本文選題：良性前列腺增生 + 經(jīng)尿道雙極等離子前列腺剜除術(shù)　； 參考：《南方醫(yī)科大學(xué)》2014年碩士論文

【摘要】：研究背景 良性前列腺增生(benign prostatic hyperplasia,BPH)是引起中老年男性排尿障礙原因中最為常見的一種良性疾病,主要臨床表現(xiàn)為尿頻、尿急、排尿困難及尿不盡感。BPH的治療主要包括觀察等待、藥物治療及外科治療。治療目的是為了緩解患者下尿路癥狀,改善患者的生活質(zhì)量同時保護(hù)腎功能。對于中、重度良性前列腺增生患者,下尿路癥狀會顯著影響生活質(zhì)量,在藥物治療效果不佳或拒絕接受藥物治療的情況下,可以考慮手術(shù)治療。BPH的外科治療主要包括開放手術(shù)和腔內(nèi)手術(shù)治療,自經(jīng)尿道前列腺電切術(shù)(transurethral resection of theprostate TURP)問世后,漸漸取代開放手術(shù)成為BPH的主流治療方式。在歐美國家,TURP應(yīng)用于臨床已有70余年歷史,具有無手術(shù)切口、創(chuàng)傷小、術(shù)后痛苦少、恢復(fù)快、住院時間短等優(yōu)點(diǎn),TURP被公認(rèn)為是BPH手術(shù)治療的金標(biāo)準(zhǔn)。TURP雖然在治療BPH方面取得良好的效果,但仍有許多不足之處,手術(shù)操作較難掌握,手術(shù)并發(fā)癥有一定發(fā)生率,其中主要并發(fā)癥有經(jīng)尿道電切綜合征(TURS)和出血,嚴(yán)重者可威脅患者的生命。另外,在10年內(nèi)有10%—15%的患者可能需要二次手術(shù)干預(yù)。本世紀(jì)初,等離子雙極設(shè)備開始被應(yīng)用于治療良性前列腺增生。該設(shè)備采用雙極回路動態(tài)離子切割機(jī)制,無需使用負(fù)極板,能夠達(dá)到止血確切的效果。另外在低溫運(yùn)行時,電極表面溫度約40℃—70℃,由于等離子雙極設(shè)備有限的熱損傷,可減少對周圍組織的熱穿透,減少膀胱刺激癥狀,不會損傷勃起神經(jīng),能保護(hù)前列包膜,減小包膜穿孔的機(jī)會。等離子經(jīng)尿道前列腺切除術(shù)(Plasmakinetic resection of the prostate PKRP)與單極TURP相比,由于其術(shù)中切割時形成創(chuàng)面凝固層厚度約為0.5至1.0毫米,在切割的同時具有良好的止血效果,因此具有術(shù)中出血少的優(yōu)點(diǎn)；另外由于PKRP術(shù)中可用生理鹽水沖洗,從而避免了經(jīng)尿道電切綜合征(TURS)的發(fā)生。因此有人認(rèn)為PKRP是TURP這一BPH手術(shù)治療“金標(biāo)準(zhǔn)”的延續(xù)。隨著手術(shù)的技術(shù)的不斷發(fā)展和創(chuàng)新,我國泌尿外科劉春曉等醫(yī)生在總結(jié)前期手術(shù)經(jīng)驗(yàn)的基礎(chǔ)上,將PKRP與開放性前列腺摘除術(shù)兩種術(shù)式的優(yōu)點(diǎn)相結(jié)合,開創(chuàng)了一項(xiàng)新的前列腺手術(shù)方式—經(jīng)尿道雙極等離子前列腺剜除術(shù)(Plasmakinetic enucleation of the prostate, PKEP)。該術(shù)式是用電切鏡鏡鞘模擬開放前列腺摘除術(shù)的手指動作,沿前列腺外科包膜處的潛在間隙在前列腺窩內(nèi)逆行剝離完整的增生腺體組織,中斷其血液供應(yīng),然后將剝離的腺體組織進(jìn)行“收獲性切割”。相比之前各種前列腺術(shù)式,PKEP切除腺體更為徹底,并縮短了術(shù)中電凝止血時間,減少了出血量。 目的 回顧分析我院開展PKEP和TURP治療BPH的臨床資料,對兩種手術(shù)方式治療BPH患者的療效、手術(shù)時間、留置尿管時間、并發(fā)癥、手術(shù)前后血紅蛋白、血鈉的變化等綜合資料進(jìn)行比較,進(jìn)一步探討兩種術(shù)式的優(yōu)缺點(diǎn),為基層臨床選擇手術(shù)治療方案提供一些指導(dǎo)和幫助。 方法 回顧分析2011年01月—2012年12月在我院泌尿外科由副主任醫(yī)師及以上操作完成的TURP、PKEP術(shù)的患者臨床資料,手術(shù)者為科內(nèi)副主任醫(yī)師及以上,均能熟練進(jìn)行TURP和PKEP,以盡量減少因操作者因素所造成的差異。納入標(biāo)準(zhǔn)：(1)伴有明顯下尿路梗阻癥狀的中、重度BPH患者,有外科手術(shù)指征,且均能配合手術(shù),IPSS評分10分以上,QOL評分4分及以上；(2)均為2011年01月至2012年12月在我醫(yī)院泌尿外科由熟練手術(shù)者完成的TURP及PKEP患者；(3)患者經(jīng)前列腺超聲檢查,前列腺體積在30ml-100ml;(4)均行PSA測定,PSA4ng/ml;(5)不伴有嚴(yán)重的內(nèi)科疾病,如心力衰竭、嚴(yán)重的心律失常、COPD、腦梗死、精神疾病的患者。排除標(biāo)準(zhǔn)：(1)合并有嚴(yán)重的尿路感染者；(2)PSA大于4ng/ml者；(3)術(shù)后病理報告為前列腺癌、合并前列腺癌或前列腺上皮內(nèi)瘤(prostatic intraethelial neoplasia, PIN)。 選取接受TURP和PKEP的BPH病例210例,按上述納入和排除標(biāo)準(zhǔn),最終入選病例共150例,其中TURP組：85例,PKEP組：65例。TURP組完成術(shù)后1年隨訪的患者為66例；PKEP組完成術(shù)后1年隨訪的患者為54例,最終將研究病例共120例患者進(jìn)行臨床療效、并發(fā)癥、術(shù)后1年隨訪資料進(jìn)行比較分析。主要比較指標(biāo)有：IPSS、QOL評分、Qmax、兩組手術(shù)時間、術(shù)中出血量、并發(fā)癥、術(shù)后尿管留置時間、術(shù)后住院時間、術(shù)后膀胱沖洗時間、住院期間血紅蛋白、血鈉的變化、前列腺切除體積(PV)、術(shù)后殘余尿量(PVR)、術(shù)后tPSA等。 結(jié)果 1、兩組患者的年齡、前列腺體積(PV)、血紅蛋白(Hb)、膀胱殘余尿量(PVR)、最大尿流率(Qmax)、國際前列腺癥狀(IPSS)評分、生活質(zhì)量(QOL)評分、血清總PSA水平(tPSA),經(jīng)獨(dú)立樣本t檢驗(yàn),差異無統(tǒng)計學(xué)意義(p0.05)。 2、TURP組術(shù)前血鈉和血紅蛋白分別為：(140.5±3.1)mmol/L、(137.7±7.8)g/L,手術(shù)結(jié)束時血鈉平均(136.7±4.8)mmol/L,血紅蛋白平均(126.7±8.9)g/L,與術(shù)前比較降低,差異有統(tǒng)計學(xué)意義(P0.05);PKEP組術(shù)前血鈉和血紅蛋白分別為：(140.4±2.8)mmol/L、(136.9±8.5)g/L,手術(shù)結(jié)束時血鈉平均(139.7±3.6)mmol/L,血紅蛋白平均(135.7±9.0)g/L,與術(shù)前比較差異無統(tǒng)計學(xué)意義(P0.05);TURP與PKEP兩組手術(shù)結(jié)束時血鈉、血紅蛋白的比較,差異有統(tǒng)計學(xué)意義(P0.05)。 3、TURP組與PKEP組手術(shù)時間分別為：(70.5±9.3)min及(66.5±7.1)min；術(shù)中出血量分別為：(160.5±50.1)ml及(130.5±42.3)ml；前列腺切除體積分別為：(34.8±15.1)ml及(40.1±12.9)ml；術(shù)后膀胱沖洗時間分別為：(2.8±0.4)d及(2.0±-0.6)d；術(shù)后尿管留置時間分別為：(3.5±1.3)d及(2.8±0.9)d；術(shù)后住院時間分別為：(7.5±1.6)d及(6.5±1.2)d；兩組間上述各項(xiàng)指標(biāo)相比,差異有統(tǒng)計學(xué)意義(P0.05)。 4、兩組術(shù)式在手術(shù)過程中均未發(fā)生死亡、包膜穿孔、閉孔神經(jīng)反射、直腸損傷、膀胱損傷。 5、TURP組66例患者及PKEP組54例患者完成術(shù)后1年隨訪,兩組手術(shù)患者分別于術(shù)后1、6、12個月進(jìn)行隨訪登記,其中所有患者均于術(shù)后隨訪中自訴排尿時間較術(shù)前明顯縮短,尿線明顯變粗,尿頻、尿急等癥狀明顯改善。兩組手術(shù)患者于術(shù)后1、6、12個月IPSS、QOL評分及Qmax均較術(shù)前有明顯改善,兩組于術(shù)后12個月PVR較術(shù)前有明顯改善,與術(shù)前比較有統(tǒng)計學(xué)意義(P0.05)；兩組于術(shù)后12個月PV及tPSA均較術(shù)前明顯降低,差異有統(tǒng)計學(xué)意義(P0.05)。組間比較結(jié)果顯示：兩種術(shù)式在術(shù)后1、6、12月IPSS、 QOL評分及Qmax的差異無統(tǒng)計學(xué)意義(P0.05),兩種術(shù)式在術(shù)后12個月PVR的比較差異無統(tǒng)計學(xué)意義(P0.05),說明兩種術(shù)式在治療BPH的近期療效上無明顯差別。兩組術(shù)式在術(shù)后12個月PV、tPSA均較術(shù)前明顯降低,但兩組間的差異均有統(tǒng)計學(xué)意義(P0.05)。 6、TURP組與PKEP組手術(shù)并發(fā)癥情況：TURP組在術(shù)中發(fā)生TURS有2例(3.0%),因大出血需要輸血1例(1.5%);PKEP組術(shù)中未發(fā)生TURS及輸血,TURP組中術(shù)后有8例(12.1%)出現(xiàn)暫時性尿失禁,PKEP組中有5例(9.3%)出現(xiàn)暫時性尿失禁,兩組間比較差異無統(tǒng)計學(xué)意義(P0.05);TURP組患者術(shù)后發(fā)生尿道狹窄3例(4.5%), PKEP組患者發(fā)生尿道狹窄有2例(3.7%),兩組間比較差異無統(tǒng)計學(xué)意義(P0.05);TURP組及PKEP組患者術(shù)后發(fā)生膀胱痙攣分別為1例(1.5%)、2例(3.7%),兩組間比較差異無統(tǒng)計學(xué)意義(10.05);TURP組與PKEP組術(shù)后6個月發(fā)生逆行射精分別有17例(25.7%)、8例(14.5%),兩組間比較差異無統(tǒng)計學(xué)意義(P0.05)；兩組術(shù)后12個月發(fā)生逆行射精分別有10例(15.2%)、7例(13.0%),兩組間比較差異無統(tǒng)計學(xué)意義(P0.05)；兩組患者術(shù)后均未出現(xiàn)永久性尿失禁。但是,TURP組及PKEP組患者術(shù)后6個月總并發(fā)癥例數(shù)分別為34(51.5%)、17(31.5%),兩組比較差異有統(tǒng)計學(xué)意義(P0.05)。 結(jié)論 1、PKEP與TURP相比,近期手術(shù)療效相似,均是治療BPH較安全的術(shù)式。 2、PKEP術(shù)中、術(shù)后并發(fā)癥發(fā)生率低,PKEP組術(shù)中出血量少于TURP組,PKEP組在手術(shù)時間、術(shù)后膀胱沖洗時間、術(shù)后尿管留置時間、術(shù)后住院時間等均短于TURP組,是治療BPH的較好方法。 3、PKEP組前列腺切除體積大于TURP組,術(shù)中切除組織標(biāo)本獲得率較TURP局,PKEP術(shù)中切除增生前列腺腺體較TURP完全,有利于減少術(shù)后BPH復(fù)發(fā)。 4、PKEP需要術(shù)者更好地掌握增生前列腺腺體與外科包膜之間的解剖結(jié)構(gòu),準(zhǔn)確尋找到外科包膜層面是手術(shù)成功的關(guān)鍵。
[Abstract]:Research background
Benign prostatic hyperplasia (benign prostatic hyperplasia, BPH) is the most common benign disease causing urination in middle-aged and old men. The main clinical manifestations are frequency of urination, urgency of urine, difficulty of urination, and.BPH of urination, including observation waiting, drug treatment and surgical treatment. The purpose of the treatment is to relieve the patients. The symptoms of urinary tract can improve the quality of life and protect the renal function. For patients with moderate and severe benign prostatic hyperplasia, the lower urinary tract symptoms can significantly affect the quality of life. Surgical treatment of.BPH can be considered mainly including open and intracavitary surgery in the case of adverse drug treatment or refusal to receive medication. After the advent of transurethral resection of theprostate TURP (resection), it has gradually replaced open surgery to become the mainstream of the treatment of BPH. In European and American countries, TURP has been used for more than 70 years in clinical history, with the advantages of no surgical incision, small trauma, less pain, quick recovery and short hospitalization. TURP has been recognized. TURP has been recognized. The gold standard.TURP for the treatment of BPH has good results in the treatment of BPH, but there are still a lot of shortcomings, the operation is difficult to master, the operation complications have a certain incidence, the main complications are the transurethral electrotangent syndrome (TURS) and bleeding, the serious person can threaten the patient's life. In addition, in 10 years, there are 10% to 15%. At the beginning of this century, plasma bipolar devices began to be used in the treatment of benign prostatic hyperplasia. The device uses a bipolar circuit dynamic ion cutting mechanism, without the need to use a negative plate, to achieve the exact effect of hemostasis. In addition, the surface temperature of the electrode is about 40 - 70 - 70 at low temperature. The limited thermal damage of the ion bipolar device can reduce the heat penetration of the surrounding tissue, reduce the bladder irritation symptoms, do not damage the erectile nerve, protect the Prost membrane, and reduce the opportunity for the perforation of the capsule. Plasma transurethral resection of the prostate (Plasmakinetic resection of the prostate PKRP) is compared with the unipolar TURP, due to its intraoperative cutting. The thickness of the wound solidified layer is about 0.5 to 1 millimeters, and it has good hemostatic effect at the same time of cutting, so it has the advantage of less bleeding in the operation; in addition, because of the use of saline irrigation in PKRP, it avoids the occurrence of transurethral electrotangent syndrome (TURS). Therefore, it is thought that PKRP is the "TURP" BPH operation "gold standard" With the continuous development and innovation of the surgical technique, Liu Chunxiao and other doctors in our department of Urology, based on the experience of the early operation, combined the advantages of the PKRP and open prostatic extirpation, and created a new method of prostate surgery - transurethral bipolar plasma prostatectomy (Plasm Akinetic enucleation of the prostate, PKEP). The operation is to simulate open prostatic extirpation with an electrosurgical mirror sheath. The potential clearance along the membrane of the prostate is retrograde to dissection the intact gland tissue in the prostatic fossa, interrupting the blood supply, and then the stripped gland tissue is "harvested". Compared with the previous prostatectomy, PKEP removed the gland more thoroughly, and reduced the time of coagulation and hemostasis during operation, and reduced the amount of bleeding.
objective
The clinical data of PKEP and TURP in the treatment of BPH in our hospital were reviewed and analyzed. The results of two surgical methods for the treatment of BPH patients, the time of operation, the time of indwelling catheter, the complications, the hemoglobin and the change of blood sodium were compared, and the advantages and disadvantages of the two kinds of surgical procedures were further discussed. For some guidance and help.
Method
A retrospective analysis was made of the clinical data of TURP, PKEP, performed by the deputy chief physician and above in the Department of Urology of our hospital from 01 to December 2012 2011. The surgeon, the deputy director of Kone, and above, could be proficient in TURP and PKEP in order to minimize the difference caused by the operator factors. In the patients with obstructive symptoms, severe BPH patients had surgical indications, and all were combined with surgery. The IPSS score was above 10 points, and the QOL score was 4 points and above. (2) all were TURP and PKEP patients completed from 01 months to December 2012 in our hospital by skilled surgeons; (3) the prostate volume was 30ml-100ml; (4) PSA determination, PSA4ng/ml; (5) no serious medical diseases, such as heart failure, severe arrhythmia, COPD, cerebral infarction, and mental illness. Exclusion criteria: (1) with severe urinary tract infection; (2) PSA greater than 4ng/ml; (3) postoperative pathological report of prostate cancer, combined with prostate or prostatic intraepithelial neoplasia (pro) Static intraethelial neoplasia, PIN).
210 cases of BPH cases received TURP and PKEP were selected, according to the above inclusion and exclusion criteria, 150 cases were finally selected, of which group TURP: 85 cases, PKEP group: 65 cases of.TURP group completed 1 year follow-up for 66 cases; the PKEP group completed the 1 year follow-up of 54 patients, and finally studied the case of 120 patients to carry out clinical efficacy, complications, complications, and complications. The 1 year follow-up data were compared and analyzed. The main indexes were: IPSS, QOL score, Qmax, two groups of operation time, intraoperative bleeding, complications, postoperative catheter indwelling time, postoperative hospital stay, postoperative bladder irrigation time, hemoglobin, blood sodium, volume of prostatectomy (PV), postoperative residual urine volume (PVR), postoperative tP SA and so on.
Result
1, the age of the two groups, the volume of the prostate (PV), the hemoglobin (Hb), the residual urinary bladder (PVR), the maximum urinary flow rate (Qmax), the International Prostatic Symptom (IPSS) score, the quality of life (QOL), the serum total PSA (tPSA), and the independent sample t examination, the difference was not statistically significant (P0.05).
2, before operation, the blood sodium and hemoglobin in group TURP were (140.5 + 3.1) mmol/L, (137.7 + 7.8) g/L, the average blood sodium (136.7 + 4.8) mmol/L at the end of the operation and the average hemoglobin (126.7 + 8.9) g/L. The difference was statistically significant (P0.05). The serum sodium and hemoglobin in group PKEP were (140.4 + 2.8) mmol/L and (136.9 + 8.5) g/L before operation in PKEP group. The mean blood sodium was (139.7 + 3.6) mmol/L at the end of the operation and the average hemoglobin (135.7 + 9) g/L. There was no significant difference between the blood sodium and the preoperative (P0.05). The difference between the blood sodium and hemoglobin at the end of the operation of TURP and PKEP two groups was statistically significant (P0.05).
3, the operation time of group TURP and group PKEP were (70.5 + 9.3) min and (66.5 + 7.1) min, and the amount of bleeding in the operation was (160.5 + 50.1) ml and (130.5 + 42.3) ml, and the volume of prostatectomy was (34.8 + 15.1) ml and (40.1 + 12.9) ml respectively. The difference was (3.5 + 1.3) D and (2.8 + 0.9) d, and the postoperative hospitalization time was (7.5 + 1.6) D and (6.5 + 1.2) d, and the differences between the two groups were statistically significant (P0.05).
4, two groups of operations during operation did not die, capsule perforation, obturator nerve reflex, rectal injury, bladder injury.
5, 66 patients in group TURP and 54 patients in group PKEP were followed up for 1 years. The two groups were followed up for 1,6,12 months after the operation. All the patients were obviously shorter than before the operation, the urine line was obviously thicker, the urine frequency and urgency were obviously improved. The two groups of patients underwent 1,6,12 after operation. The scores of QOL and Qmax were significantly improved at month IPSS, and the two groups were significantly improved at 12 months after the operation than before the operation. There were statistical significance (P0.05) compared with pre operation (P0.05). The two groups were significantly lower in PV and tPSA 12 months after the operation than before the operation. The difference was statistically significant (P0.05). The comparison between the groups showed that the two kinds of operation were in 1,6,12 month IPSS, Q after the operation. There was no significant difference in the difference of OL score and Qmax (P0.05). There was no significant difference in the comparison between the two kinds of surgical methods at 12 months after the operation (P0.05), indicating that there was no significant difference in the short-term effect of the two kinds of operation in the treatment of BPH. The two groups were significantly lower in PV and tPSA than before the operation in 12 months after the operation, but the difference between the two groups was statistically significant (P0.05).
6, group TURP and group PKEP complications: in group TURP, there were 2 cases of TURS in operation (3%), 1 cases of blood transfusion (1.5%) due to massive hemorrhage, no TURS and blood transfusion in group PKEP, 8 cases (12.1%) in group TURP and 5 cases (9.3%) in group PKEP (9.3%) with temporary incontinence, and there was no statistical difference between two groups (P0). .05); in group TURP, there were 3 cases of urethral stricture (4.5%), 2 cases of urethral stricture in group PKEP (3.7%), and there was no significant difference between the two groups (P0.05). There were 1 cases of bladder spasm in group TURP and group PKEP (1.5%) and 2 cases (3.7%), and there were no significant difference between the two groups (10.05) and TURP group and PKEP group after operation 6. There were 17 cases (25.7%) and 8 cases (14.5%) of retrograde ejaculation in the month, and there was no significant difference between the two groups (P0.05). The two groups had 10 cases (15.2%) and 7 cases (13%) of retrograde ejaculation in 12 months after operation, and there was no significant difference between the two groups (P0.05). All the patients in the two group had no permanent urinary incontinence after operation, but group TURP and PKEP group. The total complications in 6 months after operation were 34 (51.5%) and 17 (31.5%) respectively, and the difference between the two groups was statistically significant (P0.05).
conclusion
1, compared with TURP, PKEP has similar surgical effect in recent years, and is a safer operation for BPH.
2, in PKEP, the incidence of postoperative complications is low, and the amount of bleeding in group PKEP is less than that of group TURP. The time of operation, the time of bladder irrigation after operation, the time of postoperative urinary catheter indwelling, and the time of postoperative hospitalization in group PKEP are shorter than that of the TURP group, which is a better method for the treatment of BPH.
3, the volume of prostatectomy in group PKEP was greater than that in group TURP, and the rate of obtaining tissue specimen was more than that of TURP, and that of hyperplasia of prostate gland in PKEP was more TURP than that of TURP. It was beneficial to reduce the recurrence of BPH after operation.
4, PKEP requires better understanding of the anatomical structure between the proliferative prostate gland and the surgical envelope, and accurately finding the surgical envelope is the key to the success of the operation.
【學(xué)位授予單位】：南方醫(yī)科大學(xué)
【學(xué)位級別】：碩士
【學(xué)位授予年份】：2014
【分類號】：R697.3

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