TURP与PKEP治疗良性前列腺增生的临床对比分析

发布时间：2018-05-30 10:35

本文选题：良性前列腺增生 + 经尿道双极等离子前列腺剜除术　；参考：《南方医科大学》2014年硕士论文

【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碍原因中最为常见的一种良性疾病,主要临床表现为尿频、尿急、排尿困难及尿不尽感。BPH的治疗主要包括观察等待、药物治疗及外科治疗。治疗目的是为了缓解患者下尿路症状,改善患者的生活质量同时保护肾功能。对于中、重度良性前列腺增生患者,下尿路症状会显著影响生活质量,在药物治疗效果不佳或拒绝接受药物治疗的情况下,可以考虑手术治疗。BPH的外科治疗主要包括开放手术和腔内手术治疗,自经尿道前列腺电切术(transurethral resection of theprostate TURP)问世后,渐渐取代开放手术成为BPH的主流治疗方式。在欧美国家,TURP应用于临床已有70余年历史,具有无手术切口、创伤小、术后痛苦少、恢复快、住院时间短等优点,TURP被公认为是BPH手术治疗的金标准。TURP虽然在治疗BPH方面取得良好的效果,但仍有许多不足之处,手术操作较难掌握,手术并发症有一定发生率,其中主要并发症有经尿道电切综合征(TURS)和出血,严重者可威胁患者的生命。另外,在10年内有10%—15%的患者可能需要二次手术干预。本世纪初,等离子双极设备开始被应用于治疗良性前列腺增生。该设备采用双极回路动态离子切割机制,无需使用负极板,能够达到止血确切的效果。另外在低温运行时,电极表面温度约40℃—70℃,由于等离子双极设备有限的热损伤,可减少对周围组织的热穿透,减少膀胱刺激症状,不会损伤勃起神经,能保护前列包膜,减小包膜穿孔的机会。等离子经尿道前列腺切除术(Plasmakinetic resection of the prostate PKRP)与单极TURP相比,由于其术中切割时形成创面凝固层厚度约为0.5至1.0毫米,在切割的同时具有良好的止血效果,因此具有术中出血少的优点；另外由于PKRP术中可用生理盐水冲洗,从而避免了经尿道电切综合征(TURS)的发生。因此有人认为PKRP是TURP这一BPH手术治疗“金标准”的延续。随着手术的技术的不断发展和创新,我国泌尿外科刘春晓等医生在总结前期手术经验的基础上,将PKRP与开放性前列腺摘除术两种术式的优点相结合,开创了一项新的前列腺手术方式—经尿道双极等离子前列腺剜除术(Plasmakinetic enucleation of the prostate, PKEP)。该术式是用电切镜镜鞘模拟开放前列腺摘除术的手指动作,沿前列腺外科包膜处的潜在间隙在前列腺窝内逆行剥离完整的增生腺体组织,中断其血液供应,然后将剥离的腺体组织进行“收获性切割”。相比之前各种前列腺术式,PKEP切除腺体更为彻底,并缩短了术中电凝止血时间,减少了出血量。目的回顾分析我院开展PKEP和TURP治疗BPH的临床资料,对两种手术方式治疗BPH患者的疗效、手术时间、留置尿管时间、并发症、手术前后血红蛋白、血钠的变化等综合资料进行比较,进一步探讨两种术式的优缺点,为基层临床选择手术治疗方案提供一些指导和帮助。方法回顾分析2011年01月—2012年12月在我院泌尿外科由副主任医师及以上操作完成的TURP、PKEP术的患者临床资料,手术者为科内副主任医师及以上,均能熟练进行TURP和PKEP,以尽量减少因操作者因素所造成的差异。纳入标准：(1)伴有明显下尿路梗阻症状的中、重度BPH患者,有外科手术指征,且均能配合手术,IPSS评分10分以上,QOL评分4分及以上；(2)均为2011年01月至2012年12月在我医院泌尿外科由熟练手术者完成的TURP及PKEP患者；(3)患者经前列腺超声检查,前列腺体积在30ml-100ml;(4)均行PSA测定,PSA4ng/ml;(5)不伴有严重的内科疾病,如心力衰竭、严重的心律失常、COPD、脑梗死、精神疾病的患者。排除标准：(1)合并有严重的尿路感染者；(2)PSA大于4ng/ml者；(3)术后病理报告为前列腺癌、合并前列腺癌或前列腺上皮内瘤(prostatic intraethelial neoplasia, PIN)。选取接受TURP和PKEP的BPH病例210例,按上述纳入和排除标准,最终入选病例共150例,其中TURP组：85例,PKEP组：65例。TURP组完成术后1年随访的患者为66例；PKEP组完成术后1年随访的患者为54例,最终将研究病例共120例患者进行临床疗效、并发症、术后1年随访资料进行比较分析。主要比较指标有：IPSS、QOL评分、Qmax、两组手术时间、术中出血量、并发症、术后尿管留置时间、术后住院时间、术后膀胱冲洗时间、住院期间血红蛋白、血钠的变化、前列腺切除体积(PV)、术后残余尿量(PVR)、术后tPSA等。结果 1、两组患者的年龄、前列腺体积(PV)、血红蛋白(Hb)、膀胱残余尿量(PVR)、最大尿流率(Qmax)、国际前列腺症状(IPSS)评分、生活质量(QOL)评分、血清总PSA水平(tPSA),经独立样本t检验,差异无统计学意义(p0.05)。 2、TURP组术前血钠和血红蛋白分别为：(140.5±3.1)mmol/L、(137.7±7.8)g/L,手术结束时血钠平均(136.7±4.8)mmol/L,血红蛋白平均(126.7±8.9)g/L,与术前比较降低,差异有统计学意义(P0.05);PKEP组术前血钠和血红蛋白分别为：(140.4±2.8)mmol/L、(136.9±8.5)g/L,手术结束时血钠平均(139.7±3.6)mmol/L,血红蛋白平均(135.7±9.0)g/L,与术前比较差异无统计学意义(P0.05);TURP与PKEP两组手术结束时血钠、血红蛋白的比较,差异有统计学意义(P0.05)。 3、TURP组与PKEP组手术时间分别为：(70.5±9.3)min及(66.5±7.1)min；术中出血量分别为：(160.5±50.1)ml及(130.5±42.3)ml；前列腺切除体积分别为：(34.8±15.1)ml及(40.1±12.9)ml；术后膀胱冲洗时间分别为：(2.8±0.4)d及(2.0±-0.6)d；术后尿管留置时间分别为：(3.5±1.3)d及(2.8±0.9)d；术后住院时间分别为：(7.5±1.6)d及(6.5±1.2)d；两组间上述各项指标相比,差异有统计学意义(P0.05)。 4、两组术式在手术过程中均未发生死亡、包膜穿孔、闭孔神经反射、直肠损伤、膀胱损伤。 5、TURP组66例患者及PKEP组54例患者完成术后1年随访,两组手术患者分别于术后1、6、12个月进行随访登记,其中所有患者均于术后随访中自诉排尿时间较术前明显缩短,尿线明显变粗,尿频、尿急等症状明显改善。两组手术患者于术后1、6、12个月IPSS、QOL评分及Qmax均较术前有明显改善,两组于术后12个月PVR较术前有明显改善,与术前比较有统计学意义(P0.05)；两组于术后12个月PV及tPSA均较术前明显降低,差异有统计学意义(P0.05)。组间比较结果显示：两种术式在术后1、6、12月IPSS、 QOL评分及Qmax的差异无统计学意义(P0.05),两种术式在术后12个月PVR的比较差异无统计学意义(P0.05),说明两种术式在治疗BPH的近期疗效上无明显差别。两组术式在术后12个月PV、tPSA均较术前明显降低,但两组间的差异均有统计学意义(P0.05)。 6、TURP组与PKEP组手术并发症情况：TURP组在术中发生TURS有2例(3.0%),因大出血需要输血1例(1.5%);PKEP组术中未发生TURS及输血,TURP组中术后有8例(12.1%)出现暂时性尿失禁,PKEP组中有5例(9.3%)出现暂时性尿失禁,两组间比较差异无统计学意义(P0.05);TURP组患者术后发生尿道狭窄3例(4.5%), PKEP组患者发生尿道狭窄有2例(3.7%),两组间比较差异无统计学意义(P0.05);TURP组及PKEP组患者术后发生膀胱痉挛分别为1例(1.5%)、2例(3.7%),两组间比较差异无统计学意义(10.05);TURP组与PKEP组术后6个月发生逆行射精分别有17例(25.7%)、8例(14.5%),两组间比较差异无统计学意义(P0.05)；两组术后12个月发生逆行射精分别有10例(15.2%)、7例(13.0%),两组间比较差异无统计学意义(P0.05)；两组患者术后均未出现永久性尿失禁。但是,TURP组及PKEP组患者术后6个月总并发症例数分别为34(51.5%)、17(31.5%),两组比较差异有统计学意义(P0.05)。结论 1、PKEP与TURP相比,近期手术疗效相似,均是治疗BPH较安全的术式。 2、PKEP术中、术后并发症发生率低,PKEP组术中出血量少于TURP组,PKEP组在手术时间、术后膀胱冲洗时间、术后尿管留置时间、术后住院时间等均短于TURP组,是治疗BPH的较好方法。 3、PKEP组前列腺切除体积大于TURP组,术中切除组织标本获得率较TURP局,PKEP术中切除增生前列腺腺体较TURP完全,有利于减少术后BPH复发。 4、PKEP需要术者更好地掌握增生前列腺腺体与外科包膜之间的解剖结构,准确寻找到外科包膜层面是手术成功的关键。
[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.
【学位授予单位】：南方医科大学
【学位级别】：硕士
【学位授予年份】：2014
【分类号】：R697.3

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