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Objective:To investigate the relationship between the positive surgical margin and clinical factors such as neoadjuvant hormonal therapy after robot-assisted laparoscopic radical prostatectomy (RARP) in high-risk patients with prostate cancer.Methods:The clinical data of 164 patients with high-risk prostate cancer being performed RARP by one surgeon were analyzed retrospectively in our hospital from January 2016 to January 2022. The mean patient’s age was (65.3±6.2) years old, mean body mass index (BMI) was (25.6±3.0) kg/m 2, the median value of total prostate specific antigen (tPSA) before operation was 18.6(11.3, 31.3)ng/ml, the median value of Gleason score before operation was 7 (7, 8), the median value of prostate volume was 29.3 (22.4, 40.2) ml, and the clinical stage was T 2aN 0M 0-T 4N 0M 0. 80 patients with prostate cancer were treated with neoadjuvant endocrine therapy. All of them were treated with complete androgen blockade with a median course of 3 months. Univariate analysis was used to analyze the correlation between age, BMI, prostate volume, neoadjuvant hormonal therapy, preoperative tPSA, clinical stage, Gleason score before operation and positive surgical margin. Then multivariate logistic regression was used to further analyze the independent risk factor of positive surgical margin after RARP. Results:The postoperative pathological diagnosis included pT 2 stage in 111 cases (67.7%), pT 3a stage in 15 cases (9.1%), pT 3b stage in 25 cases (15.2%), pT 4 stage in 13 cases (7.9%). No lymph node metastasis was noticed in all patients. The Gleason scores included 6 in 11 cases (6.7%), 3+ 4 in 26 cases (15.9%), 4+ 3 in 36 cases (22.0%), 8 in 17 cases (10.4%), 9-10 in 24 cases (14.6%), un-evaluation due to endocrine therapy in 50 (30.5%). The positive surgical margin of high-risk patients with prostate cancer was 44.5% (73/164). Univariate analysis showed that the neoadjuvant hormonal therapy, tPSA and clinical stage were correlated with positive surgical margin ( P<0.05). Multivariate logistic regression analysis showed that non-neoadjuvant hormonal therapy, preoperative tPSA>20ng/ml and clinical stage>T 2b were independent risk factors for positive surgical margin of high-risk patients with prostate cancer. Stratified analysis showed that when the preoperative tPSA was 10-20 ng/ml(21.1% vs.55.9%, P=0.014), the clinical stage was T 2c(29.6% vs.49.1%, P=0.040), the Gleason score before operation was 7(19.4% vs.54.1%, P=0.003), the positive surgical margin of high-risk patients in the neoadjuvant hormonal therapy group was significantly lower than that in the non-neoadjuvant hormonal therapy group ( P<0.05). Conclusions:Non-neoadjuvant hormonal therapy, preoperative tPSA>20 ng/ml and clinical stage>T 2b were independent risk factors for positive surgical margin of RARP in the high-risk patients with prostate cancer. For high-risk patients with preoperative tPSA of 10-20 ng/ml, clinical stage of T 2c and Gleason score before operation of 7, neoadjuvant hormonal therapy has important clinical significance in reducing the positive surgical margin of RARP.
RESUMEN
Objective:To investigate the technical points and clinical effect of thulium fiber laser lobes-enucleation of the prostate (ThuLLEP).Methods:A total of 90 patients underwent ThuLLEP and plasmakinetic enucleation of prostate (PKEP) in our hospital from November 2018 to December 2020 were collected. The age of patients in the two groups was (67.7±6.8) years and (65.7±7.1) years, the prostate volume was 56.0 (46.0-83.5) ml and 61.0 (53.5-79.5) ml, the serum PSA was 3.6 (2.2-6.0) ng/ml and 4.4 (1.8-7.3) ng/ml, the international prostate symptom score (IPSS) was 27 (22-31) and 28 (23-30), the quality of life score (QOL) was 5 (5-6) and 5 (5-6), the maximum urinary flow rate (Q max) was (8.5±5.7) ml/s and (7.8±3.8) ml/s, the post-void residual volume (PVR) was 127 (47-250) ml and 100 (27-209) ml. The differences had no statistical significance ( P>0.05). The glands were bluntly dissected to establish the surgical capsule plane on both sides of the verumontanum after the verumontanum being located. And then the middle lobe was removed. The glands formed grooves at 12 o'clock after vaporization, which served as anatomical marker. The left and right lobes were removed step by step. Finally, tissue crushing was performed. The PKEP group was enucleated by three lobes enucleation. Perioperative indicators were compared between the two groups. Results:All the operations were completed successfully. The median operative time in ThuLLEP and PKEP groups was 60 (50-73) minutes and 75 (60-100) minutes, the postoperative bladder irrigation time was 2.8 (2.3-3.6) d and 3.8 (2.6-4.7) d, the catheter indwelling time was 4.1 (3.7-4.9) d and 4.9 (4.7-6.0) d, the postoperative hospital stay was 5 (4-6) d and 6 (5-7) d. The decreased hemoglobin was 8.0 (1.5-14.5) g/L and 15.0 (6.5-21.0) g/L. The differences had statistical significance ( P<0.05). Follow-up was performed for 6 months after surgery. The median IPSS score of the two groups was 5 (2-11) and 6 (3-9), the QOL score was 1 (1-2) and 1 (1-2) respectively, which had statistical significance compared with the preoperative parameters ( P<0.05), but no statistical significance between the two groups ( P>0.05). The ThuLLEP group had 1 case of postoperative blood transfusion, 1 case of transient urinary incontinence and 2 cases of urethral stricture. The PKEP group had 1 case of fever and blood transfusion, 3 cases of transient urinary incontinence and 3 cases of urethral stricture. Conclusions:ThuLLEP has definite clinical effect because of less bleeding, quicker recovery and fewer complications. The relatively simple operation steps are beneficial for beginners to master.