随着机器人微创外科技术的引入和不断发展，根治性前列腺切除术的手术入路也有了不同程度的创 新和发展，此外加速康复外科理念在临床实践中不断深入，其目的都是为了更好地实现“三连胜（肿瘤控制、尿控 及性功能保留）”的治疗目标。本综述将从手术入路的角度进行总结和分析，希望能为泌尿外科医师选择不同手术 入路时提供一定的参考和借鉴。

With the development of minimally invasive robotic techniques, surgical approaches for radical prostatectomy have also been innovated and developed to some extent. In addition, the concept of enhanced recovery after surgery has been further promoted in clinical practice with the purpose of achieving the Trifecta Goal (cancer control, preservation of continence and preservation of sexuality) better. By reviewing and summarizing experiences on different surgical approaches, this article hopes to provide some references for urologists on choosing different surgical approaches in performing radical prostatectomy.

收稿日期：2021-08-30  录用日期：2021-12-09 

Received Date: 2021-08-30  Accepted Date: 2021-12-09 

基金项目：国家自然科学基金项目（82060467）；国家自然科学基金项目（81760457）；江西省科技重大专项（20161ACG70013）

Foundation Item: National Natural Science Foundation of China (82060467); National Natural Science Foundation of China (81760457); Jiangxi Provincial Science and Technology Major Project(20161ACG70013) 

通讯作者：王共先，Email：wanggx-mr@126.com 

Corresponding Author: WANG Gongxian, Email: wanggx-mr@126.com 

引用格式：程晓锋，王共先 . 根治性前列腺切除术手术入路创新进展与加速康复外科 [J]. 机器人外科学杂志（中英文），2022， 3（6）：500-510. 

Citation: CHENG X F, WANG G X. Innovative advances of surgical approach in radical prostatectomy and enhanced recovery after surgery[J]. Chinese Journal of Robotic Surgery, 2022, 3(6): 500-510.

[1] Siegel R L, Miller K D, Fuchs H E, et al. Cancer Statistics, 2021 [J]. CA Cancer J Clin, 2021, 71(1): 7-33. 

[2] LIU X, YU C, BI Y, et al. Trends and age-period-cohort effect on incidence and mortality of prostate cancer from 1990 to 2017 in China [J]. Public Health, 2019.DOI: 10.1016/j.puhe.2019.04.016. 

[3] 马春光 , 叶定伟 , 李长岭 , 等 . 前列腺癌的流行病 学特征及晚期一线内分泌治疗分析 [J]. 中华外科杂 志 , 2008, 46(12): 921-925.

[4] Lancee M, Tikkinen K A O, De Reijke T M, et al. Guideline of guidelines: primary monotherapies for localised or locally advanced prostate cancer [J]. BJU Int, 2018, 122(4): 535-548.

[5] Tilki D, Pompe R S, Bandini M, et al. Local treatment for metastatic prostate cancer: A systematic review [J]. Int J Urol, 2018, 25(5): 390-403. 

[6] Young H H. VIII. Conservative perineal prostatectomy: the results of two years’ experience and report of seventy-five cases [J]. Ann Surg, 1905, 41(4): 549-557.

[7] Sathianathen N J, Konety B R, Crook J, et al. Landmarks in prostate cancer [J]. Nat Rev Urol, 2018, 15(10): 627-642. 

[8] Millin T. Retropubic prostatectomy: a new extravesical technique; report of 20 cases [J]. Lancet, 1945, 2(6380): 693-696. 

[9] Walsh P C. Radical prostatectomy for the treatment of localized prostatic carcinoma [J]. Urol Clin North Am, 1980, 7(3): 583-591. 

[10] Ferzli G, Trapasso J, Raboy A, et al. Extraperitoneal endoscopic pelvic lymph node dissection [J]. J Laparoendosc Surg, 1992, 2(1): 39-44. 

[11] Schuessler W W, Schulam P G, Clayman R V, et al. Laparoscopic radical prostatectomy: initial short-term experience [J]. Urology, 1997, 50(6): 854-857. 

[12] Guillonneau B, Vallancien G. Laparoscopic radical prostatectomy: the Montsouris experience [J]. J Urol, 2000, 163(2): 418-422. 

[13] Saranchuk J W, Kattan M W, Elkin E, et al. Achieving optimal outcomes after radical prostatectomy [J]. J Clin Oncol, 2005, 23(18): 4146-4151. 

[14] Binder J, Kramer W. Robotically-assisted laparoscopic radical prostatectomy [J]. BJU Int, 2001, 87(4): 408-410.

[15] Menon M, Tewari A, Peabody J O, et al. Vattikuti Institute prostatectomy, a technique of robotic radical prostatectomy for management of localized carcinoma of the prostate: experience of over 1100 cases [J]. Urol Clin North Am, 2004, 31(4): 701-717. 

[16] Costello A J. Considering the role of radical prostatectomy in 21st century prostate cancer care [J]. Nat Rev Urol, 2020, 17(3): 177-188. 

[17] Arenas-Gallo C, Shoag J E, Hu J C. Optimizing surgical techniques in robot-assisted radical prostatectomy [J]. Urol Clin North Am, 2021, 48(1): 1-9.

[18] Ficarra V, Cavalleri S, Novara G, et al. Evidence from robot-assisted laparoscopic radical prostatectomy: a systematic review [J]. Eur Urol, 2007, 51(1): 45-56. 

[19] Yaxley J W, Coughlin G D, Chambers S K, et al. Robot-assisted laparoscopic prostatectomy versus open radical retropubic prostatectomy: early outcomes from a

randomised controlled phase 3 study [J]. Lancet, 2016, 388(10049): 1057-1066.

[20] Coughlin G D, Yaxley J W, Chambers S K, et al. Robotassisted laparoscopic prostatectomy versus open radical retropubic prostatectomy: 24-month outcomes from a randomised controlled study [J]. Lancet Oncol, 2018, 19(8): 1051-1060.

[21] Bianco F J Jr, Scardino P T, Eastham J A. Radical prostatectomy: long-term cancer control and recovery of sexual and urinary function (“trifecta”) [J]. Urology, 2005, 66(5 Suppl): 83-94. [22] OU Y C, YANG C K, WANG J, et al. The trifecta outcome in 300 consecutive cases of robotic-assisted laparoscopic radical prostatectomy according to D’Amico risk criteria [J]. Eur J Surg Oncol, 2013, 39(1): 107-113. 

[23] Savera A T, Kaul S, Badani K, et al. Robotic radical prostatectomy with the “Veil of Aphrodite” technique: histologic evidence of enhanced nerve sparing [J]. Eur Urol, 2006, 49(6): 1065-1074. 

[24] Menon M, Tewari A, Peabody J. Vattikuti Institute prostatectomy: technique [J]. J Urol, 2003, 169(6): 2289-2292. 

[25] Walsh P C, Donker P J. Impotence following radical prostatectomy: insight into etiology and prevention [J]. J Urol, 1982, 128(3): 492-497. 

[26] Zvara P, Spiess P E, Merlin S L, et al. Neurogenic erectile dysfunction: the course of nicotinamide adenine dinucleotide phosphate diaphorase-positive nerve fibers on the surface of the prostate [J]. Urology, 1996, 47(1): 146-151. 

[27] Sato Y, Rehman J, Santizo C, et al. Significant physiological roles of ancillary penile nerves on increase in intracavernous pressure in rats: experiments using electrical stimulation of the medial preoptic area [J]. Int J Impot Res, 2001, 13(2): 82-88.

[28] Walz J, Burnett A L, Costello A J, et al. A critical analysis of the current knowledge of surgical anatomy related to optimization of cancer control and preservation of continence and erection in candidates for radical prostatectomy [J]. Eur Urol, 2010, 57(2): 179-192.

[29] Eichelberg C, Erbersdobler A, Michl U, et al. Nerve distribution along the prostatic capsule [J]. Eur Urol, 2007, 51(1): 105-111. 

[30] De Carvalho P A, Barbosa J, Guglielmetti G B, et al. Retrograde release of the neurovascular bundle with preservation of dorsal venous complex during robotassisted radical prostatectomy: optimizing functional outcomes [J]. Eur Urol, 2020, 77(5): 628-635. 

[31] Wagaskar V G, Mittal A, Sobotka S, et al. Hood technique for robotic radical prostatectomy-preserving periurethral anatomical structures in the space of retzius and sparing the pouch of douglas, enabling early return of continence without compromising surgical margin rates [J]. Eur Urol, 2021, 80(2): 213-221.

[32] 王共先 , 刘伟鹏 , 周晓晨 . 前列腺癌根治术入路的 选择 [J]. 临床泌尿外科杂志 , 2018, 33(6): 423-427. 

[33] Pasticier G, Rietbergen J B, Guillonneau B, et al. Robotically assisted laparoscopic radical prostatectomy: feasibility study in men [J]. Eur Urol, 2001, 40(1): 70-74.

[34] Galfano A, Ascione A, Grimaldi S, et al. A new anatomic approach for robot-assisted laparoscopic prostatectomy: a feasibility study for completely intrafascial surgery [J]. Eur Urol, 2010, 58(3): 457-461. 

[35] Dalela D, Jeong W, Prasad M A, et al. A pragmatic randomized controlled trial examining the impact of the retzius-sparing approach on early urinary continence recovery after robot-assisted radical prostatectomy [J]. Eur Urol, 2017, 72(5): 677-685.

[36] Menon M, Dalela D, Jamil M, et al. Functional recovery, oncologic outcomes and postoperative complications after robot-assisted radical prostatectomy: an evidence-based analysis comparing the retzius sparing and standard approaches [J]. J Urol, 2018, 199(5): 1210-1217.

[37] Checcucci E, Veccia A, Fiori C, et al. Retziussparing robot-assisted radical prostatectomy vs the standard approach: a systematic review and analysis of comparative outcomes [J]. BJU Int, 2020, 125(1): 8-16.

[38] Garisto J, Bertolo R, Wilson C A, et al. The evolution and resurgence of perineal prostatectomy in the robotic surgical era [J]. World J Urol, 2020, 38(4): 821-828.

[39] Minafra P, Carbonara U, Vitarelli A, et al. Robotic radical perineal prostatectomy: tradition and evolution in the robotic era [J]. CurrOpinUrol, 2021, 31(1): 11-17.

[40] Kaouk J H, Akca O, Zargar H, et al. Descriptive technique and initial results for robotic radical perineal prostatectomy [J]. Urology, 2016.DOI: 10.1016/ j.urology.2016.02.063.

[41] Tugcu V, Akca O, Simsek A, et al. Robot-assisted radical perineal prostatectomy: First experience of 15 cases [J]. Türk Üroloji Dergisi/turkish Journal of Urology, 2017, 43(4): 476-483. [42] Tuğcu V, Akça O, Şimşek A, et al. Robotic-assisted perineal versus transperitoneal radical prostatectomy: A matched-pair analysis [J]. Turkish Journal of Urology, 2019, 45(4): 265-272. [43] Ramirez D, Maurice M J, Kaouk J H. Robotic perineal radical prostatectomy and pelvic lymph node dissection using a purpose-built single-port robotic platform [J]. BJU Int, 2016, 118(5): 829-833.

[44] Mattei A, Naspro R, Annino F, et al. Tension and energyfree robotic-assisted laparoscopic radical prostatectomy with interfascial dissection of the neurovascular bundles [J]. Eur Urol, 2007, 52(3): 687-694. 

[45] Cusumano S, Annino F, Selas E R, et al. Feasibility, technique, and principles of tension-and energyfree laparoscopic radical prostatectomy with lateral intrafascial dissection of the neurovascular bundles with the use of a high-definition optical device [J]. J Endourol, 2008, 22(9): 1981-1987. 

[46] Dal Moro F, Crestani A, Valotto C, et al. Anesthesiologic effects of transperitoneal versus extraperitoneal approach during robot-assisted radical prostatectomy: results of a prospective randomized study [J]. Int Braz J Urol, 2015, 41(3): 466-472. 

[47] Uy M, Cassim R, Kim J, et al. Extraperitoneal versus transperitoneal approach for robot-assisted radical prostatectomy: a contemporary systematic review and meta-analysis [J]. J Robot Surg, 2021.DOI: 10.1007/ s11701-021-01245-0. 

[48] Kallidonis P, Rai B P, Qazi H, et al. Critical appraisal of literature comparing minimally invasive extraperitoneal and transperitoneal radical prostatectomy: A systematic review and meta-analysis [J]. Arab JUrol, 2017, 15(4): 267-279. 

[49] Desai M M, Aron M, Berger A, et al. Transvesical robotic radical prostatectomy [J]. BJU Int, 2008, 102(11): 1666-1669. 

[50] Gao X, Pang J, Si-Tu J, et al. Single-port transvesical laparoscopic radical prostatectomy for organ-confined prostate cancer: technique and outcomes [J]. BJU Int, 2013, 112(7): 944-952. [51] 周晓晨 , 胡兵 , 傅斌 , 等 . 3 种机器人辅助腹腔镜根 治性前列腺切除术手术入路对比研究 : 前入路、 后入路及经膀胱入路 [J]. 临床泌尿外科杂志 , 2019, 34(7): 501-506. 

[52] ZHOU X, FU B, ZHANG C, et al. Transvesical robotassisted radical prostatectomy: initial experience and surgical outcomes [J]. BJU Int, 2020, 126(2): 300-308.

[53] Martini A, Falagario U G, Villers A, et al. Contemporary techniques of prostate dissection for robot-assisted prostatectomy [J]. Eur Urol, 2020, 78(4): 583-591.

[54] DENG W, JIANG H, LIU X, et al. Transvesicalretziussparing versus standard robot-assisted radical prostatectomy: a retrospective propensity scoreadjusted analysis [J]. Front Oncol, 2021. DOI: 10.3389/ fonc.2021.687010. 

[55] DENG W, ZHANG C, JIANG H, et al. Transvesical versus posterior approach to retzius-sparing robotassisted radical prostatectomy: a retrospective comparison with a 12-month follow-up [J]. Front Oncol, 2021.DOI: 10.3389/fonc.2021.641887. 

[56] 徐臻 , 李忠义 , 郑嘉文 , 等 . 日间手术模式行经膀 胱入路机器人辅助腹腔镜下根治性前列腺切除术 的临床研究 [J]. 机器人外科学杂志 ( 中英文 ), 2021, 2(4): 287-294. 

[57] Kaouk J, Beksac A T, Zeinab M A, et al. Single port transvesical robotic radical prostatectomy: initial clinical experience and description of technique [J]. Urology, 2021. DOI: 10.1016/j.urology.2021.05.022.

[58] Villers A, Puech P, Flamand V, et al. Partial prostatectomy for anterior cancer: short-term oncologic and functional outcomes [J]. Eur Urol, 2017, 72(3): 333-342.

[59] Krambeck A E, Humphreys M R, Andrews P E, et al. Natural orifice translumenal endoscopic surgery: radical prostatectomy in the canine model [J]. J Endourol, 2010, 24(9): 1493-1496. 

[60] Humphreys M R, Sauer J S, Ryan A R, et al. Natural orifice transluminal endoscopic radical prostatectomy: initial perioperative and pathologic results [J]. Urology, 2011, 78(6): 1211-1217. [61] Nagele U, Anastasiadis A G, Walcher U, et al. Natural orifice (NOTES) transurethral sutureless radical prostatectomy with thulium laser support: first patient report [J]. World J Urol, 2012, 30(5): 625-631. 

[62] Duty B, Roy O, Micali S, et al. The application of natural orifice surgery for adenocarcinoma of the prostate [J]. Urol Oncol, 2011, 29(3): 330-333.

[63] YE Z, CHEN J, SHEN T, et al. Enhanced recovery after surgery (ERAS) might be a standard care in radical prostatectomy: a systematic review and meta-analysis [J]. Ann Palliat Med, 2020, 9(3): 746-758. 

[64] LV Z, CAI Y, JIANG H, et al. Impact of enhanced recovery after surgery or fast track surgery pathways in minimally invasive radical prostatectomy: a systematic review and meta-analysis [J]. Transl Androl Urol, 2020, 9(3): 1037-1052.

[65] Schoentgen N, Califano G, Manfredi C, et al. Is it worth starting sexual rehabilitation before radical prostatectomy? Results from a systematic review of the literature [J]. Front Surg, 2021. DOI: 10.3389/ fsurg.2021.648345. 

[66] Sawczyn G, Lenfant L, Aminsharifi A, et al. Predictive factors for opioid-free management after robotic radical prostatectomy: the value of the SP(R) Robotic Platform [J]. Minerva UrolNefrol, 2020.DOI: 10.23736/S0393- 2249.20.04038-2. 

[67] Reynolds B R, Bulsara C, Zeps N, et al. Exploring pathways towards improving patient experience of robot-assisted radical prostatectomy (RARP): assessing patient satisfaction and attitudes [J]. BJU International, 2018, 121(Suppl 3): 33-39. 

[68] Patel V R, Samavedi S, Bates A S, et al. Dehydrated human amnion/chorion membrane allograft nerve wrap around the prostatic neurovascular bundle accelerates early return to continence and potency following robotassisted radical prostatectomy: propensity scorematched analysis [J]. Eur Urol, 2015, 67(6): 977-980. 

[69] Porpiglia F, Bertolo R, Fiori C, et al. Chitosan membranes applied on the prostatic neurovascular bundles after nerve-sparing robot-assisted radical prostatectomy: a phase II study [J]. BJU Int, 2018, 121(3): 472-478.

[70] Manny T B, Patel M, Hemal A K. Fluorescenceenhanced robotic radical prostatectomy using realtime lymphangiography and tissue marking with percutaneous injection of unconjugated indocyanine green: the initial clinical experience in 50 patients [J]. Eur Urol, 2014, 65(6): 1162-1168.