膀胱颈瘢痕电切联合局部激素注射治疗TURP术后膀胱颈挛缩的疗效和安全性

Efficacy and safety of bladder neck resection combined with local steroid injection in the treatment of bladder neck contracture after TURP

目的探讨膀胱颈瘢痕电切联合曲安奈德多点注射治疗经尿道前列腺电切术(TURP)后膀胱颈挛缩(BNC)的疗效和安全性。方法回顾性分析2019年7月至2021年11月于四川大学华西医院接受经尿道手术的25例经尿道前列腺切除术(TUPR)术后初发BNC患者的病例资料,根据治疗方式将患者分为2组。激素注射组15例,平均年龄为(67.5±8.8)岁,合并糖尿病1例,高血压病2例;平均TURP术后时间为(21.9±29.1)个月;术前国际前列腺症状评分(IPSS)(30.0±3.5)分,生活质量(QOL)评分(5.7±0.5)分。非激素注射组10例,平均年龄为(65.2±10.5)岁,合并糖尿病1例,高血压病2例;平均TURP术后时间为(29.3±33.5)个月;术前IPSS(30.4±2.6)分,QOL评分(5.8±0.4)分。两组比较差异均无统计学意义(P>0.05)。激素注射组行膀胱颈电切联合曲安奈德多点注射手术,患者取截石位,直视下将冷切镜经尿道置入狭窄段远端观察,置入超滑导丝;用冷刀于6点方向电切狭窄段,顺利到达膀胱;更换电切镜,切除尿道狭窄段瘢痕直至暴露膀胱颈正常组织,电凝止血,电切后尿道无活动性出血;置入膀胱注射针,于膀胱颈口3~9点方向分6针等距注射曲安奈德注射液80 mg(12 ml);置入超滑导丝,沿导丝留置三腔硅胶尿管。非激素注射组单纯行膀胱颈电切手术。术后3、6个月复查尿道镜,患者出现明显排尿困难且镜检提示膀胱颈狭窄复发定义为BNC复发。比较两组的疗效、并发症,以及无复发生存率。分析术后BNC复发的预测因素。结果两组手术均顺利完成。激素注射组和非激素注射组的手术时间分别为(36.0±17.8)min和(48.5±57.9)min(P=0.438),术中出血量分别为(1.9±3.0)ml和(12.0±31.1)ml(P=0.221),住院时间分别为(5.8±1.2)d和(4.4±2.5)d(P=0.070)。激素注射组术后发生短暂性血尿和附睾炎各1例,非激素注射组发生短暂性血尿和短暂性排尿困难各1例(P>0.05),对症治疗后均缓解。激素注射组和非激素注射组术后3个月IPSS分别为(11.0±5.6)分和(12.4±3.9)分,术后6个月分别为(10.1±4.9)分和(14.7±7.7)分;术后3个月QOL评分分别为(1.7±1.2)分和(2.1±1.5)分,术后6个月分别为(1.5±1.3)分和(3.0±2.0)分,与术前比较差异均有统计学意义(P<0.05)。激素注射组和非激素注射组术后3个月BNC复发例数分别为1例和2例(P=0.543),术后6个月分别为1例和5例(P=0.023)。两组的生存曲线比较差异有统计学意义(P=0.013)。联合激素治疗(OR=14.000,95%CI1.299~150.889,P=0.030)、瘢痕电切术后时间(OR=1.138,95%CI1.017~1.273,P=0.025)、术后IPSS(OR=1.302,95%CI1.018~1.666,P=0.036)、术后QOL评分(OR=4.280,95%CI1.523~12.030,P=0.006)是患者术后6个月BNC复发的预测因素。结论膀胱颈瘢痕电切联合激素注射治疗TURP术后BNC是安全、有效的,局部激素注射有助于降低术后BNC再次复发率。

Objective To investigate the efficacy and safety of bladder neck resection combined with multipoint injection of triamcinolone acetonide in the treatment of bladder neck contractures(BNC)after transurethral resection prostate(TURP).Methods The data of 25 patients with BNC after TUPR who underwent transurethral surgery in West China Hospital of Sichuan University from July 2019 to November 2021 were retrospectively analyzed,and the patients were divided into 2 groups according to the treatment method.There were 15 cases in the steroid injection group,with an average age of(67.5±8.8)years,1 case of diabetes,and 2 cases of hypertension.And the average postoperative time after TURP was(21.9±29.1)months,the preoperative International Prostate Symptom Score(IPSS)was(30.0±3.5)points,quality of life(QOL)score was(5.7±0.5)points.There were 10 cases in the non-steroid injection group,with an average age of(65.2±10.5)years,1 case of diabetes,and 2 cases of hypertension.And the average postoperative time of TURP was(29.3±33.5)months,and the preoperative IPSS was(30.4±2.6)points,QOL score was(5.8±0.4)points.There was no significant difference between the two groups(P>0.05).In the steroid injection group,bladder neck resection combined with multipoint injection of triamcinolone acetonide was performed.The patients were in the lithotomy position,and a scope was placed through the urethra into the distal end of the narrow urethra under direct vision for observation,and a supersmooth guide wire was placed.The narrow section is then incised at 6 o'clock.After replacing the resectoscope,the urethral stricture scar was excised until the normal tissue of the bladder neck was exposed.Hemostasis by electrocoagulation resulted in no active bleeding from the urethra after resection.After the bladder injection needle was inserted,80 mg(12 ml)of triamcinolone acetonide injection was injected in 6 equally spaced needles at the direction of the bladder neck from 3 to 9 o'clock.A supersmooth guide wire was placed,and a three-channel silicone urinary catheter was indwelled along the guide wire.The non-steroid injection group underwent simple bladder neck resection.Re-examination of urethroscopy at 3 and 6 months after operation showed that the patient had obvious dysuria and the microscopic examination showed that the recurrence of bladder neck stenosis was defined as the recurrence of stenosis.The efficacy,complications,and recurrence-free survival rates of the two groups were compared.Predictors of postoperative BNC recurrence were analyzed.Results The operations in both groups were successfully completed.The operation time of the steroid injection group and the non-steroid injection group were(36.0±17.8)min and(48.5±57.9)min respectively(P=0.438),and the intraoperative blood loss was(1.9±3.0)ml and(12.0±31.1)ml(P=0.221)respectively.The length of hospital stay was(5.8±1.2)d and(4.4±2.5)d,respectively(P=0.070).There was 1 case of transient hematuria and 1 case of epididymitis in the steroid injection group,and 1 case of transient hematuria and 1 case of transient dysuria in the non-steroid injection group(P>0.05),all of which were relieved after symptomatic treatment.The IPSS of steroid injection group and non-steroid injection group were(11.0±5.6)points and(12.4±3.9)points at 3 months after operation,and(10.1±4.9)points and(14.7±7.7)points at 6 months after operation,respectively.QOL at 3 months after operation was(1.7±1.2)points and(2.1±1.5)points,respectively,and at 6 months after operation,it was(1.5±1.3)points and(3.0±2.0)points,respectively.There was statistical significance(P<0.05).There were 1 case and 2 cases of recurrence in the steroid injection group and non-steroid injection group at 3 months after operation(P=0.543),and 1 case and 5 cases at 6 months after operation(P=0.023).The difference in survival curve between the two groups was statistically significant(P=0.013).Combined steroid therapy(OR=14.000,95%CI1.299-150.889,P=0.030),time after scar resection(OR=1.138,95%CI1.017-1.273,P=0.025),postoperative IPSS(OR=1.302,95%CI1.018-1.666,P=0.036),postoperative QOL score(OR=4.280,95%CI1.523-12.030,P=0.006)were the predictors of stenosis recurrence 6 months after surgery.Conclusion Bladder neck scar resection combined with steroid injection could be safe and effective in the treatment of BNC after TURP,and local steroid injection may help reduce the recurrence rate of postoperative stenosis.