您好, 访客   登录/注册

经尿道等离子前列腺剜除术治疗大体积前列腺增生的疗效

来源:用户上传      作者:

  摘要:目的  探討经尿道等离子前列腺剜除术(TPKEP)治疗大体积良性前列腺增生的疗效。方法  收集2016年3月~2018年1月佳木斯市中心医院泌尿外科收治的大体积前列腺增生患者126例,根据治疗方法分为对照组(58例)和观察组(68例)。对照组采用经尿道等离子前列腺电切术(TPKRP)治疗,观察组采用TPKEP治疗,比较两组围手术期指标(手术时间、术中出血量、前列腺切除重量、膀胱冲洗时间、留置尿管时间、术后住院时间)及术前、术后3、12个月IPSS评分、QOL评分、最大尿流率(Qmax)、残余尿量(RUV)和术后并发症发生情况。结果  观察组手术时间、术中出血量、前列腺切除重量均优于对照组[(75.12±38.18)min vs(90.50±45.66)min]、[(98.33±26.71)ml vs(117.32±34.70)ml]、[(53.82±8.05)g vs(41.80±6.77)g],差异有统计学意义(P<0.05);两组膀胱冲洗时间、尿管留置时间、术后住院时间比较,差异无统计学意义(P>0.05)。两组术后3、12个月IPSS评分、QOL评分较术前降低,Qmax较术前增高,RUV较术前减少,差异有统计学意义(P<0.05)。观察组术后3个月QOL评分高于对照组,RUV低于对照组,差异有统计学意义(P<0.05);两组术后3个月IPSS评分、Qmax比较,差异无统计学意义(P>0.05)。观察组术后12个月Qmax高于对照组,RUV低于对照组,差异有统计学意义(P<0.05);两组术后12个月IPSS评分、QOL评分比较,差异无统计学意义(P>0.05)。观察组术后3、12个月并发症总发生率低于对照组,差异有统计学意义(P<0.05)。结论  TPKEP治疗大体积前列腺增生临床疗效确切,可有效缩短手术时间、减少术中出血量、收割更多的增生腺体组织,达到满意的排尿功能,有助于改善患者术后的生活质量,且并发症的发生率较低,具有较高的临床应用价值。
  关键词:良性前列腺增生;经尿道等离子前列腺剜除术;经尿道等离子前列腺电切术
  中图分类号:R697+.32                               文献标识码:A                               DOI:10.3969/j.issn.1006-1959.2020.01.033
  文章编号:1006-1959(2020)01-0109-04
  Effect of Transurethral Plasma Kinetic Enucleation of  Prostate
  for Large-volume Prostatic Hyperplasia
  FENG You-liang
  (Department of Urology,Jiamusi Central Hospital,Jiamusi 154002,Heilongjiang,China)
  Abstract:Objective  To investigate the efficacy of transurethral plasma kinetic enucleation of  prostate(TPKEP) for large-volume benign prostatic hyperplasia. Methods  A total of 126 patients with large benign prostatic hyperplasia treated in the Urology Department of Jiamusi Central Hospital from March 2016 to January 2018 were collected and divided into the control group (58 cases) and the observation group (68 cases) according to the treatment method. The control group was treated with transurethral plasma kinetic resection of prostate (TPKRP), and the observation group was treated with TPKEP.The perioperative indexes (operation time, intraoperative bleeding volume, prostate resection weight, bladder flushing time, indwelling catheter time, postoperative hospitalization time) and preoperative, postoperative 3 and 12 months IPSS score, QOL score, maximum urinary flow rate (Qmax), residual urine volume (RUV) and postoperative complications were compared between the two groups.Results  The observation group had better operation time, intraoperative blood loss, and prostate resection weight than the control group [(75.12±38.18) min vs (90.50±45.66) min], [(98.33±26.71) ml vs (117.32±34.70) ml], [(53.82±8.05) g vs (41.80±6.77) g], the difference was statistically significant (P<0.05); there was no statistically significant difference in bladder irrigation time, urinary indwelling time, and postoperative hospital stay between the two groups (P>0.05). At 3 and 12 months after surgery, the IPSS score and QOL score of the two groups were lower than before surgery, Qmax was higher than before surgery, and RUV was lower than before surgery,the difference was statistically significant (P<0.05). The QOL score of the observation group at 3 months after operation was higher than that of the control group, and the RUV was lower than that of the control group, the difference was statistically significant (P<0.05). There was no significant difference in the IPSS score and Qmax at 3 months after operation between the two groups(P>0.05). The Qmax of the observation group at 12 months after operation was higher than that of the control group, and the RUV was lower than that of the control group, the difference was statistically significant (P<0.05). There was no significant difference in IPSS score and QOL score between the two groups after 12 months (P>0.05). The total incidence of complications in the observation group at 3 and 12 months after surgery was lower than that in the control group,the difference was statistically significant (P<0.05). Conclusion  TPKEP is effective in treating large-volume benign prostatic hyperplasia, which can effectively shorten the operation time, reduce the amount of intraoperative blood loss, harvest more proliferative glandular tissues, and achieve satisfactory urination function, which can help improve the surgical operation quality of life and low incidence of complications, it has high clinical application value.   Key words:Large-volume benign prostatic hyperplasia;benign prostatic hyperplasia;transurethral plasma kinetic enucleation of prostate;transurethral plasma kinetic resection of prostate
  良性前列腺增生(benign prostatic hyperplasia)是引起中老年男性排尿障碍的最常见病因。经尿道前列腺电切术(transurethral resection of the prostate,TURP)是治疗症状性良性前列腺增生的金标准[1],但传统的TURP具有深部组织热传递损伤、刺激周围神经肌肉,以及导致心脏起搏器功能障碍的风险;另外,低渗冲洗液的吸收增加了TURP综合征的潜在风险[2]。随着微创技术的不断发展,经尿道等离子前列腺剜除术(transurethral plasma kinetic enucleation of prostate,TPKEP)在经尿道等离子前列腺电切术(transurethral plasma kinetic resection of prostate,TPKRP)技术基础上建立的一项技术[3],研究表明[4],TPKEP是一种安全可行的治疗方法,具有并发症少、创伤小的优点。本研究主要探讨TPKEP治疗大体积良性前列腺增生的疗效,现报道如下。
  1资料和方法
  1.1一般资料   回顾性分析2016年3月~2018年1月佳木斯市中心医院泌尿外科收治的大体积前列腺增生患者126例,按照手术方法不同分为观察组(68例)和对照组(58例)。观察组年龄60~79岁,平均年龄(71.41±6.40)岁;PSA 2.2~6.2 ng/L,平均PSA(3.29±1.30)ng/L;前列腺体积56~130 ml,平均体积(117.00±18.00)ml。对照组年龄62~79岁,平均年龄(72.50±6.21)岁;PSA 2.3~5.4 ng/L,平均PSA(3.76±1.53)ng/L;前列腺体积65~144 ml,平均体积(121.20±13.43)ml。两组年龄、PSA、前列腺体积比较,差异无统计学意义(P>0.05),临床可比。
  1.2纳入及排除标准
  1.2.1纳入标准  ①符合前列腺增生所致下尿路梗阻的诊断标准;②彩超测定前列腺体积56~160 ml。
  1.2.2排除标准  ①严重心肺功能不全,肝肾功能不全,凝血功能异常者;②合并膀胱肿瘤、膀胱结石、尿道狭窄、小容量膀胱、尿动力提示膀胱逼尿肌无力、膀胱顺应性差及尿道外括约肌功能障碍;③病理检查被证实为前列腺癌患者。
  1.3方法
  1.3.1对照组  行TPKRP手术:采用等离子电切系统(英国佳乐,型号744000)、12°电切镜(德国STORZ,27005FA),电切环(德国STORZ,27050G2),将电切镜通过尿道置入,先行5~7点范围的腺体切割,由膀胱颈至精阜上方均匀切割前列腺,深度尽量达到前列腺包膜,切除一條标志沟,再向两侧切,然后切11~1点范围的腺体,远近缘与标志沟平齐,最后切割精阜周围腺体和膀胱颈口部位。行止血处理,Eric冲洗器抽吸前列腺组织碎块并留置三腔尿管,持续膀胱冲洗。
  1.3.2观察组  行TPKEP手术:采用等离子电切系统(英国佳乐,型号744000),12°电切镜(德国STORZ,27005FA),电切环(德国STORZ,27050G2),直视下将电切镜经尿道置入尿道,精阜近端5~7点切开、镜鞘推剥找到增生的腺体与外科包膜的间隙,镜鞘沿包膜平面推剥中叶,将游离的中叶推入膀胱;镜鞘于侧叶近精阜处找到包膜推剥两侧叶;参照包膜平面精细切除或剜除与膀胱颈部相连的腺体。前列腺剜除后,仔细检查前列腺腺窝并彻底止血;在膀胱充盈情况下,置入大白鲨组织粉碎器端头刨削腺体并吸出体外,术毕留置三腔尿管,持续膀胱冲洗。
  1.4评价指标  比较两组围手术期指标(手术时间、术中出血量、前列腺切除重量、膀胱冲洗时间、留置尿管时间、术后住院时间)及术前、术后3、12个月IPSS评分、QOL评分、最大尿流率(Qmax)、残余尿量(RUV)和术后并发症发生率。
  1.4.1 IPSS评分  采用IPSS评分评估患者下尿路症状严重程度,0~7分为轻度症状、8~19分为中度症状、20~35分为重度症状;IPSS评分越高,表明患者症状或病情越严重。
  1.4.2 QOL评分  采用QOL评分评估患者受下尿路症状困扰程度,0分为高兴、1分为满意、2分为大致满意、3分为还可以、4分为不太满意、5分为苦恼、6分为很糟;QOL评分越低,表明患者生活质量越好。
  1.4.3 Qmax  通过尿动力学检查进行测定。
  1.4.4 RUV  通过泌尿系彩超进行测定。
  1.4.5并发症  包括尿潴留、血尿、假性尿失禁、逆行射精、尿道狭窄、膀胱颈挛缩。
  1.5统计学方法  采用SPSS 16.0统计软件进行数据分析,计量资料以(x±s)表示,组间比较采用t检验;计数资料以[n(%)]表示,组间比较采用?字2检验。以P<0.05表示差异有统计学意义。
  2结果
  2.1两组围手术期指标比较  观察组手术时间、术中出血量、前列腺切除重量均优于对照组,差异有统计学意义(P<0.05);两组膀胱冲洗时间、尿管留置时间、术后住院时间比较,差异无统计学意义(P>0.05),见表1。   2.2两组术前术后IPSS评分、QOL评分、Qmax、RUV比较  两组术前IPSS评分、QOL评分、Qmax、RUV比较,差异无统计学意义(P>0.05)。两组术后3、12个月IPSS评分、QOL评分较术前降低,Qmax较术前增高,RUV较术前减少,差异有统计学意义(P<0.05)。观察组术后3个月QOL评分高于对照组,RUV低于对照组,差异有统计学意义(P<0.05);两组术后3个月IPSS评分、Qmax比较,差异无统计学意义(P>0.05)。观察组术后12个月Qmax高于对照组,RUV低于对照组,差异有统计学意义(P<0.05);两组术后12个月IPSS评分、QOL评分比较,差异无统计学意义(P>0.05),见表2。
  2.3两组并发症发生率比较  观察组术后3个月并发症总发生率低于对照组,差异有统计学意义(?字2=26.271,P=0.001);观察组术后12个月并发症总发生率低于对照组,差异有统计学意义(?字2=34.122,P=0.001),见表3。
  3讨论
  良性前列腺增生是老年男性常见的一种前列腺疾病,其可导致不同程度的膀胱出口阻塞,造成患者肾功能损伤[5]。临床上良性前列腺增生常见的表现是良性前列腺增生、排尿异常及尿动力学显示良性前列腺梗阻。TURP是良性前列腺增生症治疗的金标准,但术后并发症较多,使其临床应用受到一定限制。TPKEP是TPKRP技术基础上发展而来的一项新技术,结合了TPKRP和开放手术的特点,具有一定的安全性、可行性和有效性,适用于任何前列腺大小[6]。由于大体积前列腺经尿道切除术后有出血和TUR综合征的风险,因此开放式前列腺剜除术仍有不可替代的地位[7]。TPKRP在解剖学上类似于开放式前列腺剜除术,已经成为一种治疗大体积前列腺增生的新型术式,通过准确判断前列腺外科包膜及其锥切技术弥补前列腺电切的不足[8]。有研究指出[9],PKERP可降低手术创伤,促进尿道功能恢复,减少性功能受损程度,有助于前列腺增生叶的彻底切除,具有重要的临床应用价值。
  TPKRP手术要点在于前列腺包膜寻找、创面止血、前列腺尖部处理、括约肌保护和组织粉碎,其中前列腺包膜的寻找要求正确进入包膜与腺体的层面,利用镜鞘推剥与激光切割或电切相结合,寻找最薄弱处进入层面,避免过度暴力与结节间包膜的干扰[10]。TPKEP利用镜鞘剥离前列腺腺体,将增生腺体从包膜内解剖性切除,在剥除过程中,可保持完整的前列腺叶[11]。TPKEP治疗大体积前列腺,其安全性和有效性在大量研究中得到证实[12-14]。本研究结果显示,观察组手术时间、术中出血量、前列腺切除重量均优于对照组[(75.12±38.18)min vs(90.50±45.66)min]、[(98.33±26.71)ml vs(117.32±34.70)ml]、[(53.82±8.05)g vs(41.80±6.77)g],差异有统计学意义(P<0.05);两组膀胱冲洗时间、尿管留置时间、术后住院时间比较,差异无统计学意义(P>0.05),表明TPKEP治疗大体积前列腺增生患者,可有效缩短手术时间、减少术中出血量、可收割更多的增生腺体组织,与张振丰[15]研究结论一致,再次证明TPKEP具有较好的治疗效果。两组术后3、12个月IPSS评分、QOL评分较术前降低,Qmax较术前增高,RUV较术前减少,差异有统计学意义(P<0.05)。观察组术后3个月QOL评分高于对照组,RUV低于对照组,差异有统计学意义(P<0.05);两组术后3个月IPSS评分、Qmax比较,差异无统计学意义(P>0.05)。观察组术后12个月Qmax高于对照组,RUV低于对照组,差异有统计学意义(P<0.05);两组术后12个月IPSS评分、QOL评分比较,差异无统计学意义(P>0.05),表明TPKEP可达到满意的排尿功能,有效改善大体积前列腺增生患者术后的生活质量。
  此外,本研究中观察组术后3个月并发症总发生率低于对照组(38.23% vs 58.62%),差异有统计学意义(P<0.05);观察组术后12个月并发症总发生率低于对照组(23.52% vs 48.27%),差异有统计学意义(P<0.05),表明与TPKRP相比,TPKEP治疗大体积前列腺增生的术后并发症低,手术安全性高,与Wei Y等[16]研究结论类似。但本研究也存在不足:①本研究為回顾性研究,且患者例数较少,存在偏倚,可能对结论产生影响;②一些可能影响预后的因素,在本研究中无法完全排除。
  综上所述,TPKEP治疗大体积前列腺增生临床效果确切,可有效缩短手术时间、减少术中出血量、收割更多的增生腺体组织,达到满意的排尿功能,改善患者术后的生活质量,且并发症的发生率较低,具有较高的临床应用价值。但结果仍需更大样本的随机对照研究进一步验证。
  参考文献:
  [1]郝炜,云志中,马可为.双极等离子前列腺剜除术与电切术治疗前列腺增生症的随机对照研究[J].临床和实验医学杂志,2017,16(4):388-390.
  [2]江敦勤.经尿道双极等离子前列腺剜除术治疗良性前列腺增生症效果观察[J].山东医药,2016,56(46):97-99.
  [3]王世先,杨水法,杨恩明,等.不同前列腺体积采用经尿道双极等离子电切术与剜除术治疗的前瞻性对比研究(附521例报告)[J].微创泌尿外科杂志,2016,5(3):145-149.
  [4]巩向文,刘伟光,高佃军,等.经尿道双极等离子前列腺剜除术与电切术术后尿失禁发生率比较[J].青岛大学医学院学报,2016,52(3):352-354,358.
  [5]Foo KT.What is a disease?What is the disease clinical benign prostatic hyperplasia (BPH)[J].World Journal of Urology,2019,37(7):1293-1296.   [6]Abou-Taleb A,El-Shaer W,Kandeel W,et al.Bipolar Plasmakinetic Enucleoresection of the Prostate:Our Experience with 245 Patients for 3 Years of Follow-Up[J].Journal of Endourology,2017,31(3):300-306.
  [7]Wang Z,Zhang J,Zhang H,et al.Impact on sexual function of plasma button transurethral vapour enucleation versus plasmakinetic resection of the large prostate >90 ml:Results of a prospective, randomized trial[J].Andrologia,2019:e13390.
  [8]Samir M,Tawfick A,Mahmoud MA,et al.Two-year Follow-up in Bipolar Transurethral Enucleation and Resection of the Prostate in Comparison with Bipolar Transurethral Resection of the Prostate in Treatment of Large Prostates. Randomized Controlled Trial[J].Urology,2019(133):192-198.
  [9]刘俊峰,谭朝晖,李星智,等.经尿道双极等离子电切术治疗80 ml以上前列腺增生的疗效分析[J].重庆医学,2015.44(6):795-797.
  [10]Giulianelli R,Gentile BC,Mirabile G,et al.Bipolar plasma enucleation of the prostate vs open prostatectomy in large benign prostatic hyperplasia:a single centre 3-year comparison[J].Prostate Cancer and Prostatic Diseases,2019,22(1):110-116.
  [11]Mordasini L,Moschini M,Mattei A,et al.Green light laser for benign prostatic hyperplasia[J].Current Opinion in Urology,2018,28(3):322-328.
  [12]Gratzke C,Bachmann A,Descazeaud A,et al.EAU guidelines on the assessment of non-neurogenic male lower urinary tract symptoms including benign prostatic obstruction[J].European Urology,2015,67(6):1099-1109.
  [13]Elkoushy MA,Elshal AM,Elhilali MM.Postoperative lower urinary tract storage symptoms:does prostate enucleation differ from prostate vaporization for treatment of symptomatic benign prostatic hyperplasia[J].Journal of Endourology,2015,29(10):1159-1165.
  [14]Kim KS,Lee SH,Cho HJ,et al.Comparison of Bipolar Plasma Vaporization versus Standard Holmium Laser Enucleation of the Prostate:Surgical Procedures and Clinical Outcomes for Small Prostate Volumes[J].Journal of Clinical Medicine,2019,8(7):E1007.
  [15]張振丰.经尿道前列腺等离子剜除术对大体积前列腺增生的治疗效果[J].河南医学研究,2019(16):2937-2938.
  [16]Wei Y,Xu N,Chen SH,et al.Bipolar transurethral enucleation and resection of the prostate versus bipolar resection of the prostate for prostates larger than 60gr:A retrospective study at a single academic tertiary care center[J].International Brazilian Journal of Urology,2016,42(4):747-756.
  收稿日期:2019-06-27;修回日期:2019-07-30
  编辑/杜帆
转载注明来源:https://www.xzbu.com/1/view-15105402.htm