two Clavien system, grade I complications (Ileus in one case and intraoperative urinary bladder perforation with repair in one) was noted. Whole-mount step section of prostate pathology disclosed adenocarcinoma in 19 cases (38%), PIN (high grade: 6, low:5) in 11 cases , atypical hyperplasia in 4 cases and nodular hyperplasia (with or without inflammation) in 16 cases ( 32%). pT2 in 13 cases and pT3 in 6 cases was found. Two positive surgical margin in two cases. Nineteen cases of prostate cancer showed Gleason score (GS) 5 in 3 cases , GS 6 in 9 cases, GS 7 in 6 cases and GS 8 in one case. The tumor volume ranged 0.1 ml to 12 ml with mean 3.59 ml. The tumor percentage in whole prostate was 8.2% (0.1%-65%). Preoperatively urodynamic study revealed voided urine volume (VV) 208 ml, maximal/mean flow rate 10.85/4.5 ml/sec and post-void residual urine volume (PVR) 72.42 ml. Postperatively urodynamic study revealed voided urine volume (VV) 234 ml, maximal/mean flow rate 20.66/11.4 ml/sec and post-void residual urine volume (PVR) 9.36 ml. The international prostate symptom score (IPSS) was statistically significant reduced from 19.82 to 2.67 and also bother score decreased from 4 to 0.125. All patients experienced continence of urination in mean 10.7 post-operative day (POD) ( POD 0-40). Two patient with biochemical recurrence (BCR) was noted.
CONCLUSIONS：Robotic-assisted laparoscopic radical prostatectomy for suspicious prostate cancer preoperatively and moderate LUTS disclosed 38% with adenocarcinoma and 30% of PIN or atypical hyperplasia. The subset of those patients have most satisfactory outcome. It is a novel application for robotic surgery.