本文由泌尿外科王志华医生原创,转载请注明来源。前列腺癌在西方国家是男性最常见的恶性肿瘤,占恶性肿瘤死亡原因第 2 位。近年来,我国前列腺癌的发病率也呈现上升趋势,现居我国男性恶性肿瘤发病第 6 位。统计数据表明,我国中晚期前列癌患者的比例明显高于欧美国家,这对我国前列腺癌患者的治疗效果及长期生存产生直接影响。早期的前列腺癌通常没有典型症状,当出现排尿困难、血尿、骨痛、贫血等症状时,往往提示癌症已经进入晚期。如何才能早期发现前列腺癌呢?下面将给大家介绍目前临床常用的早期筛查手段——PSA(前列腺特异性抗原)1、什么是PSAPSA是前列腺特异性抗原的英文缩写,是一种单链糖蛋白,主要由前列腺上皮细胞产生,因具有前列腺组织特异性而得名。它是一种能够帮助凝固的精液恢复液体状态的酶类,与男性生育力有关。世界著名泌尿外科专家WilliamJ.Catalona教授率先发现PSA检测可以用于前列腺癌的一线筛查,因此被称为“前列腺癌PSA之父”。他在St.Louis(圣路易斯,美国密苏里州东部城市)进行的一项 36000人的普查研究使得PSA 检测和fPSA 检测通过了FDA(美国食品药品监督管理局)认证。2、为什么要查PSA血清PSA是目前公认的前列腺癌的特异性标志物,可用于前列腺癌的筛查和早期诊断。正常情况下,前列腺上皮细胞的下面有一层致密的基底膜,基底膜就像一面“高墙”将上皮细胞与血液分开。因此,几乎所有的PSA只能通过导管进入精液,而不能进入血液。所以,正常男性血清PSA浓度很低,而精液中PSA浓度约为血清PSA浓度的100万倍。当患有前列腺疾病时,基底膜就会受到不同程度的破坏,特别是发生前列腺癌时,癌细胞的异常生长会使基底膜遭受严重破坏,使PSA通过这种“异常途径”进入血液。因前列腺管腔内PSA浓度远远高出血液,从而造成血清PSA水平的大幅度升高。怀疑前列腺增生的患者,PSA检测主要是筛查有无并发前列腺肿瘤。PSA检查很方便,只需抽取2ml血液,检查前无需空腹,吃饭、喝水并不会影响检查的结果。3、PSA的正常值正常情况下,PSA无法直接进入血液,因此,正常男性血清PSA浓度很低。一般认为,血清PSA的正常值为(0~4)ng/ml,各医院依据自己的检查仪器标准、所用的试剂不同,可能有细微的差异。当血清PSA(tPSA)>10ng/ml时,应高度怀疑前列腺癌,提高警惕,及时到泌尿外科医生处就诊,必要时进行前列腺磁共振成像(MRI)检查和前列腺穿刺活检,以进一步明确是否有前列腺癌。当tPSA介于4~10ng/ml时,发生前列腺癌的可能性约为25%(欧美国家)。临床上将4~10ng/ml称为 PSA 的灰区,是指当 PSA 在这一范围内时,很难判断患者是否有可能患有前列腺癌。此时,推荐参考PSA相关变数:游离PSA(fPSA),PSA密度(PSAD),PSA速率(PSAV)。这些参数由于相对复杂,在此不做详细介绍。【参考文献】1. 中国泌尿外科疾病诊断治疗指南 2014版.2.UrologicalResearchFoundation.ThesiteforprostatecancerinformationfromDr.WilliamCatalona.http://www.drcatalona.com 3. 中国前列腺癌早期诊断专家共识. 中华泌尿外科杂志,2015,36(8):561-564. 4. 不同水平前列腺抗原的前列腺癌诊断率.中华医学杂志,2008,88:16-18. 5. 图片来自网络及自绘.
随着我国人口生育率的持续下降和人均预期寿命的不断延长,全国人口老龄化进程正持续加剧。最新统计资料显示,到2015年,中国60以上老年人口将超过2亿以上。营造健康的老龄化环境,可减少老年人对卫生资源的需求,同时又能提高老年人的生活质量,增强老年朋友的幸福感。前列腺疾病对老年男性健康的影响前列腺为男性特有器官,也是男性生殖器官中最大的附属性腺,具有外分泌、内分泌、控制排尿和精液运输等重要作用。前列腺疾病(主要包括前列腺增生和前列腺癌)是影响老年男性身体健康和生活质量的主要因素之一。在我国大于60岁以上的老年男性中,前列腺增生症患病发生率大于80%,而我们实际临床诊断的前列腺增生症患病率远低于其发病率,这表明,前列腺增生症对老年男性的危害完全没有得到足够的重视。前列腺增生常见的临床表现是排尿症状,这是由于增生的前列腺组织对尿道的挤压所引起的。我们常可听到患者诉说,他们的排尿次数增多,先为夜尿次数增加,尿等待以后随着增生的前列腺对尿道挤压的加剧,患者感到排尿费力,有时需憋气增加腹压以帮助排尿,而且排尿起始延缓,排尿时间长,尿线变细而无力。前列腺增生很大地影响了人们的生活质量,如不及时诊疗,也可能导致急慢性尿潴留,并发泌尿系感染、膀胱结石、血尿,影响性功能,并可导致肾积水甚至肾功能衰竭、尿毒症等。另外,前列腺癌在欧美国家的发病率一直位居男性恶性肿瘤发病率之首。随着我国老龄化人口加剧和人们生活习惯及饮食结构的改变,前列腺癌发病率逐年攀升。至2008年,在我国较发达城市北京、上海和广州均等地,前列腺癌发病率和死亡率已经跃居男性泌尿生殖系肿瘤第一位。据临床统计资料显示,约60%的前列腺癌病人就诊时已是晚期,22%患者有远处转移,治疗效果不佳,长期预后极差。因此,早期发现前列腺癌,对于提高该病治疗效果,减少前列腺癌患者死亡率十分重要。哪些不良习惯伤害前列腺?一怕嗜烟:根据调查,吸烟者前列腺疾病患病率比不吸烟者高1~2 倍。吸烟越多前列腺受害越大。二怕饮食不节:经常食用辛辣、酸性食物和饮烈性酒,可引起血管扩张,促使前列腺充血。三怕受凉:前列腺有丰富的肾上腺能受体,受凉时极易引起交感神经兴奋,导致腺体收缩,使尿道内压增加,影响排尿;而排尿困难,又会对前列腺产生不良的影响,恶性循环可使前列腺发生病变。四怕性事不当:短时间内持续多次性交者,发生急性前列腺炎的比率高达89.7% 。相反,性欲旺盛者因故无法正常排泄,致前列腺分泌大量“囤积”,时间长了导致前列腺过度扩张与充血,也可引发炎症。此外,体外排精、性交中断等同样可使前列腺充血肿胀而引起炎症。五怕便秘:便秘者直肠内积聚大量粪便,会加重邻近的前列腺充血。同时,便秘者往往排便时用力过大、腹压增加,压迫前列腺,可使尿道变细、排尿受阻,对前列腺健康不利。六怕感染:某患者去医院导过几次尿后,自己买了两条导尿管和一瓶甘油,稍有排尿不快,就自己插管导尿,结果越插越勤,最后竟拔不掉了。经化验,尿里有大量脓性白血球。医生介绍,自己插管导致感染,加重了前列腺肿大,导致排尿更加困难。七怕挤压:久坐或经常骑自行车使前列腺长时间受到挤压,导致局部血液循环不畅。特别是在骑自行车时,车座与会阴产生磨擦,刺激尿道上段和前列腺等处,促皮下组织慢性增生、发硬、肿大,甚至发炎,压迫尿道和前列腺,容易造成前列腺疾病和排尿困难。八怕憋尿:经常人为地憋尿,可使膀胱充盈胀大,导致排尿无力,加重前列腺增生的症状。前列腺疾病诊断和治疗的误区1. 讳疾忌医调查表明,一半以上男性正在或曾经患有男性泌尿生殖系统疾病,严重影响身心健康和生活质量。泌尿生殖疾病往往比较隐私,患者又存在诸多错误认知,其中有些人将泌尿生殖疾病与性病混淆,导致很多人患病后羞于启齿,不愿到医院就诊。殊不知,此举不但可能延误治疗,使病情加重,还极易诱发心理问题,甚至危及生命。2. 前列腺增生症状是很自然的生理老化现象,不用太担心调查发现,50 岁以上男性的患病率约为50% ,60岁以上男性的患病率约为60% ,80 岁以上男性的患病率几乎为100%。中国医师协会在上述报告中建议: 50 岁以上的男性,即使目前还没有出现良性前列腺增生的症状,也要定期去医院泌尿外科进行前列腺增生风险筛查。一旦发现有任何前列腺增生风险,要及早治疗。对于已经发现症状的男性,更不能一拖再拖,以免贻误病情。3. 前列腺增生是小问题,应优先治疗其他疾病前列腺增生为良性病变。一般病程比较缓慢,如不引起梗阻几乎没有症状,对寿命也没什么影响。但是当前列腺增生到了一定程度引起排尿症状了,尤其是出现排尿困难和尿潴留时就会对健康有不利影响,往往会导致疝气、痔疮、血尿、膀胱结石、反复尿路感染、肾积水、尿毒症等并发症。如果排尿症状没有得到及时治疗并得到缓解,频繁的夜尿将严重影响睡眠和休息,因而会加重高血压、冠心病、糖尿病、心力衰竭、脑血管病等老年常见疾病,形成恶性循环,直接影响老年人的寿命。4. 前列腺增生患者擅自停药在那些已经接受治疗的患者当中,当症状得到初步改善之后,他们就擅自停药,造成病情的反复或者恶化。治疗前列腺增生的药物与治疗高血压、糖尿病的药物一样,是需要终生服用的。5. 前列腺增生“一切了之”前列腺增生不是一切了之,事实上大多数的增生都不需要手术。第一, 一些无症状或症状轻微的、无合并症的患者可以采用“观察等待”的方法,根据症状发展情况复查或定期复查,决定是否需要进一步治疗。第二, 对大多数轻中度患者,建议药物治疗。什么情况下需要手术治疗?需先了解前列腺增生的绝对手术指征:①梗阻引起尿路结石。②反复的尿路感染。③形成上尿路积水。肾功能受影响。④前列腺血管曲张,反复出现血尿。⑤解不出小便,尿潴留。当病人出现了这些情况,在身体条件许可的状态下应推荐病人进行手术治疗。6. 混淆前列腺增生和前列腺癌前列腺癌的早期症状并不明显,有时表现为类似前列腺增生症的排尿梗阻症状,如进行性排尿困难、尿流变细、尿流分叉、尿程延长、尿频、尿急、夜尿增加、尿意不尽感等。还有的患者会出现疼痛、消瘦、乏力、食欲减退,但这些通常已经是晚期肿瘤的信号了。20世纪 90年代开始,欧美国家已广泛开展血清前列腺特异抗原(PSA) 检测,使早期前列腺癌患者的检出率大大增加。作为前列腺癌最敏感、应用最广泛的肿瘤标志物,国内很多医院也开展了PSA 检测,男同胞们只需献出几毫升血,便可方便排除患癌的可能。一般整个普查过程只需要 5分钟左右,也没有什么痛苦。专家建议50岁以上男性每年应至少检测一次 PSA ,有家族史的朋友,检测年龄须提前到45 岁。7. 前列腺癌的认识误区“以为癌症只是‘遥远的传说’,而身边的癌症患者却越来越多”,许多人都有这样的感觉。有些患者或家属对于恶性肿瘤过分恐惧,认为患恶性肿瘤即不治之症,无异被判死刑。其实不然。癌症≠绝症,世界卫生组织在报告中指出,1/3 癌症可以预防,1/3 可通过早发现、早诊断、早治疗,最终治愈,1/3 通过适当治疗,可延长生命、提高生活质量。权威专家的意见是:只要正确认识、科学防治,癌症并没有那么可怕。前列腺癌只要能早期发现、早期诊断,其治愈率相当高。根据我院近20年的统计数据显示,局限性前列腺癌患者接受根治手术切除的病人,其5 年生存率接近100%。因此,早期前列腺癌是一种完全可以治愈的肿瘤。
关于转移性前列腺癌(mPCa)的治疗一直是泌尿外科,肿瘤科棘手的问题,但是随着医疗水平的提高,对于前列腺癌的诊断治疗方式方法近年来有了很大的进步。NEJM的一篇社论(Antonarakis and Eisenberger 2011)就此话题展开讨论,我们将其简要翻译并介绍给大家。前列腺癌是一种雄激素受体依赖的肿瘤性疾病,因此阻断雄激素受体一直该病治疗过程中的重要手段。但尽管大多数患者都可以从雄激素剥夺治疗中获益,由于受多重因素的影响,肿瘤还是无可避免地会在1至4年内继续进展;一旦癌症进入“去势抵抗CRPC”的状态,而这对于患者而言无疑是死神的召唤。临床上通过影像学尽早发现转移性前列腺癌并及时开展去雄治疗对于患者来说是十分有益的,另一方面,医学新技术的发展应用也使得肿瘤进展至终末期的时间日以延长。尽管详细数据尚未完全得到统计,但从发现癌症转移至病患去世的时间,目前可能已经超过5年。以往研究认为去势后CRPC仅会在肿瘤进展时才能发生;但目前研究表明,即使睾酮浓度仍在去势水平(小于50ng/dl),雄激素受体仍可能处于激活状态。因而控制去势后相关雄激素受体在腺体、肿瘤内的表达对于转移性前列腺癌的患者而言至关重要。正如本期NEJM中所介绍的醋酸阿比特龙就是依靠选择性抑制睾酮合成过程中的关键酶CYP17从而达到抑制性腺外雄激素合成的目的;并且其对于晚期前列腺癌患者的显著效果也在文中被详尽报道。该研究结果再次表明mPCa仍然对于雄激素有着很强的依赖作用。但阿比特龙同其他药物何用的治疗效果目前还缺乏长期临床数据支持,此外,该药物在不同分期的前列腺癌的患者中的作用,仍有待于更进一步的试验结果。几年前,在延长去势抵抗患者寿命的治疗方法十分有限,只有多烯紫杉醇(FDA2004年认证,转移性前列腺癌一线化疗药物)和更早前被FDA认证的米托蒽醌(能改善患者的生活质量)。直到2010年,FDA才又认证了两种治疗方法,自体免疫治疗产物前列腺癌疫苗Provenge(sipuleucel-T, 适用于无症状或仅有极少症状的患者)以及Jevtana(cabazitaxel, 适用于多烯紫杉醇化疗后疾病再次进展的患者)。此外,地诺单抗(denosumab)由于能够预防转移性去势抵抗前列腺癌患者骨骼相关事件的发生率也被FDA认证。在当前的研究过程中,仍有不少问题值得我们去注意和思考。首先,在药物试验过程中如何对待接受过和未接受过化疗的患者?如若他们疾病分期相同,能否分入相同试验组?其次,目前不少药物试验的结果均显示该药物的“显著”效果,那么在进行临床药物试验时如继续使用安慰剂作为对照,是否还符合人道主义精神?如何选取恰当合理的药物对照?目前尽管转移性去势抵抗性前列腺癌mCRPC的治疗选择已经相对较多了,但我们不得不承认在这些治疗手段下,患者的疾病无进展存活率和整体存活率仍相对较低。但随着我们对于转移性前列腺癌的相关机制的认识的逐步深入,可以预想在不久的将来,更多有效的治疗手段能够更进一步改善晚期前列腺癌患者的预后;更多临临床学、影像学、基因学靶点能够被确认及发现,它们必将取代目前临床使用的一些标准并给予患者个性化治疗方案。以上论文中提到的观点代表目前部分前列腺癌专家的观点,是否确切需要循证医学的证据。。。原文来自Antonarakis, E. S. and M. A. Eisenberger (2011). “Expanding treatment options for metastatic prostate cancer.” N Engl J Med 364(21): 2055-2058
自从WALSH教授提出保留性神经血管束(NVB)的前列腺癌根治术(RP)以来,如何解剖定位一直众说不一,Emre教授认为保留筋膜的前列腺癌根治术,也就是我们国内专家谈到的筋膜内前列腺癌根治术是保留NVB的前列腺癌根治术的一种新的解剖学定义。但是适应症需要严格把握,对于根治术来说,无瘤原则是第一位的。下面我与大家一起分享此文…Novel anatomical identification of nerve-sparing radical prostatectomy: fascial-sparing radical prostatectomyEmre HuriDepartment of Urology, Ankara Training and Research Hospital, Ankara, TurkeyAbstractRadical prostatectomy (RP) became a first choice of treatment for prostate cancer after the advance in nerve-sparing techniques. However, the difficult technical details still involved in nerve-sparing RP (nsRP) can invite unwanted complications. Therefore, learning to recognize key anatomical features of the prostate and its surrounding structures is crucial to further improve RP efficacy. Although the anatomical relation between the pelvic nerves and pelvic fascias is still under investigation, this paper characterizes the periprostatic fascias in order to define a novel fascial-sparing approach to RP (fsRP), which will help spare neurovascular bundles. In uroanatomic perspective, it can be stated that nsRP is a functional identification of the surgical technique while fsRP is an anatomic identification as well. The functional and oncological outcomes related to this novel fsRP are also reviewed.Keywords: Cadaver, Urology, Prostate, Neurovascular bundleINTRODUCTIONRadical prostatectomy (RP) is one of the main options for the treatment of localized and locally advanced prostate cancer in some cases [1]. The nerve-sparing technique remains the target anatomical approach to achieve better functional outcomes related to potency and continence. The technical details of this procedure make the operation difficult, however, and some authors have stressed the importance of anatomical landmarks in RP in their series [2–4]. RP has some associated morbidity, which can be decreased dramatically as a result of improved surgical technique [5,6]. Additionally, a positive impact of nerve-sparing RP (nsRP) on sexual function [7–9] and lower urinary tract function [7,10] has been shown in the literature. Various technological devices have been used to improve the technique of nsRP, such as laparoscopic and robotic devices. Furthermore, advances in the anatomical elucidation of the prostate and periprostatic structures have contributed excellent survival and functional results after RP [11–15].Nielsen et al. [16] have reported perfecting the technique of nsRP with sequential modifications since 1982. In their report, Nielsen et al. [16] describe performing wide excision of the neurovascular bundle (NVB) in 1982 for 110 patients and high anterior release of the NVB in 2005 for 3,649 patients to ensure better functional outcome. However, the requirement for appreciation of the anatomy of the prostatic and periprostatic fascial layers to perform nsRP is widely acknowledged [17]. Many controversies exist in the literature regarding the description of these fascias [18]; moreover, the anatomical relation between the pelvic nerves and fascias is still under investigation. Cornu et al. [19] described the anatomy of the periprostatic fascias in order to spare the NVBs during RP. The aim of this article was define novel anatomical identification of nsRP and to review the functional and oncological outcomes related to fascial-sparing RP (fsRP).ANATOMY OF PELVIC FASCIA AND FASCIAS OF PROSTATEThe anatomy of the prostate and fascias of the prostate is to a certain extent complicated by the close relations of the pelvic organs to each other and by the narrowness of the pelvis [20]. For this reason, performing surgery from an anatomical point of view will ensure better visualization and understanding of the pelvic anatomy and fascias. In the Skandalakis surgical anatomy atlas, the anatomical relation between the fascia (parietal layer of pelvic fascia), vessels (internal iliac vessels), and nerves (sacral plexus) is clearly shown from the skin to peritoneum scheme [21]. The atlas shows the close anatomical locations of the three major structures, which also have critical importance at the prostate level (Fig. 1). The main focus in nsRP is to protect the nerve that is completely adjacent to the fascias and vessels.Fig. 1.Anatomical relation between the fascia (parietal layer of pelvic fascia), vessels (internal iliac vessels), and nerve (sacral plexus) in the pelvic region.The surgico-anatomical layers are divided into five sections: pelvic peritoneum and its specialization, blood vessels of the pelvis, pelvic fascia, nerves of the pelvis, and the muscles. The pelvic organs are covered by the pelvic fascia. This fascia is referred to as the endopelvic fascia (EPF) by some authors [22,23]. The EPF has two major divisions: the parietal and the visceral parts. The parietal component, which is a strong, membranous layer, covers the medial aspects of the levator ani, obturator internus, and piriformis muscles. The visceral fascia is essentially the connective tissue that encapsulates the individual organs within the pelvis, such as the prostate, bladder, and rectum. Briefly, the EPF covers the pelvic organs and the pelvic side wall, and full access to the prostate can be obtained after incision of the EPF at the fusion between the parietal and visceral parts at the antero-lateral corner of the prostate [24–26].The other important anatomical landmark is the tendinous arch of the pelvic fascia, at which point both layers of the prostatic fascia (PF) and the EPF are adherent and fused laterally. These structures join the puboprostatic ligaments (PPLs) that connect the prostate to the pubic bone [19] and are part of a larger urethral suspensor mechanism attaching the membranous urethra to the pubic bone and ensuring continence [27]. The PPLs and EPF have an indirect positive effect on the continence mechanism owing to the fascial continuum of EPF. After reopening the EPF on the prostatic side, the PF (periprostatic fascia, lateral pelvic fascia [LPF], paraprostatic fascia) can be clearly seen [19]. The PF covers the whole prostate surface in a dense fashion and anatomical dissection of the PF allows finding a plane front of cavernous nerves surrounded by fatty tissue. The LPF (PF, the part of prostate; rectal fascia, the part of rectum) extends in a posterior direction to also cover the NVB and consists not of a single layer of tissue but of collagen and connective tissue positioned in several layers over the prostate [22,25,28,29]. Thus, the close anatomical relation of the fascial structures and NVB over the prostate and at the posterior part of the prostate is evident.The anterior surface of the prostate is located between the apex and the base. Multiple large veins called the dorsal venous complex separate the surface from the symphysis pubis (Fig. 2). The visceral part of the EPF also covers the vascular structures located at the anterior side of the prostate (Fig. 2).Fig. 2.Dorsal vein complex (V) with visceral fascia of veins (F), periprostatic fascia (FP), and symphysis pubis (SP).The posterior surface of the prostate is in direct contact with Denonvilliers’ fascia (DF; rectoprostatic fascia) (Fig. 3). It lies at the posterior and lateral angle of the prostate and also covers the posterior aspect of the seminal vesicle (Fig. 3) [30]. At the posterior aspect of the prostate, the anatomical locations of the fascial layers from the anterior to the posterior side are the anterior layer of DF, space of Proust, posterior layer of DF, and rectal fascia, consecutively [21]. The DF also covers the plexus vesicoprostaticus and the ampoules of the ductus deferens [2]. Laterally, it is interwoven with the fascia pelvis. Van Ophoven and Roth [31] reported that the DF consists of a single layer that is formed from the fusion of two walls of embryological peritoneal cul-de-sac. A double layer fashion exists histologically, but is not distinguishable intraoperatively. As in the pelvis, the nerves and fascial layers on the posterior side of the prostate show a similar anatomical distribution.Fig. 3.(A) Posterior part of the prostate, anterior layer of Denonvilliers’ fascia (DE). (B) Seminal vesicles (SVs) at the posterior view of the prostate.The fascial parts of the prostate and periprostatic structures have various topographic relations. At the center of the posterior prostate surface, in almost all cases a fusion of the DF with the prostatic capsule is shown. Conversely, the DF shows no adherence to the prostatic capsule on the lateral aspect [29]. However, it was confirmed that the space between the DF and the prostatic capsule is filled by adipose tissue and the NVB [32]. As a result, the anatomical spaces between the fascial layers are completely related to the NVBs, which are of primary importance in nsRP.HISTORY OF nsRP AND TECHNICAL ADVANCES IN FASCIAL SURGERYThe discovery of the cavernous nerves was a milestone for identifying a purposeful nsRP technique for the treatment of localized prostate cancer. Walsh stressed that anatomy texts are not helpful for determining the exact anatomical configuration of the autonomic innervations to the cavernous body and reported that an infant cadaver is the best model for understanding more about the location of the branches [33]. The vascular part of the NVBs provides the scaffolding for the nerves and can be used as a macroscopic landmark to identify the nerves during surgery [34]. However, it was reported that during the nerve-sparing technique, one part of the LPF, the PF, must remain on the prostate [34], and then the levator fascia or periprostatic fascia must be spared with the nerves.The first nsRP was performed by Patrick Walsh in a 52-year-old patient [33]. The development of a database that included anatomical observations, changes in technique, cancer control, and quality of life was reported as the key technique for perfecting nsRP [35] As we know, the most important advantage of nsRP is related to functional outcomes during the follow-up after the surgery. Improvements in the surgical technique have had a significant positive impact on sexual [7–9] and lower urinary tract function [7–10]. The nerve-sparing technique mainly focuses on the preservation of the autonomic nerve fibers from the pelvic plexus (including afferent and efferent fibers) that form the nervi erigentes, which are responsible for penile erection and also innervate the sphincteric mechanism [36]. One report confirmed that in sexually active men with organ-confined disease, the bilateral nerve-sparing technique preserved erectile function in 32% to 86% and unilateral nerve-sparing surgery preserved function in 13% to 56% [8,37,38].Thus, it has been shown that the key anatomical point during nsRP is the nerves. However, the extension and location of the periprostatic nerves are still controversial. As such, the location of the nerves according to the topographic prostate anatomy has been studied by some authors. The variability in recovery of erectile function can be attributed to the fact that there is no definite or exact anatomy of the periprostatic nerve fibers, especially the cavernosal nerves. Several urologists have reported surgical techniques according to the anatomy of the NVB and periprostatic fascia related to postoperative functional outcomes. For example, Lunacek et al. [39] reported a modified technique of nerve sparing called “curtain dissection,” which involves periprostatic fascial incision and dissection of the NVB far more anteriorly than previously described. The modifications of periprostatic fascial surgery continued with the report of Graefen et al. [40], who stressed incision of the parapelvic fascia of the prostate at the lateroventral aspect of the prostate at 10 o’clock and 2 o’clock. Whereas Kiyoshima et al. [29] reported a cord-like pattern in the NVB, some authors [40] have confirmed a scattered pattern of the NVB at the periprostatic region. Menon et al. [41] and Graefen et al. [40] both noted the importance of starting the incision high up on the ventral aspect of the prostate to preserve the maximum number of nerve fibers, because substantial numbers of nerve fibers are located ventrally. The preservation of periprostatic fascia (veil of Aphrodite) was described by Menon et al. [41], who reported that the veil-nerve-sparing procedure offers superior erectile function compared with the traditional nerve-sparing technique [42].In another histologic study [43], the anatomical location of the periprostatic nerve bundles that run along the surface of the anterolateral zones was identified within the lateral PF (periprostatic fascia). It was found that the nerve bundle counts of the anterolateral zones differ between the two techniques (veil of Aphrodite technique and standard technique) with statistical significance [43]. However, Sung et al. [44] confirmed that the mean percentage of nerves in the ventral part of the prostate was 6.7%, with 33.3% in the dorsal, 29.6% in the right lateral, and 30.1% in the left lateral parts. The distance between the prostatic capsule and nerve fibers and the thickness of the periprostatic nerve fibers were reported as important anatomical features related to nsRP in cadavers [44]. Ganzer et al. [45] reported that the periprostatic nerve density decreases from the base towards the apex. Additionally, they stressed the variability of periprostatic nerve distribution [45]. Clarebrough et al. [46] reported a similar periprostatic nerve distribution pattern that showed that the most periprostatic neural tissue was located in the posterolateral region with a smaller proportion on the anterior surface of the prostate.fsRP: NOVEL ANATOMICAL IDENTIFICATIONSince the description of nsRP, many technical advances have been identified for perfecting nsRP. Nevertheless, the relationship between the PF and the NVB is still controversial and under investigation [31,47,48]. However, Hong et al. [32] stressed that periprostatic adipose tissue is present on 48% of all prostatic surfaces and that this may cause the difficulty in making an exact anatomical determination of the NVB and fascial compartments. The location of the NVB is identified between the prostate capsule and either the levator ani fascia or the posterior PF. No nerve fibers are found lateral to the levator ani fascia or dorsal to the posterior PF [4,28,32,49,50]. Cornu et al. [19] reported that when performing RP, it is mandatory to locate the fascia surrounding the prostate, the EPF, the PF, and the posterior PF to respect the NVBs. This report also confirms the preservation of the fascial layers located at the periprostatic region during nsRP.In the technology era, surgical advances regarding the nerve-sparing technique are still being made with awareness of the periprostatic fascial anatomy. Depending on the dissection plane chosen during the procedure, intra- and interfascial technical variations have been identified [18]. Both techniques can be identified as fascial-sparing surgery. The main goal in intrafascial dissection is to remove the prostate without the fascial layers on the prostate capsule [2,51,52]; however, the dissection is considered outside or lateral to the PF at the anterolateral and posterolateral aspects of the prostate [18]. The NVB might be more prone to partial resection with interfascial dissection because this dissection will not allow preserving more fascial layers at the anterolateral surface of the prostate, presumably resulting in an oncologically safer approach [2,25,52,53].The robotic and laparoscopic approaches have brought innovation and better anatomical perspectives to RP. All technical advances have been made with the use of technologic tools. However, the experience of surgeons who prefer the open approach has increased with the anatomical technical improvements in robotic RP [54]. Recently, the high anterior release technique [16] and the veil of Aphrodite technique [43] of robot-assisted nsRP were identified. With these techniques, the PF is incised very anteriorly to spare the anterior accessory nerves, which can be important anatomical structures for potency. It is clear that high anterior release of the levator fascia (or periprostatic fascia) refers to the preservation of the periprostatic fascia during nsRP and can be called fascial-sparing RP, or fsRP (Fig. 4). Park et al. [55] stressed the importance of the neuroanatomy of the prostate in relation to functional outcomes in their article. Nielsen et al. [16] reported excellent oncological results and improved postoperative sexual function after this technique. I suggest that working collaboratively with a clinical anatomist is crucial to update the anatomical terminology of the prostate, which contiguous structures are clinically useful, and the surgical procedure [56].Fig. 4.Anatomical description of fascial-sparing radical prostatectomy (RP). SP, symphysis pubis; P, prostate; PF, periprostatic fascia; R, rectum; →→→, prostatic fascia; ---, periprostatic nerve fibers.CONCLUSIONFor urologists performing RP and uroanatomists performing anatomical cadaveric prostate dissection, the gross anatomy of the prostate and periprostatic fascial layers, the microscopic anatomy of the prostate, the location of the NVBs, and the relation of the periprostatic fascial layers on the anterior, lateral, and posterior sides of the prostate should be of great interest. A better understanding of the relation between nerve fibers and pelvic fascial layers is crucial for performing anatomical RP. The novel anatomical identification of nsRP as fsRP may be useful for future reports related to anatomical RP.
前列腺增生症的预防秋末至初春,注意防寒保暖,因为寒冷往往会加重病情。患者应绝对忌酒,少吃辛辣刺激性食品。饮酒可使前列腺及膀胱颈充血水肿而诱发尿潴留。辛辣食品,既可导致性器官充血,又会使痔疮、便秘症状加重,压迫前列腺,加重排尿困难。切忌长时间憋尿,憋尿会造成膀胱过度充盈,容易诱发急性尿潴留。不可过劳过度劳累,劳累会耗伤中气,中气不足会造成排尿无力,容易引起尿潴留。避免久坐或骑自行车,因为这样使会阴部充血,引起排尿困难。适量饮水,饮水过少不但会引起脱水,也不利排尿对尿路的冲洗作用,还容易导致尿液浓缩而形成不溶石。故除夜间适当减少饮水,以免睡后膀胱过度充盈,白天应多饮水。前列腺癌的预防1. 定期进行健康体检:“每年做1 次健康体检”这是基本的要求。尤其 50 岁以上或 40 岁以上有前列腺癌家族史的男性,要特别重视对前列腺的体检,进行前列腺直肠指检和血清PSA 检测相结合检查。2. 适当的体育运动: 适量运动还有助于调节心理平衡、有效消除压力,缓解抑郁和焦虑症状,改善睡眠。要养成经常运动的习惯,建议成年人选择适合自己的运动方式、强度和运动量,每周至少进行3 次运动,每次半小时以上,有助于保持健康的体重,从而有利于降低男性患上前列腺癌的几率。3. 减少摄入高脂饮食: 多项研究显示,高脂饮食会刺激前列腺癌生长,牛肉和高脂奶制品似乎是前列腺癌的刺激物,大量奶制品的摄入可使患前列腺癌的危险增高。因此要少吃那些高脂饮食,多吃新鲜蔬菜、水果、大豆等低脂饮食,有助于降低患前列腺癌的危险。这些健康食物包括大豆、洋葱、西红柿、石榴、绿茶、红葡萄、草莓、蓝莓、豌豆、西瓜、大蒜和柑橘等。前列腺疾病就诊推荐武汉同济医院泌尿外科是国内最早成立的泌尿专科之一,是国家教育部重点学科,也是卫生部临床重点专科,也是中华医学会泌尿外科学分会主任委员所在单位,男性前列腺疾病诊治方面在国内外享有较高声誉。其科研和临床诊治等综合实力一直雄踞同行前列并达到国际领先水平,是国家“十二五”科技攻关计划(预防控制老年相关疾病的研究)和中国前列腺癌联盟的主要协作和发起单位之一。也是中国前列腺增生症和前列腺癌诊疗指南的主要编写单位。王志华教授曾参与制定中国老年前列腺增生干预规范与保健指南,参与构建全国前列腺增生防控网络,建立华中地区及全国范围的前列腺癌数据库系统。应广大患者的要求,武汉同济医院泌尿外科王志华副教授专家门诊将为老年前列腺患者提供详细规范的诊疗咨询,并帮助患者建立科学的疾病管理体系,期待为更多的前列腺疾病患者带来福音。