关键词： 前列腺癌；直肠癌；前列腺癌根治术；吻合口尿漏；机器人
宋正尧，周 骏，杨 诚，陈 伟，梁朝朝
目的：报道本中心收治的1 例前列腺癌合并直肠癌患者的诊断、治疗和预后的临床资料，探讨此类疾病诊疗过程中相关的注意事项。方法：回顾性分析本中心2019 年6 月收治的1 例前列腺癌合并直肠癌患者的临床资料，总结相关经验，并结合文献复习对该类疾病的诊断、治疗、围术期管理和术中注意事项进行探讨。结果：本例为76 岁男性患者，行达芬奇机器人辅助腹腔镜下直肠癌根治（Miles）+ 前列腺癌根治性切除术后尿漏，予适当牵拉尿管并固定于下肢、加强营养支持等治疗后仍无明显好转，根治术后10d 行局麻下输尿管镜下双侧单J管置入术，将双侧单J 管牵出体外并固定于尿管上，嘱适当卧床休息，置管术后盆腔引流液明显减少，3d 后无明显盆腔引流液，于置管术后第6d 拔除盆腔引流管后患者无明显不适，行盆腔超声检查盆腔无明显积液，根治术后第23d 拔除尿管，尿失禁存在，24h 尿垫约2 块，加强盆底肌锻炼后1 月，症状好转。结论：机器人辅助腹腔镜下前列腺根治性切除术术后吻合口尿漏是常见的并发症之一，当联合直肠癌根治术时因为膀胱颈- 尿道吻合口后方缺乏组织支撑、术后早期活动引起的剪切力增加吻合口不稳定性、术后肠道功能恢复慢影响饮食等均可能导致尿漏高发生率，但当调整低张力牵拉尿管、加强营养支持等治疗效果不佳时，输尿管镜下双侧输尿管单J 管置入术可作为一种有效的治疗方法。
Objective: To explore the relevant considerations in diagnosis and treatment on prostate cancer combined with rectal cancer. Methods: The clinical data of a patient with prostate cancer and rectal cancer treated in our center in June 2019 were retrospectively analyzed. The relevant experience was summarized and the literature review was performed to explore the diagnosis, treatment, perioperative management and intraoperative precautions on this type of disease. Results: The 76-year-old male patient was found urethrovesical anastomic leakage after robot-assisted laparoscopic radical rectal resection of cancer (Miles) + radical prostatectomy. No significant improvement was found after pulling the urinary tube, fixing it to the lower limbs and strengthening nutritional support. Bilateral single J-tube placement was performed under local anesthesia and ureteroscopy 10 days after radical operation, the tube was pulled out of the body and fixed on the ureter and the patient was advised to stay in bed properly. Significant reduction in pelvic drainage was found after catheterization. No obvious pelvic drainage was found 3 days after catheterization and no obvious discomfort occurred 6 days after catheterization when the pelvic drainage tube was pulled out. No fluid in pelvic detected by pelvic ultrasound. The urinary tube was removed 23 days after radical operation. 2 pieces of urine pads were needed in 24 hours because of the urinary incontinence. The urinary incontinence got better after onemonth exercise of strengthening the pelvic floor muscles. Conclusion: Urethrovesical anastomic leakage is one of the common complications after robot-assisted laparoscopic radical prostatectomy. When it combined with radical rectal resection of cancer, the lack of tissue support behind the bladder neck-urethral anastomosis, anastomotic instability increased by shear force caused in early postoperative activities, slow recovery of intestinal function after surgery may all lead to a high incidence of urinary leakage. However, if pulling catheter with low tension and strengthening nutritional support do not work well, single J-tube placement in bilateral ureters under ureteroscopy can be an effective way to treat urethrovesical anastomic leakage.