解剖标志导航钬激光剜除术治疗大体积前列腺增生的疗效分析

The application of holmium laser transurethral enucleation of the large volume prostate with navigation of ultrasonic anatomical landmarks

目的探讨解剖标志导航下钬激光前列腺剜除术治疗大体积前列腺增生的疗效及安全性。方法回顾性分析2016年1月至2018年1月收治的242例前列腺增生患者的病例资料。年龄59~88岁,平均(76.7±8.5)岁。患者术前均存在明显排尿费力、尿线变细、夜尿增多等下尿路梗阻症状。术前经直肠B超检查测量前列腺体积为80~175 cm^3,平均(103.2±21.4)cm^3。B超检查测量残余尿量为0~350 ml,平均(105±75)ml。PSA为0.2~19.5 ng/ml,平均(2.6±1.4)ng/ml。Qmax为1~14 ml/s,平均(6.4±5.2)ml/s。IPSS为10~32分,平均(22.5±5.3)分。QOL评分为2~6分,平均(4.8±1.2)分。除外合并逼尿肌无力、尿道狭窄、神经源性膀胱致排尿困难或术后病理诊断为前列腺癌的患者。242例均行解剖标志导航钬激光前列腺剜除术,术中以精阜明确剜除起点,膀胱颈口环形括约肌明确剜除终点,在外科包膜层面,由剜除起点和终点指示方向。外科包膜层面不清的患者,术中辅以经直肠B超导航寻找外科包膜。结果本研究242例手术均顺利完成,无中转开腹手术。无明显包膜穿孔、继发性出血、水中毒等并发症发生。总手术时间为35~120 min,平均(63.7±12.8)min;剜除时间为25~80 min,平均(49.0±12.2)min;取出腺体湿重45~125 g,平均(70.5±15.3)g,剜除效率为(1.6±0.3)g/min。术后第1天较术前血红蛋白下降0~26 g/L,平均(11±7)g/L。所有患者术后均行膀胱持续冲洗至冲洗液颜色淡红后停止膀胱冲洗,术后冲洗时间为3~24 h,平均(11.4±8.1)h;冲洗液用量为6~15 L,平均(8.5±1.3)L。术后留置导尿管时间为1~7 d,平均(3.2±1.5)d。拔除导尿管后,11例出现短暂压力性尿失禁,经提肛训练2周后随访,无真性尿失禁病例。术后3个月残余尿量为0~75 ml,平均(15±14)ml;Qmax为10.5~31.0 ml/s,平均(16.5±7.1)ml/s;IPSS为6~22分,平均(14.8±6.5)分;QOL评分为1~5分,平均(2.6±1.5)分,与术前比较差异均有统计学意义(P<0.01)。结论解剖标志导航下钬激光前列腺剜除术治疗大体积前列腺增生安全、高效,并发症少。

Objective To investigate the safety and efficacy of holmium laser transurethral enucleation of the prostate(HoLEP)for large volume of prostatic hyperplasia(BPH)with navigation of ultrasonic anatomical landmarks.Methods Data of 242 patients with BPH(≥80 cm^3)underwent domestic HoLEP from Jan.2016 to Jan.2018 were retrospectively analyzed.General data,IPSS,QOL,prostate volume,PSA were assessed.Their average volume of prostate was(103.2±21.4)cm^3,the average PSA was(2.6±1.4)ng/ml,the residual urine volume was(105±75)ml,Qmax was(6.4±5.2)ml/s,IPSS score was 22.5±5.3 and QOL score was 4.8±1.2.ResultAll patients were completed the operation successfully and their LUTS indicators were greatly improved.The enucleation time was between 25 and 80 min,average(49.0±12.2)min;the mass of wet weight of gland was(70.5±15.3)g;the removal efficiency was(1.6±0.3)g/min.The IPSS score dropped to 14.8±6.5,P<0.01;QOL score dropped to 2.6±1.5,P<0.01;PSA dropped to(1.1±1.2)ng/ml,P<0.01;the maximum urinary flow rate growth to(16.5±7.1)ml/s,P<0.01.ConclusionFor large volume of prostatic hyperplasia,holmium laser transurethral enucleation with ultrasonic navigation surgery is safe and efficient.