经尿道前列腺切除术后膀胱颈挛缩的微创处理

Micro-invasive treatment of bladder neck contracture following transurethral resection of prostate

目的#探讨经尿道膀胱颈切开术和腹腔镜改良膀胱颈Y-V成形术治疗经尿道前列腺切除术(TURP)后膀胱颈挛缩(BNC)的有效性和安全性。方法回顾性分析2013年1月至2022年12月上海第六人民医院收治的57例TURP术后BNC患者的临床资料,根据手术方式将患者分为两组。经尿道膀胱颈切开术组22例,年龄(73.75±7.62)岁,术前最大尿流率(3.92±2.73)ml/s,国际前列腺症状评分(IPSS)(26.92±3.34)分,生活质量(QOL)评分(4.83±0.72)分。腹腔镜改良膀胱颈Y-V成形术组35例,年龄(68.57±9.31)岁,术前最大尿流率(2.56±1.27)ml/s,IPSS(27.08±3.06)分,Q0L评分(5.08±0.84)分。经尿道膀胱颈切开术组,患者取截石位,于膀胱颈部3、9、12点切开瘢痕组织,3点和9点处切开深度达膀胱颈外脂肪,膀胱颈部明显抬高者采用等离子电切镜切除膀胱颈后唇的瘢痕组织。腹腔镜改良膀胱颈Y-V成形术组,于膀胱与前列腺交界处做一倒“Y”形切口,切开BNC的狭窄段,充分游离“V”形膀胱肌瓣,使其尖端与狭窄的远端吻合。比较两组术后的最大尿流率、IPSS和QOL评分。结果两组手术均顺利完成,腹腔镜改良膀胱颈Y-V成形术组的一次性手术治愈率为94.3%(33/35),高于经尿道膀胱颈切开术组的68.2%(15/22)(P<0.01)。经尿道膀胱颈切开术组和腹腔镜改良膀胱颈Y-V成形术组的手术时间[(31.75±12.81)min与(68.57±22.36)min]、术后住院时间[(1.73±0.94)d与(5.17±2.12)d]差异均有统计学意义(P<0.05)。术后中位随访时间12.6(7.3,27.8)个月,经尿道膀胱颈切开术组和腹腔镜改良膀胱颈Y-V成形术组的IPSS分别为(9.92±2.56)分和(7.16±2.21)分,QOL评分分别为(2.76±1.24)分和(1.31±0.95)分,术后6个月最大尿流率分别为(15.13±4.68)ml/s和(19.96±4.17)ml/s,差异均有统计学意义(P<0.05)。结论腹腔镜改良膀胱颈Y-V成形术和经尿道膀胱颈切开术治疗TURP术后BNC均安全、有效,腹腔镜改良膀胱颈Y-V成形术的临床疗效更佳。

Objective To investigated the efficacy and safety of transurethral bladder neck incision and laparoscopic modified bladder neck Y-V plasty in the treatment of bladder neck contracture(BNC)after transurethral resection of prostate(TURP).Methods The clinical data of 57 patients with BNC after TURP who were treated in the Department of Urology,Sixth People's Hospital,Shanghai Jiaotong University School of Medicine from January 2013 to December 2022 were retrospectively analyzed.And the patients were divided into two groups based on the different surgical approaches.There were 22 cases in the transurethral bladder neck incision group,with an average age of(73.75±7.62)years and the preoperative urinary flow Qmax of(3.92±2.73)ml/s.The preoperative International Prostate Symptom Score(IPSS)was(26.92±3.34)points,and the quality of life(Q0L)score was(4.83±0.72)points.There were 35 cases in laparoscopic modified bladder neck Y-V plasty group,with an average age of(68.57±9.31)years and the preoperative urinary flow Qmax of(2.56±1.27)ml/s.The preoperative IPSS was(27.08±3.06)points,and the Q0L score was(5.08±0.84)points.The patients underwent transurethral bladder neck incision:Scar tissue was incised at 3,9,and 12 oclock in the bladder neck,and the incision depth reached the external fat of the bladder neck at 3 and 9 oclock.Patients with significantly elevated bladder neck were treated with plasma electrosurgical resection to remove scar tissue.The patients underwent laparoscopic modified bladder neck Y-V plasty:After proper exposition of the bladder neck,the scar tissue was excised.the anterior bladder wall was incised in an inverted Y-shaped manner,the apex of the V-shaped flap was sutured to the distal urethrotomy to create a widened bladder neck.The postoperative urinary flow Qmax,IPSS,and QOL of the two groups were compared.Results All patients underwent surgeries successfully,with a one-time success rate of 94.3%(33/35)in the laparoscopic modified bladder neck Y-V plasty group,which was higher than the one-time success rate of 68.2%(15/22)in the transurethral bladder neck incision group(P<0.01).There were statistically significant difference in operation time[(31.75±12.81)min vs.(68.57±22.36)min]and postoperative hospital stay[(1.73±0.94)d vs.(5.17±2.12)d]between the transurethral bladder neck incision group and the laparoscopic modified bladder neck Y-V plasty group(P<0.05).The median follow-up period was 12.6(7.3,27.8)months.The IPSS of the transurethral bladder neck incision group and the laparoscopic modified bladder neck Y-V plasty group were(9.92±2.56)points and(7.16±2.21)points,respectively.The Q0L was(2.76±1.24)points and(1.31±0.95)points,respectively.The urinary flow Qmax at 6 months after operation was(15.13±4.68)ml/s and(19.96±4.17)ml/s,respectively.There was statistical significance(P<0.05).Conclusions Both laparoscopic modified bladder neck Y-V plasty and transurethral bladder neck incision are safe and effective in the treatment of BNC after TURP,and laparoscopic modified bladder neck Y-V plasty has a better clinical therapeutic effect.