经尿道刀口变向钬激光前列腺剜除术治疗良性前列腺增生的疗效和安全性分析

Clinical research of transurethral turning holmium laser enucleation of the prostate in the treatment of benign prostatic hyperplasia

目的比较经尿道刀口变向钬激光前列腺剜除术(THoLEP)和经尿道直射钬激光前列腺剜除术(HoLEP)治疗良性前列腺增生(BPH)的疗效和安全性。方法回顾性分析2016年1月至2017年12月收治的200例BPH患者的病例资料,THoLEP组和HoLEP组各100例。THoLEP组和HoLEP组的年龄分别为(74.6±8.2)岁和(75.3±7.7)岁,前列腺重量分别为(52.3±23.1)g和(52.6±22.7)g,国际前列腺症状评分(IPSS)分别为(22.8±1.3)分和(23.1±1.6)分,生活质量(QOL)评分分别为(4.4±0.5)分和(4.3±0.8)分,最大尿流率(Qmax)分别为(5.9±2.7)ml/s和(6.3±2.8)ml/s,残余尿量分别为(149.3±8.7)ml和(145.3±9.7)ml,既往有急性尿潴留史分别为7例和8例,行膀胱穿刺造瘘分别为5例和4例,合并膀胱结石分别为5例和6例,合并内科疾病分别为23例和21例,两组上述指标比较差异均无统计学意义(P>0.05)。THoLEP组使用刀口变向钬激光剜除术专用设备套件,采取两叶或三叶法行前列腺剜除术,利用刀口变向钬激光的优势特点,术中可有效减少镜鞘摆动角度。刀口变向钬激光可有效分离切割作用及爆破作用,旋转钬激光方向侧斜朝向腺体侧,利用爆破能钝性弹开腺体,分离包膜。钬激光刀口朝向腺体侧,可避免烧灼腺体与包膜分离处,保持包膜层面不丢失。分离腺体后调整钬激光方向,紧贴腺体组织离断尖部尿道,可确保外括约肌无损伤。当遇到较大出血时可将出血点调整至视野边缘,从而避开出血导致的视野盲区,并通过旋转钬激光光纤实现点对面止血。HoLEP组使用直射钬激光采取三叶法行前列腺剜除术。比较两组手术的疗效及安全性。结果THoLEP组和HoLEP组的手术时间分别为(44±13)min和(61±15)min,术中出血量分别为(101.6±13.2)ml和(119.9±18.0)ml,差异均有统计学意义(P<0.05);术中切除组织重量分别为(30.5±9.5)g和(28.7±8.5)g,差异无统计学意义(P>0.05)。THoLEP组和HoLEP组术后出现短暂性尿失禁例数分别为2例和4例(P<0.05),术后3个月两组均无尿失禁病例,两组均未出现永久性尿失禁。术后3个月,THoLEP组和HoLEP组的IPSS分别为(7.2±3.1)分和(8.1±4.2)分,QOL评分分别为(1.9±0.6)分和(2.0±0.8)分,Qmax分别为(23.9±5.6)ml/s和(24.7±5.1)ml/s,残余尿量分别为(16.1±7.3)ml和(22.7±17.0)ml,差异均无统计学意义(P>0.05);两组与术前比较差异均有统计学意义(P<0.01)。结论THoLEP与HoLEP相比,近期手术效果相似,但在缩短手术时间、减少术中出血量及术后短暂性尿失禁发生率方面更具优势,是治疗BPH安全、有效的一种改进性术式。

Objective To compare the efficacy and safety of turning holmium laser enucleation of the prostate(THoLEP)and transurethral holmium laser enucleation of the prostate(HoLEP)in the treatment of benign prostatic hyperplasia(BPH).Methods A retrospective analysis of 532 patients with BPH surgery from January 2016 to December 2017 was performed,including 289 cases of transurethral resection of holmium laser enucleation(THoLEP)and 43 cases of transurethral holmium laser enucleation(HoLEP).Cases with incomplete data were excluded.Finally,100 patients were enrolled and divided into THoLEP group and HoLEP.The mean ages of patients in the THoLEP group and the HoLEP group were(74.6±8.2)years and(75.3±7.7)years,respectively.The prostate weights were(52.3±23.1)g and(52.6±22.7)g,respectively.International prostate symptom scores(IPSS)were(22.8±1.3)and(23.1±1.6),and the quality of life score(QOL)scores were(4.4±0.5)and(4.3±0.8),respectively.The rate of mximum flow rate(Qmax)was(5.9±2.7)ml/s and(6.3±2.8)ml/s,respectively.The residual urine volume was(149.3±8.7)ml and(145.3±9.7)ml,respectively.There was no significant difference between the two groups(P>0.05).Results Compared with HoLEP group,THoLEP group showed shorter operation time[(44±13)min vs.(61±15)min,P<0.05]and less intraoperative bleeding[(101.6±13.2)ml vs.(119.9±18.0)ml,P<0.05].The weight of the resected tissue in the THoLEP group was slightly larger than that in the HoLEP group,however the difference was not statistically significant[(30.5±9.5)g vs.(28.7±8.5)g](P>0.05).The incidence of transient urinary incontinence in THoLEP group was less than that in HoLEP group[2 and 4 cases,P<0.05].There were no cases of urinary incontinence in both groups after 3 months,and no permanent urinary incontinence in both groups.THoLEP was slightly better than HoLEP group,but the difference was not statistically significant(P>0.05).Conclusions Compared with HoLEP,THoLEP has similar short-term results,and has more advantages in shortening the operation time,reducing intraoperative bleeding and transient urinary incontinence.It is a safer and effective method for the treatment of benign prostatic hyperplasia.