不同术式治疗大体积前列腺增生疗效分析及术后尿道狭窄相关因素对比

Analysis of the curative effect of three surgical methods for large benign prostatic hyperplasia and postoperative urethral stricture comparative study of related factors

目的探讨经尿道前列腺电切术(TURP)、前列腺等离子剜切术(PKERP)和钬激光剜除术(HoLEP)治疗大体积(体积≥80 mL)前列腺增生(BPH)效果及术后尿道狭窄发生情况。方法回顾性分析从2015年2月至2018年2月间在延安大学附属医院泌尿外科行经尿道手术治疗的380例大体积BPH(体积≥80 mL)患者临床资料,根据不同术式分为TURP组(n=148)、PKERP组(n=122)与HoLEP组(n=110),分别行TURP、PKERP术和HoLEP术。比较3组围手术期相关指标、术后半年相关随访指标,并对各组尿道狭窄发生情况和相关危险因素进行统计分析。结果TURP组、PKERP组与HoLEP组手术时间分别为(130.4±12.8)min、(105.5±15.8)min、(100.3±9.8)min;术中出血量分别为(204.3±23.4)mL、(96.3±15.4)mL、(65.8±11.1)mL;切除前列腺重量分别为(65.3±8.6)g、(83.6±15.3)g、(85.4±11.6)g;血红蛋白(Hb)下降值分别为(22.7±11.5)g/L、(14.3±10.2)g/L、(6.4±5.6)g/L;术后留置尿管时间分别为(5.2±0.5)d、(3.1±1.3)d、(2.5±1.2)d;住院时间分别为(10.5±1.5)d、(7.2±1.7)d、(4.8±0.6)d。以上指标组间比较差异均有统计学意义(P<0.05),PKERP组与HoLEP组在手术时间、切除前列腺重量、术后留置尿管时间方面差异无统计学意义(P>0.05)。术后半年TURP组、PKERP组与HoLEP组生活质量评分(QOL)分别为(4.3±0.5)分、(2.8±0.7)分、(2.6±0.9)分;国际前列腺症状评分(IPSS)分别为(11.5±2.5)分、(8.6±1.8)分、(7.3±1.9)分;最大尿流率(Qmax)分别为(13.3±3.5)mL/s、(16.8±2.1)mL/s、(17.5±3.6)mL/s;各组指标术前术后比较差异有统计学意义(P<0.05),TURP组术后指标改善情况较其他2组差(P<0.05),PKERP组与HoLEP组比较差异无统计学意义(P>0.05)。术后半年3组患者尿中白细胞数分别为(20.3±10.5)个/μL、(10.8±8.4)个/μL、(8.6±7.4)个/μL,尿道狭窄率分别为8.8%(13/148)、3.3%(4/122)、2.7%(3/110),TURP组较其他2组在尿路感染和尿道狭窄发生率方面显著增高(P<0.05),PKERP组与HoLEP组比较差异无统计学意义(P>0.05)。3组手术前后前列腺特异性抗原(PSA)比较差异无统计学意义(P>0.05)。logistic回归分析显示尿道狭窄与手术方式(P=0.025)、尿管时留置间(P=0.028)、失血量(P=0.013)、术后尿白细胞数(P=0.031)显著相关。结论在治疗大体积BPH时,PKERP与HoLEP较TURP术优势明显,HoLEP具有出血更少、住院时间更短等优点,PKERP更易于推广;TURP术后尿道狭窄率较PKERP与HoLEP高,主要因素为增生组织切除不彻底、术后留置尿管时间长、失血量相对较多、存在感染等因素。

Objective To investigate the effects of transurethral resection of prostate(TURP),plasmakinetic enucleation of the prostate(PKERP),and holmium laser enucleation of the prostate(HoLEP)in the treatment of large(prostate volume≥80 mL)benign prostatic hyperplasia(BPH)and the occurrence of urethral strictures happening.Methods The clinical data of 380 patients with large volume BPH who underwent transurethral surgery from February 2015 to February 2018 in our department were retrospectively analyzed and divided into TURP group(n=148),PKERP group(n=122)and HoLEP group(n=110),performed TURP,PKERP and HoLEP,respectively.The perioperative indicators and the follow-up indicators of the six months after operation were compared among the three groups,and the incidence of urethral strictures and related risk factors in each group were statistically analyzed.Results The operation time of TURP group,PKERP group and HoLEP group were(130.4±12.8)min,(105.5±15.8)min,(100.3±9.8)min.The intraoperative blood losses were(204.3±23.4)mL,(96.3±15.4)mL,(65.8±11.1)mL.The amounts of adenectomy were(65.3±8.6)g,(83.6±15.3)g,(85.4±11.6)g.The intraoperative hemoglobin levels(Hb)were respectively(22.7±11.5)g/L,(14.3±10.2)g/L,(6.4±5.6)g/L.The catheter-indwelling times were(5.2±0.5)d,(3.1±1.3)d,(2.5±1.2)d.The hospital stays were(10.5±1.5)d,(7.2±1.7)d,and(4.8±0.6)d.The differences between the above index groups were statistically significant(P<0.05).There was no statistically significant difference in the operation time,amount of adenectomy,and catheter-indwelling time between the PKERP group and the HoLEP group(P>0.05).Six months postoperative,the quality of life(QOL)of the TURP group,PKERP group and HoLEP group were(4.3±0.5)points,(2.8±0.7)points,(2.6±0.9)points.And IPSS scores were(11.5±2.5)points,(8.6±1.8)points,(7.3±1.9)points.The maximum urinary flow rates(Qmax)were(13.3±3.5)mL/s,(16.8±2.1)mL/s,(17.5±3.6)mL/s.The comparison of the indexes before and after surgery in each group was statistically significant(P<0.05).The improvement of the postoperative indicators in the TURP group was worse than that in the other two groups(P<0.05).There was no statistically significant difference between the PKERP group and the HoLEP group(P>0.05).Urinary leukocyte counts at half a year after surgery of the three groups of patients were(20.3±10.5)/μL,(10.8±8.4)/μL,and(8.6±7.4)/μL.The urethral stricture rates were 8.8%(13/148),3.3%(4/122),2.7%(3/110).The incidence of urinary tract infection and urethral stricture were significantly higher in the TURP group than in the other two groups(P<0.05).PKERP group compared with HoLEP group,there was no significant statistical significance(P>0.05).There were no significant differences of PSA between the three groups before and after surgery.Logistic regression analysis showed that urethral stricture was significantly related to operation method(P=0.025),catheter-indwelling time(P=0.028),blood loss(P=0.013),and urinary leukocyte count at half a year after surgery(P=0.031).Conclusion In the treatment of large-volume BPH,PKERP and HoLEP have obvious advantages over TURP.HoLEP has the advantages of less bleeding and shorter hospital stay.However,the learning curve is longer and PKERP is more suitable for promotion in primary hospitals.The rate of urethral stricture after TURP is higher than that of PKERP and HOLEP.The main factors are incomplete resection of hyperplastic tissue,long time of indwelling urethral catheter,high blood loss and infection.