铥激光前列腺尖部黏膜预离断式剜除术与传统三叶法前列腺剜除术治疗BPH的效果和安全性

A comparative analysis of clinical efficacy of thulium laser enucleation of the prostate-pre-transection urethral mucosa at the apex of prostate and traditional three lobe enucleation of the prostate for the treatment of benign prostatic hyperplasia

目的比较经尿道前列腺尖部黏膜预离断式铥激光剜除术(ThuLEP-PAM)和传统三叶法经尿道前列腺铥激光剜除术(ThuLEP)治疗良性前列腺增生(BPH)的有效性和安全性。方法回顾性分析2020年5月至2021年9月宁波市泌尿肾病医院收治的270例行ThuLEP-PAM和ThuLEP治疗的BPH患者的临床资料。ThuLEP-PAM组120例,ThuLEP组150例,两组的年龄[(69.8±7.7)岁与(71.4±8.0)岁]、前列腺体积[55.5(41.0,71.0)ml与58.5(45.0,80.3)ml]、前列腺特异性抗原(PSA)[3.0(1.8,4.6)ng/ml与3.3(2.1,5.5)ng/ml]、国际前列腺症状评分(IPSS)[22(17,28)分与22(17,27)分]、生活质量(QOL)评分[5(4,6)分与5(4,6)分]、最大尿流率(Q_(max))[5.6(3.5,7.3)ml/s与5.5(4.0,7.1)ml/s]、残余尿量(PVR)[31(0,81)ml与31(0,102)ml]比较差异均无统计学意义(P>0.05)。ThuLEP-PAM组首先定位外括约肌环,于括约肌环近端5 mm处用激光环形切开前列腺尖部尿道黏膜,再于精阜旁左侧沟处切开尿道黏膜至显露前列腺外科包膜间隙,剜除中叶后沿前列腺尖部尿道黏膜预切开线剜除左、右侧叶。ThuLEP组采用传统三叶法剜除。比较两组的围手术期疗效指标和术后短期随访的并发症情况。结果本研究所有手术均顺利完成,患者下尿路症状较术前均明显改善。ThuLEP-PAM组与ThuLEP组的手术时间[90(70,103)min与83(61,102)min]、剜除前列腺质量[27.0(19.3,36.5)g与27.0(19.0,39.0)g]、血红蛋白下降值[9.9(7.4,12.4)g/L与9.5(7.1,12.7)g/L]、术后导尿管留置时间[3.5(3.0,4.0)d与3.5(3.0,5.0)d]和住院时间[6.0(5.0,6.0)d与5.0(4.0,6.0)d]比较差异均无统计学意义(P>0.05)。两组术后随访均≥3个月,术后3个月ThuLEP-PAM组与ThuLEP组的PSA[1.1(0.8,1.5)ng/ml与1.0(0.8,1.6)ng/ml]、IPSS[5(4,6)分与5(4,6)分]、QOL评分[2(1,3)分与2(1,3)分]、Q_(max)[20.9(17.5,22.5)ml/s与20.4(17.8,22.7)ml/s]和PVR[0 ml与0(0,6)ml]比较差异无统计学意义(P>0.05)。ThuLEP-PAM组和ThuLEP组的需要干预的肉眼血尿[5.0%(6/120)与6.0%(9/150)]、输血[0与0.7%(1/150)]、拔管后尿潴留[0与1.3%(2/150)]和尿道狭窄[5.0%(6/120)与6.0%(9/150)]等并发症发生率比较差异均无统计学意义(P>0.05)。ThuLEP-PAM组和ThuLEP组的压力性尿失禁发生率分别为1.7%(2/120)和7.3%(11/150),差异有统计学意义(P=0.031)。结论ThuLEP-PAM和ThuLEP对BPH患者下尿路症状的改善作用相当,均具有较好的疗效和较高的安全性。与ThuLEP相比,ThuLEP-PAM的最大优势是降低了术后早期压力性尿失禁发生率。

Objective To investigate the efficacy and safety of thulium laser enucleation of the prostate-pre-transection urethral mucosa at the apex of prostate and traditional three lobe enucleation of the prostate for the treatment of benign prostatic hyperplasia patients.Methods The data of 270 patients with benign prostatic hyperplasia who were underwent ThuLEP-PAM or ThuLEP in our hospital from May 2020 to September 2021 were analyzed retrospectively.According to the operation methods,the patients were divided into two groups:ThuLEP-PAM group(120 cases)and ThuLEP group(150 cases).There was no significant difference comparing the age[(69.8±7.7)years vs.(71.4±8.0)years],prostate volume[55.5(41.0,71.0)ml vs.58.5(45.0,80.3)ml],the serum PSA[3.0(1.8,4.6)ng/ml vs.3.3(2.1,5.5)ng/ml],international prostate symptom scores(IPSS)[22(17,28)vs.22(17,27)],the quality of life score(QOL)[5(4,6)vs.5(4,6)],the maximum urinary flow rate(Q_(max))[5.6(3.5,7.3)ml/s vs.5.5(4.0,7.1)ml/s],the residual urine volume[31(0,81)ml vs.31(0,102)ml]between the ThuLEP-PAM group and the ThuLEP group.No significant difference was found between the two groups(P>0.05).In the ThuLEP-PAM group,the external sphincter ring was located firstly,and urethral mucosa at the apex of prostate was circumferentially incised at 5 mm proximal of the sphincter ring by laser.Then the urethral mucosa was incised at the left sulcus beside the verumontanum and the prostate surgical capsule gap was exposed.After the middle lobe was removed,the left and right lobes were removed along the urethral mucosa pre-incision line at the prostatic apex.The ThuLEP group was enucleated by traditional three lobes enucleation.Perioperative indicators and postoperative complications during short-term follow-up were compared between the two groups.Results All patients successfully completed the operation and the symptoms of the lower urinary tract were significantly improved.Comparison the perioperative factors between ThuLEP-PAM group and ThuLEP group included the following:operative time 90(70,103)min vs.83(61,102)min;enucleated tissue weight 27.0(19.3,36.5)g vs.27.0(19.0,39.0)g;decrease of the hemoglobin 9.9(7.4,12.4)g/L vs.9.5(7.1,12.7)g/L;catheterization time 3.5(3.0,4.0)d vs.3.5(3.0,5.0)d;hospital stay 6.0(5.0,6.0)d vs.5.0(4.0,6.0)d.NO significant difference in these parameters was found between the two groups(P>0.05).There also was no significant difference in PSA[1.1(0.8,1.5)ng/ml vs.1.0(0.8,1.6)ng/ml],IPSS score[5(4,6)min vs.5(4,6)min],QOL score[2(1,3)vs.2(1,3)],Q_(max)[20.9(17.5,22.5)ml/s vs.20.4(17.8,22.7)ml/s]and PVR[0 ml vs.0(0,6)ml]between the two groups(P>0.05)after more than 3 months of follow-up.The incidence of incontinence for ThuLEP-PAM(2 cases)were lower than that for ThuLEP(11 cases)(P=0.031),but there was no significant between the two groups in other complications such as blood transfusion,haematuria,post-voidalurinary retention and urethral stricture.Conclusions ThuLEP-PAM and ThuLEP have similar effect on the improvement of lower urinary tract symptoms in patients with benign prostatic hyperplasia,both of which have good efficacy and high safety.The biggest advantage of ThuLEP-PAM over ThuLEP is that it reduces the incidence of early postoperative stress urinary incontinence.