"U"形整叶法经尿道光纤铥激光前列腺剜切术治疗良性前列腺增生的疗效和安全性

The efficiency and safety of"U-shape"en bloc enucleation technique in Thulium fiber laser enucleation and resection of prostate

目的探讨“U”形整叶法经尿道光纤激光前列腺刻切术治疗良性前列腺增生(BPH)的疗效、安全性。方法回顾性分析2022年1一10月于北京大学第一医院同一泌尿外科医生手术治疗的105例BPH患者的临床资料。手术均采用光纤钰激光,其中50例采用"U"形整叶法前列腺刻切术("U"形整叶法组),55例采用分叶法前列腺刻除术(分叶法组)。“U”形整叶法组与分叶法组年龄[(69.1±6.9)岁与(68.8±9.1)岁]、国际前列腺症状评分(IPSS)[(22.7±1.9)分与(22.8±2.7)分]、最大尿流率(Qmax)[(9.0±3.7)ml/s与(9.3±4.3)ml/s]差异均无统计学意义(P>0.05)。"U"形整叶法组与分叶法组的前列腺特异性抗原(PSA)[7.52(3.05,8.76)ng/ml与6.78(1.61,7.45)ng/ml]、前列腺体积[(103.49±46.19)ml与(75.73±30.69)ml]差异均有统计学意义(P<0.05)。"U"形整叶法组采用尖部预离断方法离断前列腺尖部尿道黏膜及前列腺腺体,并确定尿道外括约肌,精阜旁暴露前列腺包膜及纵行切开前列腺顶端暴露前列腺外科包膜,沿前列腺外科包膜刻除整叶前列腺;分叶法组采用传统三叶法刻除,精阜旁暴露前列腺包膜,于前列腺5、7、12点纵行切开前列腺分为三叶,分别刻除中叶、左侧叶、右侧叶。比较两组围手术期临床资料、术后并发症及疗效情况。采用线性回归分析刻除效率与刻除质量之间的相关性。结果所有手术均顺利完成。“U”形整叶法组与分叶法组的粉碎时间[18(9,34)min与16(8,28)min]、刻除率(除前列腺组织质量/前列腺体积)[(0.5±0.1)g/ml与(0.5±0.1)g/ml]、术后留置导尿管时间[(3.8±1.4)d与(3.6±1.1)d]、住院时间[(4.1±0.3)d与(3.9±0.8)d]差异均无统计学意义(P>0.05);"U"形整叶法组与分叶法组的手术时间[54(42100)min与80(60,150)min]、除时间[37(26,75)min与47(31,69)min]、止血时间[4(3,6)min与9(7,15)min]、刻除效率[(1.8±0.5)g/min与(1.1±0.4)g/min]、血红蛋白下降值[13(9,22)g/L与17(10,27)g/L]差异均有统计学意义(P<0.05)。线性回归分析结果显示两种方法的刻除效率与刻除质量之间存在较强的正向线性相关(r值分别为0.791、0.880,均P<0.001),刻除效率均随着前列腺刻除质量的增加而升高。术后|U"形整叶法组和分叶法组的IPSS[(6.6±1.7)分与(6.2±1.4)分]、Qmax[(18.9±3.1)ml/s与(16.8±3.8)ml/s]差异均无统计学意义(P>0.05),且两组术后IPSS、Qmax与术前比较差异均有统计学意义(P<0.05)。“U”形整叶法组与分叶法组术后2周压力性尿失禁比例分别为10.0%(5/50)和27.3%(15/55),差异有统计学意义(P<0.05);术后3个月“U”形整叶法组与分叶法组均无压力性尿失禁及反复血尿出现,两组尿道狭窄率[2.0%(1/50)与5.5%(3/55)]差异无统计学意义(P>0.05)。结论仑“U”形整叶法光纤钰激光前列腺刻切术治疗BPH安全有效,能显著缩短手术时间,提高刻除效率,出血量更少,止血更快,有效减少术后早期压力性尿失禁。

Objective To investigate the therapeutic effectiveness and safety of"U shape"en bloc Thulium fiber laser enucleation and resection of the prostate(ThuLERP)technique.Methods The clinical data of 105 benign prostatic hyperplasia(BPH)patients treated by a single surgeon in Peking University First Hospital from January to October 2022 were retrospectively reviewed.Among them,50 patients underwent"U-shaped"en bloc technique prostate enucleation(UEBT),and 55 patients underwent prostate lobe removal using the lobe technique(LT).There were no significant differences between UEBT and LT groups(P>0.05)in term of the age[(69.1±6.9)years old vs.(68.8±9.1)years old],international prostate symptom score(IPSS)[(22.7±1.9)vs.(22.8±2.7)]and maximum flow rate(Qmax)[(9.0±3.7)ml/s vs.(9.3±4.3)ml/s].The prostate-specific antigen(PSA)of UEBT group was higher than that of LT group[7.52(3.05,8.76)ng/ml vs.6.78(1.61,7.45)ng/ml],and the prostate volume of the UEBT group was larger than that of LT group[(103.49±46.19)ml vs.(75.73±30.69)ml,all P<0.05].In the UEBT group,the apical of prostate was bluntly enucleated with pre-transection urethral mucosa at the apex of prostate technique.Secondly,glands formed grooves at 12 oclock after vaporization,which served as anatomical marker.At last,the whole lobe which was like"U shape"were resected using laser.In the LT group,glands was divided to three lobe,the middle,the left and the right lobe was bluntly enucleated respectively.Perioperative data,postoperative complications and clinical outcomes were compared between the two groups.Correlation between enucleation efficiency and enucleation weight was analysed using linear regression.Results There were no significant differences between the UEBT and LT group(P>0.05)in term of morcellation time[18(9,34)min vs.16(8,28)min],resection rate[(0.5±0.1)g/ml vs.(0.5±0.1)g/ml],catheter indwelling duration[(3.8±1.4)d vs.(3.6±1.1)d]and hospitalization stay[(4.1±0.3)d vs.(3.9±0.8)d].The difference between the UEBT group and LT group in operation time[54(42,100)min vs.80(60,150)min],enucleated time[37(26,75)min vs.47(31,69)min],hemostasis time[4(3,6)min vs.9(7,15)min],enucleation efficiency[(1.8±0.5)g/min vs.(1.1±0.4)g/min]and hemoglobin decline[13(9,22)g/L vs.17(10,22)g/L]were statistically significant(P<0.05).In both groups,postoperative IPSS were(6.6±1.7)and(6.2±1.4)respectively,and Qmax were(18.9±3.1)ml/s and(16.8±3.8)ml/s respectively,which were significantly different from that before the operation(P<0.05).However,there was no significant difference between the two groups(P>0.05).The enucleation efficiency increased with the increase of prostate volume(r=0.791,0.880 respectively,P<0.05).After 2 weeks of follow up the postoperative immediate urinary continence rate of UEBT group and LT group were 10.0%(5/50)and 27.3%(15/55),respectively,and the two groups had statistical differences(P<0.05).But after 3 months of follow up,there was no urinary continence in the two groups,and incidence of postoperative urethral stricture were 2.0%(1/50)and 5.5%(3/55)respectively in UEBT and LT group,whose difference was not significant(P>0.05).Conclusions ThuLERP can relieve lower urinary tract symptoms in a comparable way with high efficacy and safety.ThuLERP with the"U-shaped"en bloc technique was statistically superior to the lobe technique in operation time,enucleation time,enucleation efficiency,hemoglobin decline and also avoided stress urinary incontinence at early stage after operation.