经尿道2μm激光前列腺剜除术治疗良性前列腺增生的疗效分析

Transurethral prostate enucleation with 2 μm laser in the treatment of benign prostatic hyperplasia

目的探讨2μm激光剜除技术治疗BPH的疗效。方法BPH患者107例，年龄j2～85岁，平均（67±9）岁。其中伴尿潴留者10例。超声检查测量前列腺体积45～158ml，平均（72．5±17．6）ml。行RevoLix2μm激光前列腺剜除术治疗。硬膜外阻滞麻醉或全麻。术中首先从膀胱颈5、7点位置至精阜两侧各纵行切成一条状槽沟，深达包膜，并沿精阜两侧弧形向上继续切开尿道黏膜及黏膜下层至尿道外括约肌内弧线。自精阜前缘开始，切开尿道黏膜，分离找到外科包膜平面，以电切镜鞘前端沿包膜平面钝性剥离，并摆动镜鞘扩大包膜平面，中叶增生明显者采用分割切除。同样在12点的位置纵行切开，深达包膜，以逆行方式自精阜两侧的前列腺尖部组织沿包膜用镜鞘剜除侧叶，至1点和11点处，与12点沟槽汇合并保留条索状蒂，使剜除的腺体固定并悬挂在腺窝内。前列腺体积≤60ml者直接汽化切除增生腺体为小块组织；体积〉60ml者改用普通电切手件，4％什露醇持续冲洗，将剜除组织切成小块，用冲洗塑料瓶经镜鞘冲出。观察术中出血情况、手术时间、术后尿管留置时间、排尿情况、最大尿流率及住院时间。结果107例患者均顺利完成手术。手术时间45～150min，平均（74±12）min。输血5例。未发生尿道狭窄。1例一过性尿失禁者1个月后恢复。术后随访2～6个月，平均3个月，术后留置尿管4～6d，手术前后血电解质及血红蛋白浓度差异无统计学意义（P〉0．05）。最大尿流率由术前（6．3±0．6）ml／s升至（17．5±1．5）ml／s，国际前列腺症状评分及生活质量评分分别从26．4±5．5和4．6±0．5降至9．3±2．1和2．8±0．3，手术前后比较差异均有统计学意义（P〈0．01）。结论经尿道2μm激光前列腺剜除术治疗BPH安全、有效，彻底性甚至优于TURP。

Objective To investigate the feasibility and efficacy of transurethral prostate enucleation with 2 μm laser in the treatment of benign prostatic hyperplasia （BPH）. Methods One hun- dred and seven patients with BPH were treated by transurethral prostate enucleation with 2 μm laser under continuous epidural anesthesia or laryngeal mask anesthesia. The patient＇ s, average age was 67±9 yrs （52 to 85 yrs）. Of whom, 10 patients had a history of urinary retention. The mean prostate volume was 72.5±17.6 ml （45 to 158 ml）. Two deep trenches were cut at the 5 and 7 o, clock position from the bladder neck to the verumontanum. The incision continued to the urethral mucosa and submucosa along with the verumontanum bilaterally in an arc-shape and ended at the internal are of urethral sphincter. Then the urethral mucosa at the level of the verumontanum was cut and the surgical capsule plane was identified. A retrograde blunt dissection was made along the surgical capsule plane with the resectoscope sheath front-end, and the sheath was swung from side to side to extend the cap- sule plane. The significantly enlarged middle lobe was treated with laser vaporization resection. In the same way, a trench was made at the 12 o, clock position, and the lateral lobe were removed by the sheath from the verumontanum level, finally only two cord-like pedicles were kept at the 1 and 11 o, clock position at the bladder neck, so that the removed gland tissue was fixed and hung in the gland fossa. For prostate volume less than 60 ml, the laser vaporization resection was carried out directly. If the prostate volume was greater than 60ml, transurethral resection would be performed instead of laser vaporization resection. With 4% mannitol irrigation, the enueleated prostate tissue was then cut into small pieces and washed out by a Braun plastic bottle through the resectoscope sheath. Intraoperative bleeding, operative time, catheterization time, postoperative voiding status, maximum urinary flow rate （Qmax） and length of hospital stay were recorded and analyzed. Results All patients successful ly completed the transurethral prostate enucleation. The average operative time was 74± 12 min （45-- 150 min）. Five cases required blood transfusion. There was no recorded urethral stricture and no urinary incontinence except for one patient who recovered 1 mon after the operation. The follow up time was 2--6 mon. The average Qmax was 6.3±0.6 ml/s before and increased to 17.5±1.5 ml/s after the operation. The international prostate symptom score （IPSS） and quality of life （QOL） were reduced from 26.4±5.5 and 4.6±0.5 to 9.3±2.1 and 2.8±0.3 after the operation, respectively, P〈0.01. Postoperative secondary bleeding was not observed. Conclusions Transurethral prostate enucleation with 2 μm laser for BPH is a safe and effective minimally invasive treatment. Its efficacy is superior to open surgery, and even better than TURP.