姑息性经尿道前列腺切除术对前列腺癌预后的影响

Impact of palliative transurethral prostate resection on the prognosis for prostate cancer

目的探讨姑息性TURP对前列腺癌预后的影响。方法回顾1999年1月～2008年6月TURP治疗前列腺癌BOO的临床资料,根据术后PSA不同效应,将病例分为PAS下降组和上升组,并作多参数比较。结果18例前列腺癌共计做TURP 23次,其再手术率为21%。TURP时患者平均年龄为77.8岁(67～89岁),平均TURP距ADT开始时间为(31.1±34.5)月,术前PAS值为(65.89±57.77)ng/ml,B超测得前列腺大小为(69.3±68.3)g,TURP平均操作时间为(47.4±19.2)min,切除前列腺组织重量为(22.3±17.0)g,TURP后平均随访(20.7±12.2)月,17例(94.4%)术后可自行排尿,1例(5.6%)仍需耻骨上膀胱造瘘。患者感到排尿症状显著改善者10例(55.6%),短期(<3月)改善后又加重症状者4例(22.2%),症状未改善者4例(22.2%)。TURP后1月PSA值下降者10例(55.6%),下降达(36.64±40.14)ng/ml,并维持(19±14.5)月(PSA下降组);8例(44.4%)或手术前后PSA相同(2例手术前后均为150 ng/ml)或PSA上升(6例比术前PSA上升达[(34.43±24.85)ng/ml]。在2组之间,TURP距ADT开始时间(P>0.2)、术前PSA值(P>0.2)、前列腺大小(P>0.1)、TURP操作时间(P>0.5)、被切除前列腺组织重量(P>0.5)均未达到统计学的差异。但PAS上升组证实有远处转移的T4期前列腺癌(75%)(转移达睾丸、盆腔淋巴结、多处骨骼),再手术率高(37.5%),前列腺癌特定死亡率高(75%)。结论TURP解除前列腺癌BOO是一种局部的姑息性减瘤手术,在较低分期患者中,既可以解除BOO,也可以协同ADT降低PSA,有利预后。但是,在较高分期有远处转移灶的患者中,由于癌细胞增殖增快,TURP只能短期改善排尿症状,甚至使PSA升高,不利预后,可以选择其它方法解除梗阻性排尿症状。

Objective To investigate the effects on that palliative transurethral prostate resection（TURP） exerts on the prognosis for prostate cancer.Methods A retrospective review was conducted concerning all patients with prostate cancer who underwent palliative TURP for the relief of bladder outlet obstruction（BO） between January 1999 and June 2008.According to different PSA responses to the operation,the patients were divided into two groups（PSA decline group and undecline,elevated group）,and multivariate analysis was done.Results A total 23 palliative TURPs were performed in 18 patients（reoperation rate 21%）.Mean patient age at TURP was 77.8 years（range 67 to 89）.Average time from beginning of androgen deprivation therapy（ADT） to TURP was 31.1 months（range 1~108）,median PSA level ± SD was 65.89±57.77 ng/ml,median prostate weight（determined with transrectal altrasound）±SD was 69.3±68.3 gram,median operation time for TURP±SD was 47.4±19.2 minutes,median resected prostate weight ± SD was 22.3±17.0 gram.The median follow-up after TURP was 20.7 months（range 4~50）.Of all cases 17（94.4%）may self-micturate,1（5.6%）still require chronic bladder drainage via suprapubic tube.Patients were of the opinion that TURP resulted in significant improvement in voiding symptoms in 10 cases（55.6%）,shorter term improvement（3 months）but later deterioration in 4（22.2%）cases,never improvement in 4（22.2%）cases.One month after TURP,10 cases（55.6%） exprienced PSA level decline down to 36.64±40.14 ng/ml,and maintaining afterwards.6 cases had higher PSA than preoperation（rising to median 34.43±24.85 ng/ml）.The period from ADT to TURP（P0.2）,pre-operation PSA levels（P0.2）,prostate weight（P0.1）,TURP manipulatie time（P0.5）,and resected prostate weight（P0.5） all did not have statistical differences between the two groups.But the elevation PSA group had more stage T4 cases（75%） documenting metastatic disease at TURP including testicpelvic lymph nodes and bones,had higher reoperation rate（37.5%）,and the prostate cancer specific mortality was greater（75%）.Conclusion TURP for BOO due to prostate cancer is a local palliative tumor burden reduction operation.It may either arrive at relief of BOO,or lower PSA in coordination with ADT in favour of prognosis in patients with lower stage prostate cancer.Unfortunatelly,in men with greater stage the disease progressed to bones,lymph nodes,testis metastasis.With a more rapid cancer proliferation,TURP resulted in shorter term improvement in voiding symptoms only,even elevating PSA,worsening prognosis.Other treatments to relieve obstructive voiding symptoms are advised.