前列腺癌术后腹股沟疝的发生率及危险因素分析

doi:10.3877/cma.j.issn.1674-392X.2024.04.007

目的

探讨前列腺癌术后腹股沟疝（PIH）的发生率和危险因素。

方法

采用回顾性病例对照研究方法，分析深圳市人民医院2018年1月至2022年12月共260例因诊断前列腺癌行前列腺根治切除术患者的临床资料，根据术后随访是否发现并发腹股沟疝分为PIH组和非PIH组。观察2组患者基本特征、肿瘤相关指标、手术相关指标，包括年龄、体重指数、是否有下腹手术史、术前1个月内前列腺特异性抗原（PSA）结果，国际泌尿病理学会（ISUP）分级、前列腺根治术标本大小、前列腺癌病理T分期（pT）、是否术前内分泌治疗、手术时长、术中出血量、手术方式、手术入路、是否行淋巴结清扫等情况。

结果

PIH组平均年龄明显高于非PIH组[（70.48±4.47）岁比（66.31±7.75）岁]，差异有统计学意义（P<0.001）。PIH组平均体重、体重指数显著低于非PIH组[（62.71±8.84）kg比（68.60±9.82）kg，（22.46±2.71）kg/m²比（24.35±2.97）kg/m²]，差异均有统计学意义（P<0.001）。行腹腔镜前列腺癌根治术（LRP）患者的PIH发生率高于机器人辅助下腹腔镜前列腺癌根治术（RARP）（15.6%比7.6%），行盆腔淋巴结清扫术的患者PIH发生率高于未行该术者（14.9%比5.9%），差异均有统计学意义（χ²=3.97，P=0.046；χ²=4.39，P=0.036）。经腹腔入路PIH发生率明显低于腹膜外入路（8.1%比17.1%），差异有统计学意义（χ²=4.98，P=0.026）。2组身高、既往下腹手术史率、术前1个月PSA、pT、根治术标本体积、ISUP分级、术前内分泌治疗率、手术时间、手术出血量差异无统计学意义。根治性前列腺切除术术后1、2、3年累计发生率分别为7.7%、11.4%、13.4%。高龄、低体重指数对PIH发展的影响有统计学意义（HR=1.064，95% CI 1.010～1.120，P=0.020；HR=0.842，95% CI 0.743～0.953，P=0.007），手术方式、盆腔淋巴结清扫、手术时间等其他变量对PIH发展的影响无统计学意义。

结论

高龄、低体重指数是前列腺癌术后并发腹股沟疝的高危因素。

关键词: 前列腺癌, 疝，腹股沟, 危险因素

Objective

To investigate the incidence and risk factors of postoperative inguinal hernia (PIH) after prostate cancer surgery.

Methods

A retrospective case-control study was conducted to analyze the clinical data of 260 patients who underwent radical prostatectomy for the diagnosis of prostate cancer in Shenzhen People's Hospital between January 2018 and December 2022. Patients were divided into the PIH group and the non-PIH group, according to whether they were found to have concomitant inguinal hernia in the postoperative follow-up. The basic characteristics, tumor-related indexes, and surgery-related indexes of the patients in the two groups were observed, including age, body mass index (BMI), history of previous lower abdominal surgery, prostate specific antigen (PSA) results within one month before surgery, and International Society of Urological Pathology (ISUP) grade, size of the radical prostatectomy specimen, pathological T-stage (pT) of prostate cancer, whether preoperative endocrine therapy, operative time, intraoperative bleeding, surgical method, surgical approaches, and whether lymph node dissection was performed.

Results

The mean age of the PIH group was significantly higher than that of the non-PIH group (70.48±4.47 years vs. 66.31±7.75 years), with a statistically significant difference (P<0.001). The mean weight and BMI of the PIH group were significantly lower than those of the non-PIH group (62.71±8.84 kg vs. 68.60±9.82 kg, 22.46±2.71 kg/m² vs. 24.35±2.97 kg/m²), with a statistically significant difference (P<0.001). The incidence of PIH in patients undergoing laparoscopic radical prostatectomy (LRP), pelvic lymph node dissection was higher than that in patients undergoing robot-assisted laparoscopic radical prostatectomy (RARP) (15.6% vs. 7.6%), non-pelvic lymph node dissection (14.9% vs. 5.9%). The differences were statistically significant (χ²=3.97, P=0.046; χ²=4.39, P=0.036). Conversely, the incidence of PIH was significantly lower in the transperitoneal approach than in the extraperitoneal approach (8.1% vs. 17.1%), with a statistically significant difference (χ²=4.98, P=0.026). There was no statistically significant difference between the two groups in terms of height, previous history of lower abdominal surgery, one-month preoperative PSA, pT, volume of radical specimen, ISUP grade, rate of preoperative endocrine therapy, operative time, or operative bleeding. The cumulative incidence of PIH 1, 2, and 3 years after radical prostatectomy was 7.7%, 11.4%, 13.4%, respectively. A statistically significant effect of advanced age and low BMI on the development of PIH was observed (HR=1.064, 95% CI 1.010-1.120, P=0.020; HR=0.842, 95% CI 0.743-0.953, P=0.007). Surgical procedure, pelvic lymph node dissection, duration of surgery and other variables had no statistical significance on the development of PIH.

Conclusion

Advanced age and low BMI were identified as risk factors for the development of inguinal hernia after prostate cancer surgery.

Key words: Prostate cancer, Inguinal hernia, Risk factors

表1 2组前列腺癌患者的基本特征、肿瘤相关指标、手术相关指标比较

影响因素	非PIH组(n=229)	PIH组(n=31)	t/χ²/Z值	P值
基本特征
年龄(岁,±s)	66.31±7.75	70.48±4.47	-4.38	<0.001
体重(kg,±s)	68.60±9.82	62.71±8.84	3.17	0.001
身高(m,±s)	1.68±0.06	1.70±0.06	0.70	0.485
体重指数(kg/m²,±s)	24.35±2.97	22.46±2.71	3.35	<0.001
既往下腹手术史[例(%)]	36(15.7)	7(22.6)	0.93^①	0.335
肿瘤相关指标
前列腺特异性抗原[ng/ml,M(P_25～P₇₅)]	8.37(4.79,15.74)	11.26(7.59,19.2)	-1.50^②	0.133
病理T分期[例(%)]
1	4(1.5)	0(0.0)
2	159(61.2)	23(8.8)
3	55(21.1)	8(3.1)
4	0(0.0)	0(0.0)	-0.23^②	0.821
\*	11(4.2)	0(0.0)
根治术标本体积[cm³,M(P_25～P₇₅)]	70.0(47.3,96.0)	61.5(44.8,91.0)	-0.48^②	0.630
国际泌尿病理学会分级[例(%)]
1	35(13.5)	3(1.2)
2	71(27.3)	10(3.8)
3	50(19.2)	7(2.7)
4	19( 7.3)	3(1.2)
5	28(10.8)	6(2.3)	-1.11^②	0.269
\**	26(10.0)	2(0.8)
术前内分泌治疗[例(%)]	34(13.1)	3(1.2)	0.25^①	0.618
手术相关指标
手术时间(min,±s)	303.05±89.30	291.84±72.64	0.67	0.504
手术出血量[ml,M(P_25～P₇₅)]	100(50,100)	100(100,200)	-1.85	0.064

表1 2组前列腺癌患者的基本特征、肿瘤相关指标、手术相关指标比较

影响因素	非PIH组(n=229)	PIH组(n=31)	t/χ²/Z值	P值
基本特征
年龄(岁,±s)	66.31±7.75	70.48±4.47	-4.38	<0.001
体重(kg,±s)	68.60±9.82	62.71±8.84	3.17	0.001
身高(m,±s)	1.68±0.06	1.70±0.06	0.70	0.485
体重指数(kg/m²,±s)	24.35±2.97	22.46±2.71	3.35	<0.001
既往下腹手术史[例(%)]	36(15.7)	7(22.6)	0.93^①	0.335
肿瘤相关指标
前列腺特异性抗原[ng/ml,M(P_25～P₇₅)]	8.37(4.79,15.74)	11.26(7.59,19.2)	-1.50^②	0.133
病理T分期[例(%)]
1	4(1.5)	0(0.0)
2	159(61.2)	23(8.8)
3	55(21.1)	8(3.1)
4	0(0.0)	0(0.0)	-0.23^②	0.821
\*	11(4.2)	0(0.0)
根治术标本体积[cm³,M(P_25～P₇₅)]	70.0(47.3,96.0)	61.5(44.8,91.0)	-0.48^②	0.630
国际泌尿病理学会分级[例(%)]
1	35(13.5)	3(1.2)
2	71(27.3)	10(3.8)
3	50(19.2)	7(2.7)
4	19( 7.3)	3(1.2)
5	28(10.8)	6(2.3)	-1.11^②	0.269
\**	26(10.0)	2(0.8)
术前内分泌治疗[例(%)]	34(13.1)	3(1.2)	0.25^①	0.618
手术相关指标
手术时间(min,±s)	303.05±89.30	291.84±72.64	0.67	0.504
手术出血量[ml,M(P_25～P₇₅)]	100(50,100)	100(100,200)	-1.85	0.064

表2 前列腺癌患者采用不同手术处理方法术后腹股沟疝发生率的比较[例（%）]

手术处理方法	例数	术后腹股沟疝	χ²值	P值
手术方式			3.97	0.046
LRP	141	22(15.6)
RARP	119	9(7.6)
手术入路			4.98	0.026
经腹腔入路	149	12(8.1)
腹膜外入路	111	19(17.1)
盆腔淋巴结清扫			4.39	0.036
有	175	26(14.9)
无	85	5(5.9)

表2 前列腺癌患者采用不同手术处理方法术后腹股沟疝发生率的比较[例（%）]

手术处理方法	例数	术后腹股沟疝	χ²值	P值
手术方式			3.97	0.046
LRP	141	22(15.6)
RARP	119	9(7.6)
手术入路			4.98	0.026
经腹腔入路	149	12(8.1)
腹膜外入路	111	19(17.1)
盆腔淋巴结清扫			4.39	0.036
有	175	26(14.9)
无	85	5(5.9)

图1 前列腺癌根治术后患者无腹股沟疝生存率K-M曲线

图2 不同年龄层次的前列腺癌根治术后患者无腹股沟疝生存率K-M曲线

图3 不同体重指数的前列腺癌根治术后患者无腹股沟疝生存率K-M曲线

表3 术后腹股沟疝的危险因素Cox回归分析

因素	单因素		多因素(全模型)		多因素(简化模型)
因素	HR(95% CI)	P	HR(95% CI)	P	HR(95% CI)	P
年龄(岁,±s)	1.068(1.022~1.117)	0.005	1.068(1.010~1.130)	0.022	1.064(1.010~1.120)	0.020
体重指数(kg/m²,±s)	0.814(0.720~0.921)	0.001	0.833(0.733~0.946)	0.005	0.842(0.743~0.953)	0.007
既往下腹手术史[例(%)]	1.452(0.625~3.369)	0.380	1.012(0.412~2.484)	0.980
术前PSA[ng/ml, M(P_25～P₇₅)]	1.001(0.986~1.017)	0.910	0.996(0.975~1.017)	0.700
病理T分期≥3比≤2 [例(%)]	1.063(0.476~2.378)	0.881	0.874(0.348~2.196)	0.775
根治术标本体积[cm³,M(P_25～P₇₅)]	0.997(0.989~1.006)	0.540	0.997(0.987~1.007)	0.555
国际泌尿病理学会分级≥4比≤3 [例(%)]	1.391(0.633~3.056)	0.412	1.511(0.636~3.591)	0.350
手术时间(min,±s)	0.998(0.994~1.003)	0.456	0.997(0.992~1.003)	0.289
手术方式(LRP比RARP) [例（%）]	0.524(0.241~1.142)	0.104	1.237(0.474~3.230)	0.664
手术出血量[ml, M(P_25～P₇₅)]	1.001(0.999~1.002)	0.370	1.002(1.000~1.004)	0.131
盆腔淋巴结清扫[例(%)]	2.468(.0947~6.431)	0.640	3.780(1.074~13.305)	0.038	2.522(0.963~6.603)	0.060
术前内分泌治疗[例(%)]	0.653(0.198~2.147)	0.483	0.592(0.068~5.167)	0.636

表3 术后腹股沟疝的危险因素Cox回归分析

因素	单因素		多因素(全模型)		多因素(简化模型)
因素	HR(95% CI)	P	HR(95% CI)	P	HR(95% CI)	P
年龄(岁,±s)	1.068(1.022~1.117)	0.005	1.068(1.010~1.130)	0.022	1.064(1.010~1.120)	0.020
体重指数(kg/m²,±s)	0.814(0.720~0.921)	0.001	0.833(0.733~0.946)	0.005	0.842(0.743~0.953)	0.007
既往下腹手术史[例(%)]	1.452(0.625~3.369)	0.380	1.012(0.412~2.484)	0.980
术前PSA[ng/ml, M(P_25～P₇₅)]	1.001(0.986~1.017)	0.910	0.996(0.975~1.017)	0.700
病理T分期≥3比≤2 [例(%)]	1.063(0.476~2.378)	0.881	0.874(0.348~2.196)	0.775
根治术标本体积[cm³,M(P_25～P₇₅)]	0.997(0.989~1.006)	0.540	0.997(0.987~1.007)	0.555
国际泌尿病理学会分级≥4比≤3 [例(%)]	1.391(0.633~3.056)	0.412	1.511(0.636~3.591)	0.350
手术时间(min,±s)	0.998(0.994~1.003)	0.456	0.997(0.992~1.003)	0.289
手术方式(LRP比RARP) [例（%）]	0.524(0.241~1.142)	0.104	1.237(0.474~3.230)	0.664
手术出血量[ml, M(P_25～P₇₅)]	1.001(0.999~1.002)	0.370	1.002(1.000~1.004)	0.131
盆腔淋巴结清扫[例(%)]	2.468(.0947~6.431)	0.640	3.780(1.074~13.305)	0.038	2.522(0.963~6.603)	0.060
术前内分泌治疗[例(%)]	0.653(0.198~2.147)	0.483	0.592(0.068~5.167)	0.636

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Analysis of incidence and risk factors of inguinal hernia after prostate cancer surgery

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Analysis of incidence and risk factors of inguinal hernia after prostate cancer surgery