经尿道前列腺钬激光剜除术治疗小体积前列腺增生的疗效和安全性分析

The effect of holmium laser enucleation of the prostate in the treatment of small volume benign prostate hyperplasia

目的探讨经尿道前列腺摩西钬激光剜除术(MoLEP)治疗小体积(前列腺体积<40 ml)良性前列腺增生(BPH)的疗效和安全性。方法回顾性分析2017年10月至2020年4月南京医科大学第一附属医院收治的132例接受MoLEP的小体积BPH患者的临床资料。患者年龄(63.93±5.21)岁,其中12例合并膀胱结石。前列腺体积(32.16±7.81)ml,术前国际前列腺症状评分(IPSS)23(15~34)分,生活质量评分(QOL)5(2~6)分,最大尿流率(Qmax)7.80(0.80~9.80)ml/s,残余尿量158(51~409)ml。其中89例术前行尿动力学检查,最大逼尿肌收缩压(64.23±8.11)cmH_(2)O(1cmH_(2)O=0.098kPa)。手术方法:采用120W摩西激光平台,切割功率为80W(2.0J×40Hz)(窄脉宽模式),止血功率为24W(0.8J×30Hz)(宽脉宽模式)。合并膀胱结石者先行摩西钬激光碎石取石术。定位到精阜切开尿道黏膜,沿外科包膜剥离腺体,将整个腺体完整剜除,推入膀胱,保留膀胱颈。如发现前列腺钙化灶,直接行摩西钬激光碎石术。术后生理盐水持续冲洗膀胱,术后24 h拔除导尿管。记录手术情况及术中、术后并发症。术后3个月随访IPSS、QOL、Qmax和残余尿量。术后尿失禁定义为24h需≥2片尿垫。结果本组132例手术均顺利完成,术中发现合并前列腺钙化30例;手术时间(剜除时间)为(16.83±4.03)min,围手术期均未输血,均无经尿道电切综合征、尿潴留和静脉血栓栓塞症等并发症,术后无膀胱颈挛缩及膀胱结石复发。术后尿道狭窄2例(1.5%),短暂性尿失禁27例(20.5%)。术后病理检查示132例均为BPH,其中102例(77.3%)伴间质慢性炎症细胞浸润。132例术后3个月IPSS 7(0~14)分,QOL 2(0~5)分,Qmax17.55(9.40~26.50)ml/s,残余尿量27(0~46)ml,均较术前明显改善,差异有统计学意义(P<0.05)。结论MoLEP可明显改善小体积BPH患者下尿路症状及生活质量,尿道狭窄、尿失禁等并发症发生率较低,手术安全可靠,且可同期行膀胱结石碎石。

Objective To investigate the efficacy and safety of transurethral Moses holmium laser enucleation of the prostate(MoLEP)in the treatment of small-volume benign prostatic hyperplasia(BPH).Methods The clinical data of 132 patients with small BPH(prostate volume<40 ml)who underwent MoLEP from October 2017 to April 2020 in the First Affiliated Hospital of Nanjing Medical University were analyzed retrospectively.The age of the patients was(63.93±5.21)years old,including 12 patients with cystolithiasis.The prostate volume of 132 patients was(32.16±7.81)ml,the preoperative international prostate symptom score(IPSS)was 23.00(15.00-34.00),the quality of life score(QOL)was 5(2-6),the maximum urinary flow rate(Qmax)was 7.80(0.80-9.80)ml/s and residual urine volume(PVR)was 158(51-409)ml.89 patients had the preoperative maximum detrusor contractility(64.23±8.11)cmH_(2)O.Surgical methods:the 120 W Moses laser platform(Lumenis Inc)was used,the cutting power was adjusted to 80 W(2.0J×40Hz)(narrow pulse width mode),and the hemostatic power 24W(0.8J×30Hz)(wide pulse width mode).Patients with bladder calcifications underwent Moses laser bladder stone lithotripsy.After the initial resection by the level of verumontanum was performed,an anatomic plane was exposed and carried forward until the bladder neck.If prostate stones were found,Moses holmium laser lithotripsy can be performed directly.After operation,the bladder was continuously flushed with normal saline.The catheter was removed 24 hours after the operation.The operation status,intraoperative and postoperative complications were recorded.IPSS,QOL,Qmax and PVR were followed up 3 months after surgery.Postoperative urinary incontinence is defined as the need for 2 pads or more within 24 hours.Results The operations of 132 cases(including 12 cases with bladder stones)were successfully completed.30 cases with prostate calcifications were found during the operation.The operation time(enucleation time)was(16.83±4.03)min.There were no perioperative complications such as blood transfusion,transurethral resection syndrome,urinary retention and venous thromboembolism.No bladder neck contracture or recurrence of bladder stones was found after surgery.Postoperative urethral stricture occured in 2 cases(1.5%),and postoperative urinary incontinence in 27 cases(20.5%).There were 102 cases(77.3%)with chronic interstitial inflammatory cell infiltration.Three months after operation,IPSS was 7(0-14),QOL was 2(0-5),Qmax was 17.55(9.40-26.50)ml/s and PVR was 27(0-46)ml,which were significantly improved compared with preoperatively(P<0.05).Conclusions MoLEP can significantly improve lower urinary tract symptoms(LUTS)and life quality of patients with small-volume BPH.At the same time,the incidence of complications such as urethral stricture and urinary incontinence is lower.The operation is safe and reliable,and bladder stone lithotripsy can be performed at the same time.