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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