经尿道前列腺剜除术对合并糖尿病前列腺增生患者生活质量的影响研究

发布时间：2018-04-30 09:07

本文选题：经尿道前列腺剜除术 + 经尿道双极等离子前列腺电切术　；参考：《南方医科大学》2017年硕士论文

【摘要】：研究背景良性前列腺增生症(benign prostatic hyperplasia,BPH)在中老年男性人群最为常见的良性疾病之一,常引起排尿困难,亦是目前泌尿系统疾病中最常见的病种之一。BPH的主要临床症状包括排尿梗阻症状和膀胱过度活动症,梗阻症状主要表现为尿潴留、尿线变细、开始排尿时间变长、间断性排尿、排尿乏力、急迫性尿失禁、充盈性尿失禁、尿滴沥不尽感等,而膀胱过度活动症则表现为夜尿增多、尿频、急迫性尿失禁及尿急。上述主要的临床症状主要为下尿路症状,患者的日常活动、各种社会交往以及睡眠受到上述症状的严重影响,往往会进一步造成患者抑郁、焦虑等不良心境,极大地损害了患者的身心健康,患者的生活质量大大降低。目前,BPH的治疗临床上较常用的方法主要包括药物治疗、观察等待以及外科治疗,由于BPH是一种下尿路症状不断加重的临床进展性疾病,随着病程增加,大多数患者的下尿路症状及其导致的并发症往往会不断加重,口服药物治疗无效,最终需外科手术治疗。BPH的临床手术治疗主要是将过度增生的腺体组织切除,经典的外科手术治疗方法主要包括经尿道双极等离子前列腺电切术、经尿道前列腺电切术、开放性前列腺摘除术。其中,TURP仍为BPH临床手术治疗的“金标准”术式,在该术式的基础上,经尿道双极等离子前列腺电切术(transurethral resection of the prostate,TURP)为 BPH 腔内手术治疗的第三代技术及设备,具有精确切割、以生理盐水作冲洗液、较浅的热穿透及高聚焦等特点,基于上述特点,大大提高了该术式的安全性和临床疗效。随着腔镜手术设备的不断改进,以及治疗BPH的手术方法不断发展和改良,我国学者刘春晓教授创新性的将开放性手术及腔内微创手术的优势特点相结合,首次开展了经尿道双极等离子前列腺腔内剜除术(transurethral enucleation resection of the prostate,TUERP),并将该术式应用临床治疗,通过实践应用,发现其具有疗效明确、微创、安全性高的特点。该术式融合了微创腔内切除与开放前列腺摘除术两者的技术优势,既具有开放前列腺摘术的彻底性和术后不复发性的优势特点,又能达到微创手术术中出血较少、安全性高、术后恢复快及创伤小的效果,是手术治疗BPH的重大突破。另外,我国糖尿病患者的人数超过了四千万,该疾病已严重威胁了人类健康,与此同时,随着我国老年人数占比的增高,不断加重的老龄化程度,糖尿病和BPH的发病率均随人们的年龄增长而呈不断升高的趋势,其中,老年男性合并糖尿病的BPH患者人数也呈不断增加的趋势。尽管目前糖尿病的治疗方法正逐渐改进和提高,BPH的临床治疗效果亦越来越好,然而,手术治疗合并有糖尿病的BPH患者的技术仍需进一步的改善。因糖尿病造成患者机体代谢的紊乱和抵抗力的下降,导致BPH的手术治疗可耐受性差、危险性高,因而适当的术式对于提高临床疗效具有重要意义。由于目前国内外尚无评估合并糖尿病BPH患者的术后生活质量相关研究,因此,本研究通过收集我科收治的合并糖尿病BPH患者,分别行TUERP或TURP治疗,对比分析两种术式的临床疗效、围手术期并发症发生情况以及对患者生活质量的影响。综合评价TUERP在腔内微创治疗BPH的实际应用效果,验证该术式的安全性、有效性及可行性,为TUERP在临床应用的进一步推广提供科学依据。研究目的探讨TUERP和TURP两种术式对合并糖尿病的BPH患者临床疗效、可行性及安全性,以及对患者生活质量的影响,为合并糖尿病的BPH患者治疗方法选择及临床应用推广提供理论依据。研究方法收集2015年1月至2016年6月本院收治合并有糖尿病的BPH患者,根据纳入及排除标准选择符合要求的研究对象。所有患者均行直肠指检,直肠超声检测前列腺体积,尿动力学检测最大尿流率(maximum flow rate,Qmax)、残余尿量,并进行生活质量评分(QOL)、国际前列腺症状评分(IPSS)、焦虑自评量表(Self-Rating Anxiety Scale,SAS)以及抑郁自评量表(Self-Rating Depression Scale,SDS)调查评估。纳入研究的患者均为良性前列腺增生,诊断明确,且患有2型糖尿病,符合纳入标准,行TUERP或TURP治疗。应用随机对照、单盲试验设计及随机均衡分组。观察组患者40例,行TUERP治疗;对照组患者40例,行TURP治疗。对比分析两组围手术期和术后的各个观察指标,术后3月及6月进行首次对患者进行随访,随访采用电话随访、门诊复查等方式进行调查。收集的数据均采用SPSS21.0软件行统计学分析,将P0.05定义为差异有统计学意义。(1)术前研究观测指标收集所有患者的年龄、病程、BMI、最大尿流率(maximum flow rate,Qmax)、是否合并基础疾病、前列腺特异性抗原(PSA)、前列腺体积(prostate volume,PV)、残余尿量(post void residual,PVR)、国际前列腺症状评分(IPSS)、生活质量评分(QOL)、焦虑自评量表(SAS)、抑郁自评量表(SDS)调查。入院后对所有纳入患者行QOL、IPSS、SAS及SDS调查。(2)术中研究观测指标记录两组患者的术中出血量、手术时间、术中是否需输血及输血量、切除腺体重量,术后住院时间、术后膀胱持续冲洗时间、术后留置导尿管时间以及术后并发症发生情况,有无副损伤,包括膀胱、尿道损伤,是否出现经尿道电切综合症(TURS)、有无前列腺包膜穿孔,以及是否术中转开放手术。(3)术后观察指标记录两组患者的术后住院时间、术后膀胱持续冲洗时间、术后留置导尿管时间以及术后并发症发生情况。(4)随访观察指标术后第3月及6月时可评价临床疗效,术后第3月及6月时进行首次对患者进行随访,随访内容包括:术后早期有无出现排尿症状,如尿频、尿急、尿痛、排尿困难、肉眼血尿等,以及术后恢复状况,复查B超及尿流动力学检测,包括检测PVR和Qmax,并做QOL评分、IPSS评分、SAS及SDS调查,询问患者有无出现尿线变细、尿失禁、尿不尽感、尿后滴沥、排尿困难等症状,以及是否需药物进行辅助治疗。术后的客观症状指标主要包括术后3月及6月的PVR、Qmax,以及术后并发症发生率;术后3月及6月的QOL评分、IPSS评分、SAS及SDS调查则作为评估患者术后的主观感受指标。研究结果共纳入80例合并糖尿病的BPH患者,所有患者均顺利完成手术治疗,无中转开放手术患者,术中彻底止血,均未行输血治疗。(1)术前的观察指标包括年龄、BMI、病程、是否合并高血压、糖化血红蛋白、残余尿量、最大尿流率、术前IPSS评分、QOL评分、前列腺体积、tPSA等,组间差异无统计学意义(P0.05),提示两组患者分布均衡,组间具有可比性。(2)与TURP治疗患者相比较,TUERP治疗患者的手术时间、膀胱冲洗时间、尿管留置时间及术后住院时间均明显更短,出血量明显更少,而切除前列腺腺体重量明显更多,组间差异具有统计学意义(P0.05),提示TUERP可缩短手术时间,减少术中出血,加快术后康复等特点。(3)两组患者术前及术后3月及6月随访观察指标主要包括:Qmax、PVR、IPSS评分、QOL评分问卷评分、SAS及SDS调查,所有患者在术前和术后3月及6月均行Qmax和PVR的检测,给予IPSS评分、QOL评分,以评估患者的临床症状改善情况和生活质量,并进行SAS及SDS调查,以了解患者的精神心理状况,包括焦虑和抑郁。与手术治疗前相比,所有患者在术后3月及6月的Qmax明显升高,术后3月及6月的PVR、IPSS评分、QOL评分问卷评分、SAS及SDS调查评分均明显降低,组间差异具有统计学意义(P0.05);通过比较观察组和对照患者不同时间段(包括术前和术后3月及6月)各项随访指标,组间差异具有统计学意义(P0.05),而术后3月与术后6月各项指标均无统计学差异,表明相比TURP,TUERP可显著改善术后尿流率、下尿路症状,明显提高患者生活质量、缓解患者焦虑和抑郁心境状态。(4)TUERP治疗40例患者中共有4例患者出现并发症,并发症发生率为10%,包括1例术中包膜穿孔,3例术后尿失禁;而TURP治疗的40例患者中共有13例患者出现并发症,并发症发生率为32.5%,包括3例术后继发性出血、6例包膜穿孔、2例术后尿失禁、2例尿道狭窄,观察组患者的并发症发生率明显更低,其中两组患者的包膜穿孔率明显更低,组间差异具有统计学意义(P0.05),提示TUERP治疗合并糖尿病的BPH患者术后并发症较少,安全性更高。结论TUERP和TURP治疗合并糖尿病的BPH患者的临床疗效均比较确切,其中与TURP相比,TUERP的优势为创伤较小,术后恢复较快,安全性较高,明显改善术后排尿症状及生活质量,值得临床进一步推广应用。
[Abstract]:Background benign prostatic hyperplasia (benign prostatic hyperplasia, BPH), one of the most common benign diseases in middle-aged and elderly men, often causes difficulty in urination, and is also one of the most common diseases of the urinary system. The main clinical symptoms of.BPH are the symptoms of Urination Obstruction and overactivity of the bladder, and the main symptoms of obstruction. Urine retention, urine line thinning, beginning urination time, intermittent urination, urinating, urgent incontinence, filling urinary incontinence, urinary incontinence, urinary drip incontinence and so on. Bladder hyperactivity is manifested by the increase of nocturia, frequency of urine, urgent incontinence and urgency of urine. The main clinical symptoms are mainly lower urinary tract symptoms and patient's daily routine. Activities, social contacts and sleep are seriously affected by these symptoms, which often further cause depression, anxiety and other bad mood, which greatly damage the physical and mental health of the patients. The quality of life of the patients is greatly reduced. At present, the most commonly used methods of BPH treatment include drug treatment, observation and surgery. Treatment, as BPH is a progressive and progressive disease of lower urinary tract symptoms, with the increase of the course of the disease, the symptoms of the lower urinary tract and the complications in the majority of the patients are often aggravated, and the oral medication is not effective. Finally, the surgical treatment for the surgical treatment of.BPH is mainly to remove the hyperproliferative gland tissue. The classic surgical procedures include transurethral bipolar plasma prostatectomy, transurethral resection of the prostate, and open prostatectomy, of which, TURP is still a "gold standard" for BPH clinical surgery. On the basis of this operation, transurethral bipolar plasma prostatectomy (transurethral resection) Of the prostate, TURP) for the third generation technology and equipment for BPH intracavitary surgery, it has the characteristics of precise cutting, saline as flushing fluid, shallow heat penetration and high focus. Based on the above characteristics, the safety and clinical efficacy of the operation are greatly improved. With the continuous improvement of the surgical equipment of the cavity mirror and the operation of the treatment of BPH Methods to develop and improve, Professor Liu Chunxiao, a Chinese scholar, combined the advantages and characteristics of open surgery and intracavity minimally invasive surgery, and first carried out the transurethral enucleation resection of the prostate, TUERP in the transurethral bipolar plasma prostatic enucleation (TUERP). It has the advantages of minimally invasive endovascular resection and open prostatectomy, which not only has the advantages of open prostatic extraction, but also has the advantages of non recurrence and less bleeding in minimally invasive surgery, high safety and postoperative recovery. The effect of fast and small trauma is a major breakthrough in the surgical treatment of BPH. In addition, the number of people with diabetes in our country is more than forty million, which has seriously threatened human health. At the same time, the incidence of diabetes and BPH is increasing with the increase of the number of elderly people in our country, the increasing degree of aging, the incidence of diabetes and the incidence of BPH. The increasing trend, among them, the number of BPH patients with diabetes in old men is also increasing. Although the treatment of diabetes is improving and improving, the therapeutic effect of BPH is getting better and better. However, the technique of surgical treatment of BPH patients with diabetes still needs to be further improved. The disorder of the patient's body metabolism and the decline of resistance lead to poor tolerance and high risk of BPH operation. Therefore, appropriate surgical procedures are of great significance to improve the clinical efficacy. The patients with diabetic BPH were treated with TUERP or TURP respectively. The clinical efficacy of the two kinds of surgical procedures, the perioperative complications and the quality of life of the patients were compared and analyzed. The practical application of TUERP in the intracavitary minimally invasive treatment of BPH was evaluated, and the safety, effectiveness and feasibility of the operation were verified for TUERP in the future. The further promotion of bed application provides scientific basis. The purpose of this study is to explore the clinical efficacy, feasibility and safety of two kinds of TUERP and TURP methods for patients with diabetic BPH, as well as the influence on the quality of life of the patients, to provide a theoretical basis for the choice of treatment methods and clinical application of diabetic BPH patients. 5 years from January to June 2016, BPH patients with diabetes were admitted to the hospital. The subjects were selected according to the inclusion and exclusion criteria. All patients underwent rectal examination, rectal ultrasound examination of prostate volume, urodynamic test maximum urinary flow rate (maximum flow rate, Qmax), residual urine volume, and quality of life score (QOL). The prostatic symptom score (IPSS), the Self-Rating Anxiety Scale (SAS) and the self rating Depression Scale (Self-Rating Depression Scale, SDS) were evaluated. All the patients enrolled were benign prostatic hyperplasia, with a definite diagnosis, and with type 2 diabetes, which met the inclusion criteria and performed TUERP or TURP. A randomized controlled trial was used. The blind trial design and random equilibrium grouping. 40 patients in the observation group were treated with TUERP; 40 cases in the control group were treated with TURP. The peri operative and postoperative observation indexes of the two groups were compared and analyzed, and the patients were followed up for the first time in March and June after the operation. The follow-up was followed by telephone follow-up, and the outpatient reexamination was conducted. All the data collected were collected. All data collected were collected. Statistical analysis was performed by SPSS21.0 software. (1) the age of all patients, the course of disease, the course of disease, the BMI, the maximum urinary flow rate (maximum flow rate, Qmax), the combination of the basic disease, the prostate specific anti primitive (PSA), the volume of the prostate (prostate volume, PV), the residual urine volume (post), were collected before the operation. D residual, PVR), International Prostate Symptom Score (IPSS), quality of life score (QOL), self rating Anxiety Scale (SAS), and self rating Depression Scale (SDS) survey. All the patients were investigated for QOL, IPSS, SAS and SDS after admission. (2) intraoperative bleeding volume, operation time, operation time, blood transfusion and blood transfusion were recorded during the study. The weight of the gland, the time of postoperative hospitalization, the time of continuous bladder irrigation after the operation, the time of indwelling catheter after operation, and the postoperative complications, there were no side injuries, including bladder, urethral injury, urethral resection syndrome (TURS), the perforation of the prostatic membrane, and whether the operation was open or not. (3) the observation index The time of postoperative hospitalization of the two groups, the duration of postoperative bladder irrigation, the time of indwelling catheter after operation and the postoperative complications were observed. (4) the clinical efficacy was evaluated at third months and June after the follow-up observation, and the patients were followed up for the first time in third months and June after the operation. The symptoms of urination, such as frequency of urination, urination, urination, dysuria, dysuria, hematuria, and postoperative recovery, review the B-ultrasound and urodynamic test, including the detection of PVR and Qmax, and do QOL score, IPSS score, SAS and SDS investigation, and ask if the patients have symptoms such as urine thinning, urinary incontinence, urinary inconsistency, urine drop Lek, dysuria and other symptoms, and whether or not PVR, Qmax, and postoperative complications occurred in March and June after the operation; the QOL scores in March and June after operation, IPSS score, SAS and SDS survey were used to evaluate the subjective perception of patients after operation. The results were included in 80 patients with diabetes mellitus, all of which were included in all patients. The surgical treatment was completed successfully. There was no transfer to open surgery patients. No blood transfusion was performed during the operation. (1) preoperative observation indexes included age, BMI, course of disease, combined hypertension, glycated hemoglobin, residual urine volume, maximum urine flow rate, preoperative IPSS score, QOL score, prostate volume, tPSA and so on, there was no significant difference between groups (P0 .05), it was suggested that the two groups were evenly distributed and comparable between the groups. (2) compared with the patients treated with TURP, the operation time of the patients with TUERP, the time of bladder irrigation, the indwelling time of the urinary catheter and the time of hospitalization after the operation were significantly shorter, the amount of bleeding was significantly less, and the weight of the glandular gland was significantly increased, and the difference between the groups was statistically significant (P0. 05) suggested that TUERP could shorten the time of operation, reduce intraoperative bleeding and accelerate postoperative rehabilitation. (3) the indexes of follow-up and observation in two groups of patients before and after operation in March and June were mainly included: Qmax, PVR, IPSS, QOL score, SAS and SDS, all patients were tested for Qmax and PVR before and after operation, March and June, and IPSS scores, Q The OL score was used to assess the patient's clinical symptoms improvement and quality of life, and to conduct a SAS and SDS survey to understand the mental state of the patient, including anxiety and depression. Compared with the operation before the operation, all the patients were significantly elevated in March and June after the operation, PVR, IPSS score, QOL score, SAS and SDS in March and June after the operation. The difference between the groups was statistically significant (P0.05), and the difference between the observation group and the control patients in different time periods (including pre operation and March and June) was statistically significant (P0.05), but there was no statistical difference between March and June after the operation, indicating that TUERP could be compared with TURP. Improving the postoperative urinary flow rate and lower urinary tract symptoms, obviously improving the quality of life and relieving the state of anxiety and depression. (4) there were 4 cases of complications in 40 patients treated with TUERP, the incidence of complications was 10%, including 1 cases of intraoperative perforation and 3 cases of postoperative urinary incontinence, and 13 patients in 40 patients treated with TURP. Complications, complication rate was 32.5%, including 3 cases of postoperative secondary bleeding, 6 cases of perforation of capsular, 2 cases of urinary incontinence, 2 cases of urethral stricture, the incidence of complications in the observation group was significantly lower, of which the two groups were significantly lower in the envelope perforation rate, and the difference between the groups was statistically significant (P0.05), suggesting that TUERP treatment combined diabetes BP. H patients have less postoperative complications and higher safety. Conclusion the clinical efficacy of TUERP and TURP in the treatment of BPH patients with diabetes is more accurate. Compared with TURP, the advantage of TUERP is less trauma, the postoperative recovery is faster, the safety is higher, and the postoperative urination symptoms and quality of life are obviously improved. It is worthy of further clinical application.

【学位授予单位】：南方医科大学
【学位级别】：硕士
【学位授予年份】：2017
【分类号】：R699.8;R587.1

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