摘要：前列腺癌 （prostate cancer，PCa） 是男性泌尿生殖系统最常见的恶性肿瘤之一。前列腺根治性切除术 （radical prostatectomy，RP） 是治疗局限性前列腺癌的常用方法，可分为开放性耻骨后、腹腔镜、机器人辅助腹 腔镜等方法。腹股沟疝是RP术后常见并发症。随着近些年RP由传统的开放式向微创方向的转变，使其术后腹股 沟疝的临床特点发生了较大变化。本文就RP术后腹股沟疝的临床研究进展作一综述。

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余维东，张炯，杨诚.前列腺根治性切除术后腹股沟疝[J]. 泌尿外科杂志（电子版）,2023,15(1):67-75. DOI:10.20020/j.CNKI.1674-7410.2023.01.13

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前列腺癌 （prostate cancer，PCa） 是男性泌尿 生殖系统最常见的恶性肿瘤之一[1] 。前列腺根治性切 除术 （radical prostatectomy，RP） 是治疗局限性前 列腺癌的常用方法，目前主要可分为传统的开放性 耻骨后根治性前列腺切除术 （open retropubic radical prostatectomy， ORP） 和 微 创 根 治 性 前 列 腺 切 除 术 （minimally invasive radical prostatectomy，MIRP）， 后者主要包括腹腔镜根治性前列腺切除术（laparoscopic radical prostatectomy，LRP） 和机器人辅助腹腔镜 根治性前列腺切除术 （robot- assisted laparoscopic radical prostatectomy，RARP）[2 。] 腹股沟疝（inguinal hernia，IH） 指发生于腹股沟区的腹外疝，按发病机 制分为斜疝和直疝，前者疝囊经腹股沟管内环（internal inguinal ring, IIR） 斜向内下方突出经过腹股沟管， 后者疝囊经直疝三角区由后向前突出不经过腹股沟 管，以斜疝为主[3] 。一般来说，RP 术后最常见并发 症为尿失禁和勃起功能障碍[2] ，但 IH亦是其术后常见 并发症[4-5] 。随着近些年来 RP由开放向微创转变，使 其术后 IH 的临床特点发生了较大变化。本文就 RP 术后 IH （重点讨论 LRP/RARP 术后 IH） 的流行病 学、危险因素、可能的发病机制、预防措施、治疗 方法等的临床研究进展作一综述。

1 流行病学

    1.1 全球发病率

    1.2 我国发病率

2 危险因素

    2.1 下腹部或盆腔手术史

    2.2 BMI

    2.3 年龄

    2.4 PPV

    2.5 手术方式及入路方法

        2.5.1 手术方式

        2.5.2 入路方法

    2.6 术前影像学特征

3 可能的发病机制

    3.1 PPV 的存在诱发术后 IH 的形成

    3.2 术后腹膜和输精管受到牵拉使 IIR 扩大并移位

    3.3 破坏了耻骨后间隙

    3.4 RP术后 IH以右侧为主的原因

        3.4.1 PPV 和术前隐匿性 IH 多发生于右侧

        3.4.2 手术者站位

        3.4.3 乙状结肠或其系膜的保护作用

4 预防措施

    4.1 RP术中同时行IH修复术或处理PPV

    4.2 剥离 IIR附近腹膜、分离精索血管、分离或切断输精管

    4.3 保留 Retizus 间隙的 RARP

5 RP 术后 IH 的治疗

    5.1 RP术后 IH 或许可以采用微创手术方法

    5.2 关于微创的具体入路方法

    5.3 微创修复的新方法

6 总结

6 总结

综上所述，RP 术后 IH 采用 ORP 方法的发生率 显著高于LRP和RARP方法（ORP组约13.7%，LRP组约 7.5%，RARP 组约 7.9%），其以右侧、斜疝为 主要类型且好发于术后前 2年。相关危险因素主要包 括：①术前：既往下腹部或盆腔手术史、BMI、年 龄、术前 PSA和 IPSS评分；②术中：PPV、手术方 式及入路方法、偶发 IH、外科医生经验、神经保 留、同时进行盆腔淋巴结清扫、手术时间、失血量 和肿瘤参数；③术后：吻合口狭窄和尿失禁。此外 精索脂肪不对称、阴囊积液、TEOM、WRM、PMV 和 SFA 等术前影像学特征也可能是重要的危险因 素。RP术后 IH的具体发生机制尚不明确，主流观点 包括：PPV 的存在诱发疝的形成、腹膜和输精管受 到牵拉使腹股沟内环扩大并移位以及手术损伤了 Retizus间隙的解剖结构。针对可能的发生机制多种 预防措施已被提出，主要措施包括：术中同时修复 IH 和处理 PPV、剥离腹膜分离精索血管并切断输精 管和条件允许者行 RS-RARP 方法。由于样本量、 随访时间、回顾性研究等限制，这些预防方法未来 仍需大规模、多中心、前瞻性的随机对照研究进一 步深入探讨。RP术后 IH的修复除了传统的开放性疝 修复术外，也可视情况采用微创方法，包括经腹腹 膜前入路和全腹膜外入路，此外 IPOM 和 HLAA 等 方法也值得借鉴。

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