Objectives: To examine the functional outcomes of robot-assisted radical prostatectomy (RARP) with preservation of pelvic floor stabilized structure and early elevated retrograde liberation of the neurovascular bundle (PEEL). Methods: This study was a retrospective cohort study. Between June 1, 2022, and March 20, 2023, 27 cases of RARP with PEEL and 153 cases of RARP with preservation of pelvic floor stabilized structure (PPSS) were included in this study. All patients were males, aged (62.5±5.2) years (range: 50 to 73 years). There were 18 cases of ≤T2b stage and 9 cases of T2c stage. After 1∶1 propensity score matching, the postoperative functional outcomes of 27 cases of RARP with PEEL and 27 cases of RARP with PPSS were compared. All surgeries were performed by a single surgeon and included patients were clinically staged as cT1-2N0M0 without preoperative urinary incontinence or erectile dysfunction. In RARP with PEEL, the prostate was cut near the midline at the front when dissecting the neurovascular bundle, dissection was performed between the visceral layer of the pelvic fascia and the prostatic fascia, preserving the parietal layer and the visceral layer of the pelvic fascia, and the neurovascular bundle was retrogradely released from the apex. The cumulative probability curve was plotted using the Kaplan-Meier method and the Log-rank test was used to compare the differences in functional outcomes between the two groups. Univariate and multivariate analysis with the Cox proportional hazards model was used to compare postoperative urinary continence and sexual function. Results: The recovery time of continence and potency was significantly longer in the PPSS group than in the PEEL group (all P<0.05). The continence rate of the PEEL group was significantly higher than that of the PPSS group (92.59% vs. 68.10%, P=0.026) at 3 months after surgery. The potency rate of the PEEL group was also significantly higher than that of the PPSS group (40.70% vs. 15.10%, P=0.037) at 3 months after surgery. In the univariate analysis, compared to the PPSS technique, the PEEL technique was associated with a shorter recovery time of continence (HR=1.94, 95%CI: 1.08 to 3.48, P=0.027) and a shorter recovery time of potency (HR=2.06, 95%CI: 1.03 to 4.13, P=0.042). In the multivariate analysis, the PEEL technique was an independent prognosis factor for postoperative recovery of continence (HR=2.05, 95%CI: 1.01 to 4.17, P=0.047) and potency (HR=3.57, 95%CI: 1.43 to 8.92, P=0.007). All the cases of the PPSS group and the PEEL group were performed successfully with negative surgical margins. Conclusion: Compared with PPSS, PEEL may be more conducive to the recovery of urinary continence and sexual function after RARP.
目的： 探讨保留盆底稳定结构合并前方高位逆向松解神经血管束（PEEL）的机器人辅助腹腔镜根治性前列腺切除术（RARP）的功能结局。 方法： 本研究为回顾性队列研究。纳入2022年6月1日至2023年3月20日于四川大学华西医院泌尿外科接受PEEL技术治疗的27例RARP患者资料，均为男性，年龄（62.5±5.2）岁（范围：50~73岁），临床T分期≤T2b期18例，T2c期9例。PEEL技术的手术流程是从前列腺尖部靠近中线处沿盆筋膜脏层与前列腺固有包膜之间的层面进行游离，同时保留盆筋膜壁层和脏层，从尖部开始逆向松解神经血管束。通过扩展前列腺癌综合指数和男性性健康调查量表分别进行尿控恢复和性功能恢复的功能结局随访。尿控恢复定义为没有漏尿且不使用尿垫，性功能恢复定义为在一半以上的性行为尝试中达到满意勃起。所有患者接受3个月以上的随访。从同期接受保留盆底稳定结构（PPSS）技术的RARP患者中，以基线资料进行1∶1倾向性评分匹配，选出27例与PEEL组进行术后功能结局比较。通过Kaplan-Meier法绘制累积概率曲线，并使用Log-rank检验比较两组间功能结局差异。采用Cox比例风险模型进行RARP术后功能结局的单因素及多因素分析。 结果： PEEL组术后3个月尿控恢复率高于PPSS组（92.59%比68.10%，P=0.026），性功能恢复率亦高于PPSS组（40.70%比15.10%，P=0.037）。PEEL组的尿控恢复和性功能恢复均优于PPSS组（Log-rank检验：P值均<0.05）。单因素分析显示，PEEL技术与尿控恢复（HR=1.94，95%CI：1.08~3.48，P=0.027）和性功能恢复（HR=2.06，95%CI：1.03~4.13，P=0.042）相关。多因素分析结果显示，PEEL技术是尿控恢复（HR=2.05，95%CI：1.01~4.17，P=0.047）和性功能恢复（HR=3.57，95%CI：1.43~8.92，P=0.007）的独立预后因素。所有纳入分析的54例RARP术后标本病理学检查均示切缘阴性。 结论： 相较于PPSS技术，PEEL技术可能更利于RARP术后的尿控恢复和性功能恢复。.