经膀胱单孔多通道腹腔镜下前列腺剜除术的初步疗效分析

Single-port transvesical enucleation of the prostate:an initial clinical experience with 11cases

目的采用经膀胱单孔腹腔镜下前列腺剜除术治疗前列腺增生,总结初步治疗经验和体会。方法 11例前列腺增生患者,年龄67～80岁,平均(72.3±4.61)岁,体质指数18～29kg/m2,平均(22±3.81)kg/m2;超声测量前列腺体积19.9～116.9ml,平均(74.3±27.9)ml;IPSS评分20～35分,平均(27.1±4.89)分;残余尿量18～1 000ml,平均(308.3±283.6)ml;6例术前最大尿流率3.5～15.7ml/s,平均(8.42±4.09)ml/s,4例因急性尿潴留留置导尿及1例因梗阻性肾衰未行尿流率检测;术前PSA水平2.31～12.15ng/ml,平均(6.41±2.89)ng/ml,PSA>4ng/ml的6例患者术前穿刺结果均为良性前列腺增生。麻醉成功后,于脐下做2cm皮肤切口,切开白线,上推腹膜,显露膀胱顶部,在膀胱镜监视下,放置单孔多通道套件,撤出膀胱镜,连接气腹机建立气膀胱空间。置入5mm一体式腹腔镜,以可弯剪刀沿外科包膜内缘游离并剜除增生前列腺组织,经单孔套件取出。缝合膀胱裂孔后,留置导尿,并留置耻骨后引流管自切口引出。结果 1例因放置单孔套件失败,中转开放行耻骨上前列腺剜除术。其余10例手术顺利完成,耗时120～210min,平均(155±30.1)min,术中出血50～900ml,平均(355±288.1)ml,仅1例术中输血1 200ml,无其他严重并发症。10例单孔腹腔镜下切除组织12～76ml,平均(36.8±20.2)ml,术后病理均为良性前列腺增生。术后膀胱冲洗2～4d,平均(2.7±0.95)d,术后1～4d拔除耻骨后引流管,平均(2.4±0.92)d,术后住院5～11d,平均(7.1±1.73)d,2周拔除导尿管。术后随访1～3个月,最大尿流率为16.4～26.9ml/s,平均(23.2±5.59)ml/s,残余尿量10～67ml,平均(38.3±13.7)ml,IPSS评分为1～4分,平均(2.1±0.86)分,排尿均正常,无尿失禁、尿潴留、排尿困难等其他并发症。结论单中心的初步经验表明,经膀胱单孔腹腔镜前列腺剜除术安全、有效、可行,且创伤小,但确切疗效需大样本随机对照研究和长期随访观察。

Objective To treat benign prostate hyperplasia（BPH）by single-port transvesical enucleation of the prostate（STEP）and to report our preliminary experience.Methods We performed STEP in 11BPH patients,who had a mean age of 72.3±4.61（ranging 67-80）years and a mean body mass index（BMI）of 22±3.81（ranging 18-29）kg/m2.They had a mean prostate volume of 74.3±27.9（ranging 19.9-116.9）ml（by ultrasonography）,a mean IPSS of 27.1±4.89（20-35）,and a mean postvoid residual of 308.3±283.6（18to 1 000）ml.The mean maximum urinary flow rate was 8.42±4.09ml/s（ranging 3.5-15.7）in 6patients（not measured in others due to acute urinary retention in 4patients and chronic obstructive renal failure in 1patient）.The mean baseline prostate-specific antigen（PSA）level was 6.41±2.89（ranging 2.31-12.15） ng/ml before operation;prostate biopsy showed that 6patients with PSA level≥4ng/ml had BPH.Under general anaesthesia,a 2cm skin incision was made just below the umbilicus,the white line was incised and the peritoneum was pushed up to expose the dome of the bladder.The novel single-port device was inserted percutaneously into the bladder with assistance of cystoscopy.After establishment of pneumovesicum,the prostate adenoma was enucleated along the inner margin of its surgical capsule with a flexible scissor and extracted viathe port.After suturing the bladder fissure,a three-way Foley catheter and retropubic tube were left for drainage.Results Open conversion was necessary in one case due to failure of single-port device insertion.The STEP was completed in 10cases,with the mean operative duration being 155±30.1（ranging 120-210）min and the estimated intraoperative blood loss being 355±288.1（ranging 50-900）ml.One case was transfused with an amount of 1 200ml,without any other severe complications.The mean specimen volume was 36.8±20.2（ranging 12-76）ml,and the specimens were identified as BPH by pathological examination.Continuous bladder irrigation was used in all cases,with a mean period of 2.7±0.95（ranging 2-4days）.The patients had a mean retropubic drainage for 2.4±0.92（ranging 1-4）days,a mean hospital stay of 7.1±1.73（ranging 5-11）days,and a mean duration of catheterization of 2weeks.All 10patients（excluding the one converted to open prostatectomy）were voiding spontaneously after the catheter retraction.The patients were followed up for 1-3 months after surgery,and it was found that the mean maximum urinary flow rate was 23.2±5.59（ranging 16.4-26.9）ml/s,with a postvoid residual of 38.3±13.7（ranging 10-67）ml and an International Prostate Symptom Score（IPSS）of 2.1±0.86（ranging 1-4）.No patient had developed urinary incontinence,retention or dysuria.Conclusion Our initial experience shows that STEP is a safe,effective and feasible procedure,with advantages of less trauma and more cosmetic benefit,but its clinical effect needs to be observed by prospective comparative studies with a longer follow-up