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规范化扩大盆腔淋巴结清扫术在前列腺癌根治术中的应用

Clinical analysis of standardized extended pelvic lymph node dissection in radical prostatectomy

摘要:

目的:探讨前列腺癌根治术中扩大盆腔淋巴结清扫术( e-PLND)规范化技术及其临床疗效。方法回顾性分析2004年1月—2014年12月127例前列腺癌行前列腺根治+e-PLND患者的临床资料。患者年龄47~78岁,平均66.2岁。术前前列腺特异性抗原( PSA)平均13.1μg/L, Gleason评分平均6.8分。按前列腺癌危险因素分级:低危组49例、中危组46例、高危组32例;盆腔淋巴结按解剖部位分为5组9区:髂外、髂总、闭孔、髂内淋巴结组左右两侧分别为1个区,骶前淋巴结组为1个区。患者均在全身麻醉下经下腹正中切口行前列腺根治+e-PLND。比较低危组、中危组、高危组淋巴结转移率;比较淋巴结转移阳性患者中,不同解剖部位淋巴结组的转移率。观察术中、术后并发症发生情况。术后每3个月复查PSA,观察生化复发情况。采用Kaplan-Meier非参数法,统计患者3、5、10年总生存率。结果本组127例,104例5组9区淋巴结均清扫,23例清扫闭孔、髂内、髂外、髂总淋巴结4组8区。共切除淋巴结2727枚,每例切除淋巴结13~41枚,平均21.5枚。127例中,共有26例(20.5%)发生56枚淋巴结转移,平均每例转移淋巴结2.2(1~9)枚。低危、中危、高危组患者淋巴结转移率分别为2.0%(1/49)、23.9%(11/46)、43.8%(14/32),差异有统计学意义(χ2=21.209, P<0.01)。26例淋巴结转移阳性患者中,不同解剖部位组淋巴结的转移率由高到低依次为髂内组57.7%(15/26)、闭孔组50.0%(13/26)、髂外组30.8%(8/26)、骶前组11.5%(3/26)、髂总组3.8%(1/26)。术中、术后并发症总发生率为15.0%(19/127),其中术中静脉损伤2例,术后淋巴瘘5例、淋巴囊肿10例、下肢深静脉血栓2例,均予相应对症处理后痊愈。术后无一例下肢淋巴水肿。术后根据UICC肿瘤TNM病理分期:pT1期13例,pT2期50例,pT3a期49例, pT3b期15例。术后117例获随访,随访时间12~123个月,平均42.7个月。发生生化复发27例(23.1%),其中因肿瘤复发远处转移死亡3例,其他原因死亡5例。本组3、5、10年累积生存率分别为88.9%(56/63)、78.0%(32/41)、11/18。结论前列腺癌根治术中,规范化e-PLND能较彻底地清除转移淋巴结,较准确地定位易转移解剖区域,病理分期较准确,提升手术质量,提高患者生存率。

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abstracts:

Objective To describe a standardized surgical technique and clinical efficacy of extended pelvic lymph node dissection ( e-PLND) in prostate cancer patients. Methods The data of 127 prostate cancer patients with radical prostatectomy and extended pelvic lymph node dissection ( e-PLND ) from January 2004 to December 2014 were analyzed retrospectively. The mean age was 66. 2 ( 47 -78) years, preoperative PSA 13. 1 μg /L, Gleason score 6. 8. Risk group assessment showed low risk of 49 patients, medium risk of 46 patients, high risk of 32 patients. The pelvic lymph nodes were divided into 9 regions in 5 groups according to the common guideline, namely the external iliac, internal iliac, obturator and common iliac lymph nodes bilaterally, and the presacral lymph nodes. All surgical procedures were understood radical prostatectomy +e-PLND through abdominal incision under general anesthesia. The rates of lymph node metastasis at low risk, medium risk, and high risk group were compared. Relatively metastatic frequency of lymph nodes groups at the different anatomical area with node-positive lymph node&nbsp;patients. Intraoperative and postoperative complications were observed. And serum PSA was checked once every 3 months at postoperative 3 months, the biochemical recurrence was observed. Overall survival was calculated by Kaplan-Meier at 3, 5, and 10-year. Results Among 127 patients, 104 patients were lymph node dissection 5 groups, 23 patients of cleaning the obturator, internal iliac, external iliac, common iliac lymph nodes 4 groups. Totally, 2 727 lymph nodes were dissected. The average number of removed lymph nodes was 21. 5(range 13-41). Lymph nodes metastases were detected in 26 of 127 patients (20. 5%), including 2. 0%(1/49) with low risk group, 23. 9%(11/46) with intermediate risk group and 43. 8%(14/32) in high risk group (P<0. 01). The metastatic frequency of lymph node groups in these patients from higher to lower were as follows: 57. 7%(15/26) in internal lilac region, 50%(13/26) in obturator region, 30. 8%(8/26) in external iliac region, 11. 5%(3/26) in presacral region and 3. 8%(1/26) in common iliac region. The intraoperative and postoperative overall complication was diagnosed in 19 of 127 patients (15. 0%). Intraoperative venous injury was 2 patients, postoperative lymphatic leakage 5 patients, the lymphocele 10 patients, the lower extremities embolism 2 patients. They were appropriately cured after symptomatic treatment. We had no patients with lymphedema of the lower extremities. Pathological stage were pT1 13, pT2 50, pT3a 49, pT3b 15. One hundred and seventeen patients were followed up postoperatively, the time was 12-123 months, an average of 42. 7 months. Biochemical recurrence was 27 patients(23. 1%), of which 3 patients died because of tumor recurrence and distant metastasis. Other cause of death was 5 patients. The 3-, 5-, and 10-year accumulate survival rates for all patients were 88. 9%(56/63), 78. 0%(32/41), and 11/18, respectively. Conclusions The standardization of e-PLND can remove lymph nodes metastasis in radical prostatectomy more thoroughly. It is conducive to determine the anatomical localization of lymph node metastasis, the pathological staging is accurate, which can improve the quality of surgery and improve survival.

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