经尿道等离子柱状电极联合环状电极治疗男性后尿道狭窄的临床研究

发布时间：2018-05-26 23:35

  本文选题：后尿道狭窄 + 尿道狭窄冷刀内切开　； 参考：《武汉大学》2016年博士论文

【摘要】：目的：本研究将经尿道等离子柱状电极联合环状电极腔内治疗男性后尿道狭窄与经尿道冷刀切开狭窄相比较,评价经尿道等离子柱状电极联合环状电极治疗男性后尿道狭窄的有效性、安全性及可行性。为推广经尿道等离子柱状电极联合环状电极腔内治疗男性后尿道狭窄的临床应用提供科学依据。方法：本研究采用随机对照、双盲,以经尿道等离子柱状电极联合环状电极治疗男性后尿道狭窄为观察组,以经尿道冷刀切开为对照组。对比分析观察组与对照组术前术后的相关指标数据。从2013年6月至2015年8月,共计112例男性后尿道狭窄,其中膜部尿道狭窄101例。前列腺部尿道狭窄11例。随机分为观察组和对照组。观察组56例：经尿道等离子柱状电极联合环状电极腔内治疗。对照组56例：经尿道冷刀切开。记录两组患者一般情况及术前尿流率、术前尿道造影、术前残余尿、术前生活质量评分QOL以及术中并发症、手术时间等。患者在术后1月、3月、6月、9月及12月行最大尿流率测定及尿道造影。所有的患者在术后12月行尿道镜检查。若术后随访过程中出现尿流率15ml或主观感觉排尿不畅或尿道造影提示狭窄,则行尿道镜检确定有无狭窄。平均随访时间13.9个月。整个随访过程中,患者最大尿流率≥15 ml/s,主观感觉无排尿不畅、无排尿困难,且进一步行尿道造影及尿道镜检未发现再狭窄,则被评价为手术成功。若患者主观感觉有排尿不畅等排尿困难症状,行尿道造影和尿道镜发现再狭窄,需要再次手术治疗或长期尿道扩张则被评价为手术失败。结果：1、术前两组情况比较：观察组56例,对照组56例,平均年龄分别为(41.85±6.87；42.65±8.64)岁,差异无统计学意义(t=0.325,P0.05)。观察组和对照组术前生活质量评分分别为(4.5±0.70；4.68±0.80),两组差异无统计学意义(t=0.17,P0.05)。观察组和对照组术前平均狭窄长度分别为(13.23±2.48mm；12.45±2.89mm),两组术前狭窄长度差异无统计学意义。观察组和对照组术前平均最大尿流率分别为(4.68±1.88；7.8±1.47 ml/秒),两组差异无统计学意义(t=0.279,P0.05)。术前观察组和对照组平均残余尿分别为(59.86±2.48ml；61.25±2.89ml),差异无统计学意义(t=0.78,P0.05)。2、观察组与对照组手术时间比较。观察组与对照组手术时间分别为(23.45±7.64分钟vs33.45±5.45分钟)。观察组手术时间短与对照组,差异有统计学意义(t=2.25,P0.05)。3、术中并发症情况：两组患者均未出现因心肺脑血管意外的死亡病例。观察组未出现明显大出血、假道、膀胱或直肠损伤。对照组出现一例假道,未出现大出血、膀胱或直肠损伤。4、术后尿流率比较：观察组术后1、3、6、9、及12月平均最大尿流率分别为(19.54±1.78ml/s、18.54±1.74 ml/s、18.32±2.78 ml/s、18.34±1.74ml/s 17.25±2.12ml/s),观察组术后随访1月、3月、6月及9月最大尿流率保持稳定,术后12月尿流率较术前1月尿流率略有下降。复发集中在术后12月及以后。对照组1月、3月、6月、9月及12月平均最大尿流率分别为(17.54±2.36ml/s; 17.51±2.26ml/s:16.55±1.15ml/s;14.58±1.36ml/s; 13.54±2.78 ml/s)。对照组术后1月3及6月最大尿流率保持相对稳定,但从术后9月及12月开始,尿流率逐渐减少,即术后6月内疗效稳定,但从术后9月疗效逐渐下降。两组术后1月3月平均最大尿流率相近,差异无统计学意义,术后6月、9月、12月观察组最大尿流率明显好于对照组最大尿流率。差异有统计学意义(P0.05)5、术后生活质量评分QOL比较：观察组术后1、3、6、9、及12月QOL分别为(2.3±0.8；2.5±0.6;2.5±0.9；2.9±0.7；3.5±0.8分),对照组术后1、3、6、9、及12月QOL分别为(2.6±0.7；2.5±0.8；2.7±0.8；3.3±0.7；4.5±0.8分)。观察组术后随访1月、3月、6月及9月QOL保持稳定,术后12月QOL开始下降,与尿流率下降时间同步。对照组术后1月3及6月QOL保持相对稳定,但从术后9月及12月开始,QOL逐渐下降,亦与尿流率下降同步。6、术后并发症比较：观察组有一例术后出现暂时尿失禁,一周后尿失禁症状逐渐好转。术后未发生严重出血、严重尿路感染、急性附睾炎、永久性尿失禁、勃起功能障碍等严重并发症。对照组术后1例出现急性附睾炎,经加强抗感染治疗后治愈,未出现严重出血、严重尿路感染、急性附睾炎、永久性尿失禁、勃起功能障碍等严重并发症。7、术后复发率比较：观察组49例患者随访过程中未发现再狭窄,被评价为“手术成功”(87.5%)。7例患者通过尿道造影或尿道镜发现再狭窄,被评价为“术后复发”：复发率(12.5%)。对照组30例患者未发现明显再狭窄,被评价为“手术成功”(53.6%)。26例患者在随访过程中出现再狭窄,被评价为“术后复发”(46.4%)。观察组术后复发率明显低于对照组,差异有统计学意义(t=1.35,P0.01)。结论：等离子柱状电极联合环状电极治疗男性后尿道狭窄,相比传统冷刀狭窄内切开,操作简便,用时少,复发率低,无严重并发症,安全有效。1、等离子柱状电极联合环状电极腔内治疗后尿道狭窄,不仅可以切割狭窄组织,而且可以汽化瘢痕组织,治疗后尿道狭窄所需平均手术时间少于对照组。2、经尿道等离子联合环状电极腔内治疗后尿道狭窄,术中未出现严重出血、假道、及死亡等严重并发症者,术后随访未出现永久性尿失禁、严重血尿、勃起功能障碍、急性附睾炎等严重并发症。手术安全。3、经尿道等离子联合环状电极治疗后尿道狭窄,因切除瘢痕组织相对较多,通道光滑,术后尿流率保持稳定,复发率低。而对照组因冷刀仅仅能切开瘢痕狭窄环,残余瘢痕组织较多,通道不光滑,术后复发率高。
[Abstract]:Objective: To evaluate the efficacy, safety and feasibility of transurethral plasma columnar electrode combined with annular electrode in the treatment of male posterior urethral stricture by transurethral plasma columnar electrode combined with annular electrode intracavity for the treatment of male posterior urethral stricture and urethral stricture. The clinical application of combined annular electrode intracavity for the treatment of male posterior urethral stricture was provided. Methods: This study was randomized controlled and double blind. The treatment of male posterior urethral stricture by transurethral plasma columnar electrode combined with annular electrode was used as the control group with transurethral resection of the urethra. From June 2013 to August 2015, 112 cases of male posterior urethral stricture, including 101 cases of urethral stricture of the membrane and 11 cases of prostatic urethral stricture, were randomly divided into observation group and control group. 56 cases in observation group were treated with transurethral plasma columnar electrode combined with annular electrode cavity. 56 cases of control group were treated by transurethral cold knife incision. Two groups of patients were recorded in general and preoperative urinary flow rate, preoperative urethrography, preoperative residual urine, preoperative quality of life score QOL, intraoperative complications, and operation time. The patients underwent maximum urinary flow measurement and urethrography in January, March, June, September, and December. All patients underwent urethroscope after surgery in December. Follow up after operation. The urinary flow rate of 15ml or subjective urination or urethral stricture was found in the course of urethral stricture. The urethroscope was performed to determine whether there was stricture. The mean follow-up time was 13.9 months. During the whole follow-up period, the maximum urine flow rate was more than 15 ml/s, the subjective feeling of urination was not smooth, and no urination was difficult, and further urethrography and urethroscope were not found again. Stenosis was evaluated as a successful operation. If the patient had a subjective feeling of dysuria, such as difficulty in urination, urethrography and urethroscope, restenosis, the need for reoperation or long-term urethral dilatation were evaluated as failure. Results: 1, the preoperative two groups were compared: 56 cases in the observation group and 56 cases in the control group, the average age was respectively ( 41.85 + 6.87; 42.65 + 8.64 years old, the difference was not statistically significant (t=0.325, P0.05). The quality of life of the observation group and the control group was (4.5 + 0.70; 4.68 + 0.80), and there was no significant difference between the two groups (t=0.17, P0.05). The average stenosis length of the observation group and the control group was (13.23 + 2.48mm; 12.45 + 2.89mm), respectively, and the preoperative stenosis of the two group. The average maximum urine flow rate in the observation group and the control group was (4.68 + 1.88; 7.8 + 1.47 ml/ seconds), and the two groups were not statistically significant (t=0.279, P0.05). The average residual urine in the observation group and the control group was (59.86 + 2.48ml; 61.25 + 2.89ml), and the difference was not statistically significant (t=0.78, P0.05).2, the observation group Compared with the control group, the operation time of the observation group and the control group was (23.45 + 7.64 minutes vs33.45 + 5.45 minutes). The operation time of the observation group was short and the control group, the difference was statistically significant (t=2.25, P0.05).3, the complications in the operation: the two groups of patients had no fatal cases of cardiovascular and cerebrovascular accidents. The observation group did not appear in the observation group. Significant hemorrhage, false path, bladder or rectal injury. In the control group, there was a case of false path, without massive hemorrhage, bladder or rectal injury.4, and the postoperative urinary flow rate was compared: the postoperative 1,3,6,9, and the average maximum urine flow rate in the observation group were (19.54 + 1.78ml/s, 18.54 + 1.74 ml/s, 18.32 + 2.78 ml/s, 18.34 + 1.74ml/s 17.25 + 2.12ml/s), and the observation group after operation. The maximum urine flow rate remained stable in January, March, June and September. The urine flow rate in December was slightly lower than that before the operation in January. The recurrence rate was in December and after the operation. The average maximum urine flow rate was (17.54 + 2.36ml/s; 17.51 + 2.26ml/s:16.55 + 1.15ml/s; 14.58 + 1.36ml/s; 13.54 + 2.78 ml/s). The maximum urine flow rate in the control group was relatively stable in 3 and June January, but the urine flow rate decreased gradually from September and December after the operation, that is, the curative effect was stable in June, but the curative effect decreased gradually from September. The average maximum urine flow rate in the two groups was similar in January. The maximum urine flow rate was better than that of the control group (P0.05) 5, and the postoperative quality of life score QOL was compared: the postoperative 1,3,6,9 of the observation group and the December QOL were (2.3 + 0.8; 2.5 + 0.6; 2.5 + 0.9; 2.9 + 0.7; 3.5 +), and the control group was 1,3,6,9 and December QOL respectively. After operation, the observation group was followed up in January, March, June and September, QOL remained stable, and December QOL began to decrease in December and to synchronize with the decrease of urine flow rate. In the control group, 3 and June QOL remained relatively stable, but the QOL gradually declined after the operation and began to synchronize.6 with the decrease of urine flow rate, and the postoperative complications were compared: the observation group had one case after operation. There was no severe bleeding, severe urinary tract infection, acute epididymitis, permanent incontinence, erectile dysfunction and other serious complications. 1 cases of acute epididymitis in the control group, cured after strengthening anti infection treatment, no severe bleeding, severe urinary tract infection, acute Severe complications, such as epididymitis, permanent incontinence and erectile dysfunction,.7, the postoperative recurrence rate was compared: 49 patients in the observation group did not find restenosis during the follow-up process, and were evaluated as "surgical success" (87.5%).7 patients were restenosis after urethrography or urethroscope, and the recurrence rate (12.5%) was evaluated as the recurrence rate (12.5%). 30 patients had no obvious restenosis and were evaluated as "successful operation" (53.6%).26 patients had restenosis during the follow-up process and were evaluated as "postoperative recurrence" (46.4%). The postoperative recurrence rate of the observation group was significantly lower than that of the control group (t=1.35, P0.01). Conclusion: plasma columnar electrode combined with annular electrode for the treatment of men. Sexual posterior urethral stricture, compared with the traditional cold knife narrow incision, simple operation, less time, low recurrence rate, no serious complications, safe and effective.1, plasma columnar electrode combined with annular electrode intracavity treatment of posterior urethral stricture, not only can cut the narrow tissue, but also can vaporized scar tissue, the average operation time for the treatment of posterior urethral stricture Less than the control group.2, the urethral stricture of the urethra combined with the transurethral plasma plasma combined with annular electrode, no severe bleeding, false or dead complications during the operation, there were no permanent urinary incontinence, severe hematuria, erectile dysfunction, acute epididymitis and other serious complications after operation. Surgical safety of.3, transurethral plasma plasma combined ring After the treatment of urethral stricture after the electrode treatment, the resection of scar tissue is relatively more, the channel is smooth, the urine flow rate remains stable after operation, and the recurrence rate is low. And the control group only can cut the scar narrow ring because of the cold knife, the residual scar tissue is more, the channel is not smooth and the recurrence rate is high after the operation.
【学位授予单位】：武汉大学
【学位级别】：博士
【学位授予年份】：2016
【分类号】：R699.6

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