经尿道柱状水囊前列腺扩开术治疗BPH的临床应用经验

The clinical experience of transurethral columnar balloon dilation of prostate for benign prostatic hyperplasia

目的总结经尿道柱状水囊前列腺扩开术(TUCBDP)治疗良性前列腺增生(BPH)的临床应用经验。方法回顾性分析2015年6月至2018年6月湖北省中医院收治的379例BPH患者的临床资料。年龄(71.3±14.5)岁。病程1个月至36年。前列腺体积(47.4±2.1)ml。术前最大尿流率(Qmax)(9±4)ml/s,残余尿量(PVR)(123.1±72.4)ml,国际前列腺症状评分(IPSS)(21±6)分,生活质量评分(QOL)(5±1)分。32例术前有性生活者国际勃起功能指数问卷表(IIEF-5)评分(15±4)分。379例均行TUCBDP,以2016年6月导管结构改进定型时间为界,将患者分为早期阶段(2015年6月至2016年5月)121例和近期阶段(2016年6月至2018年6月)258例。早期阶段手术原则是扩裂导管内囊扩张膜部尿道,外囊扩张前列腺部尿道和膀胱颈,术毕分次放水减压。主要手术步骤包括插入扩裂导管,于阴囊根部皮肤触及水囊定位突,内外囊注水,内外囊首次放水减压,扩裂导管接水持续冲洗,内外囊再次分次放水减压,拔出扩裂导管并更换普通尿管持续冲洗。近期阶段手术原则是导管内囊仅起定位固定作用,外囊全程扩张膜部尿道、前列腺部尿道和膀胱颈,术毕内、外囊一次性放水减压,术前、术毕常规应用电切镜检查。主要手术步骤包括先行电切镜检查膀胱及尿道,术者示指经直肠引导扩裂导管进入膀胱,于前列腺尖部扪及定位突后,内囊注水定位,内囊补水及外囊注水,内外囊一次性放水减压,拔出扩裂导管行排尿试验,电切镜观察腺体扩开情况,更换普通导尿管持续冲洗等。观察患者术后1、3、6、12、24个月的Qmax、PVR、IPSS、QOL变化情况;比较两阶段患者并发症以及国际尿失禁咨询委员会尿失禁问卷表简表(ICI-Q-SF)评分差异。对于术前有性生活者,记录IIEF-5评分变化情况。结果本组379例术中及术后均无死亡。手术时间(18.5±6.7)min。术后1、3、6、12、24个月随访例数分别为326、253、201、194、181例。术后1、3、6、12、24个月Qmax分别为(17±9)ml/s、(15±2)ml/s、(12±4)ml/s、(13±6)ml/s、(13±4)ml/s;PVR分别为(17.4±11.6)ml、(20.6±9.8)ml、(25.4±13.1)ml、(31.5±11.5)ml、(29.1±12.4)ml;IPSS分别为(7±5)分、(4±4)分、(4±4)分、(6±5)分、(4±4)分;QOL均为(2±1)分;与术前比较差异均有统计学意义(P<0.05)。32例术前有性生活者,术后IIEF-5评分(17±6)分,与术前比较差异无统计学意义(P>0.05);2例出现短暂性逆行射精,术后6个月内自行缓解。近期阶段组发生假性尿失禁4例(1.5%),较早期阶段组[6例(4.9%)]差异无统计学意义(P>0.05);近期阶段组发生大出血1例(0.4%),较早期阶段组[6例(4.9%)]差异有统计学意义(P<0.05);近期阶段组术后发生急性尿潴留2例(0.7%),较早期阶段组[15例(12.4%)]差异有统计学意义(P<0.05)。结论TUCBDP治疗BPH整体疗效肯定、安全性较高。近期阶段并发症除假性尿失禁外,均明显低于早期阶段,与导管结构改进、临床经验积累等有关。

Objective To summarize the clinical experience of transurethral columnar balloon dilation of prostate(TUCBDP)in the treatment of patients with benign prostatic hyperplasia(BPH).Methods A retrospective analysis of 379 BPH clinical data from the Hubei Provincial Hospital of Traditional Chinese Medicine using TUCBDP was performed between June 2015 and June 2018.Their age was(71.3±14.5)years old.The history of disease ranged from 1 month to 36 years.The prostate volume was(47.4±2.1)ml.Preoperative maximum urinary flow rate was(Qmax)(9±4)ml/s,postvoid residual urine(PVR)was(123.1±72.4)ml.Their international prostate symptom score(IPSS)was(21±6)points.The quality of life score(QOL)was(5±1)points.The international index erectile function questionnaire(IIEF-5)in 32 patients,who had sex before surgery,was 15±4.We set the time of catheter structure improvement in June 2016 as the boundary,including the early stage(June 2015 to May 2016,121 cases)and the recent stage(June 2016 to June 2018,258 patients).In the early stage,the principle of operation is the inner balloon of the catheter to dilate the membrane urethra,and the outer balloon to dilate the urethra of the prostate and the bladder neck.The main surgical steps include the insertion of a dilatation catheter,localization by touching the skin of the scrotum bottom,the inner and outer balloon are filled with water,the first time of drainage and decompression in the inner and outer balloon,the catheter continuous irrigation,drainage and decompression of the inner and outer balloon again,removing the dilatation catheter,and the ordinary urinary catheter was replaced and continuous irrigation.In the recent stage,the principle of surgery is that the inner balloon only served for positioning and fixation.The outer balloon is used to dilate the membrane urethra,prostate urethra,and bladder neck.The inner and outer balloon are drained and decompressed at one time after surgery.The main surgical steps are that the resectoscope was used to examine the bladder and urethra and to guide the dilatation catheter into the bladder.The apex of the prostate touching was used to conform the location.The inner balloon water filling was used for fix the positioning.The inner and outer balloon are filled with water,decompressed and pulled out for urination test,the gland expansion is observed under the resectoscope,and ordinary urinary catheter is replaced for continuous flushing.We observed the changes in Qmax,PVR,IPSS,and QOL at 1,3,6,12,and 24 months after the operation.the complications differences in two-stage patien,including the International Incontinence Advisory Committee Urinary Incontinence Questionnaire(ICI-Q-SF)score;those who had sex before surgery were recorded changes in the IIEF-5 score,was compared.Results There were no deaths during and after operation in this study.The operation time was(18.5±6.7)min.The number of follow-up cases at 1,3,6,12,and 24 months after operation were 326,253,201,194,and 181,respectively.The Qmax at 1,3,6,12,and 24 months after operation were(17±9)ml/s,(15±2)ml/s,(12±4)ml/s,(13±6)ml/s and(13±4)ml/s,respectively.The PVR were(17.4±11.6)ml,(20.6±9.8)ml,(25.4±13.1)ml,(31.5±11.5)ml,and(29.1±12.4)ml,respectively.The IPSS were(7±5)points,(4±4)points,(4±4)points,(6±5)points,(4±4)points,respectively.The QOL were(2±1)points,(2±1)points,(2±1)points,(2±1)points,and(2±1),respectively.All those results that were significantly different from those before surgery(P<0.05).There were 32 patients who had sex before the operation.The postoperative IIEF-5 score was(17±6),which was not significantly different from that before the operation(P>0.05).Two patients had transient retrograde ejaculation,which relieved spontaneously within the 6 month.4 cases with pseudourinary incontinence in the recent stage(1.5%)were not statistically different from 6 cases(4.9%)in the early stage(P>0.05).one case(0.4%)of major bleeding in the recent stage was statistically different from 6 cases(4.9%)in the early stage(P<0.05).2 cases(0.7%)of patients with acute urinary retention in the recent stage were significantly different from 15 cases(12.4%)in the early stage(P<0.05).Conclusions TUCBDP has a positive overall effect and high safety.The major complications of surgery in the recent stage,except for pseudo-urinary incontinence,are significantly lower than that in the early stage,which may be related to the improvement of the catheter structure and the accumulation of clinical experience.