本文選題：經(jīng)尿道前列腺剜除術(shù) + 經(jīng)尿道雙極等離子前列腺電切術(shù)　； 參考：《南方醫(yī)科大學(xué)》2017年碩士論文

【摘要】：研究背景良性前列腺增生癥(benign prostatic hyperplasia,BPH)在中老年男性人群最為常見的良性疾病之一,常引起排尿困難,亦是目前泌尿系統(tǒng)疾病中最常見的病種之一。BPH的主要臨床癥狀包括排尿梗阻癥狀和膀胱過度活動(dòng)癥,梗阻癥狀主要表現(xiàn)為尿潴留、尿線變細(xì)、開始排尿時(shí)間變長(zhǎng)、間斷性排尿、排尿乏力、急迫性尿失禁、充盈性尿失禁、尿滴瀝不盡感等,而膀胱過度活動(dòng)癥則表現(xiàn)為夜尿增多、尿頻、急迫性尿失禁及尿急。上述主要的臨床癥狀主要為下尿路癥狀,患者的日�；顒�(dòng)、各種社會(huì)交往以及睡眠受到上述癥狀的嚴(yán)重影響,往往會(huì)進(jìn)一步造成患者抑郁、焦慮等不良心境,極大地?fù)p害了患者的身心健康,患者的生活質(zhì)量大大降低。目前,BPH的治療臨床上較常用的方法主要包括藥物治療、觀察等待以及外科治療,由于BPH是一種下尿路癥狀不斷加重的臨床進(jìn)展性疾病,隨著病程增加,大多數(shù)患者的下尿路癥狀及其導(dǎo)致的并發(fā)癥往往會(huì)不斷加重,口服藥物治療無效,最終需外科手術(shù)治療。BPH的臨床手術(shù)治療主要是將過度增生的腺體組織切除,經(jīng)典的外科手術(shù)治療方法主要包括經(jīng)尿道雙極等離子前列腺電切術(shù)、經(jīng)尿道前列腺電切術(shù)、開放性前列腺摘除術(shù)。其中,TURP仍為BPH臨床手術(shù)治療的“金標(biāo)準(zhǔn)”術(shù)式,在該術(shù)式的基礎(chǔ)上,經(jīng)尿道雙極等離子前列腺電切術(shù)(transurethral resection of the prostate,TURP)為 BPH 腔內(nèi)手術(shù)治療的第三代技術(shù)及設(shè)備,具有精確切割、以生理鹽水作沖洗液、較淺的熱穿透及高聚焦等特點(diǎn),基于上述特點(diǎn),大大提高了該術(shù)式的安全性和臨床療效。隨著腔鏡手術(shù)設(shè)備的不斷改進(jìn),以及治療BPH的手術(shù)方法不斷發(fā)展和改良,我國學(xué)者劉春曉教授創(chuàng)新性的將開放性手術(shù)及腔內(nèi)微創(chuàng)手術(shù)的優(yōu)勢(shì)特點(diǎn)相結(jié)合,首次開展了經(jīng)尿道雙極等離子前列腺腔內(nèi)剜除術(shù)(transurethral enucleation resection of the prostate,TUERP),并將該術(shù)式應(yīng)用臨床治療,通過實(shí)踐應(yīng)用,發(fā)現(xiàn)其具有療效明確、微創(chuàng)、安全性高的特點(diǎn)。該術(shù)式融合了微創(chuàng)腔內(nèi)切除與開放前列腺摘除術(shù)兩者的技術(shù)優(yōu)勢(shì),既具有開放前列腺摘術(shù)的徹底性和術(shù)后不復(fù)發(fā)性的優(yōu)勢(shì)特點(diǎn),又能達(dá)到微創(chuàng)手術(shù)術(shù)中出血較少、安全性高、術(shù)后恢復(fù)快及創(chuàng)傷小的效果,是手術(shù)治療BPH的重大突破。另外,我國糖尿病患者的人數(shù)超過了四千萬,該疾病已嚴(yán)重威脅了人類健康,與此同時(shí),隨著我國老年人數(shù)占比的增高,不斷加重的老齡化程度,糖尿病和BPH的發(fā)病率均隨人們的年齡增長(zhǎng)而呈不斷升高的趨勢(shì),其中,老年男性合并糖尿病的BPH患者人數(shù)也呈不斷增加的趨勢(shì)。盡管目前糖尿病的治療方法正逐漸改進(jìn)和提高,BPH的臨床治療效果亦越來越好,然而,手術(shù)治療合并有糖尿病的BPH患者的技術(shù)仍需進(jìn)一步的改善。因糖尿病造成患者機(jī)體代謝的紊亂和抵抗力的下降,導(dǎo)致BPH的手術(shù)治療可耐受性差、危險(xiǎn)性高,因而適當(dāng)?shù)男g(shù)式對(duì)于提高臨床療效具有重要意義。由于目前國內(nèi)外尚無評(píng)估合并糖尿病BPH患者的術(shù)后生活質(zhì)量相關(guān)研究,因此,本研究通過收集我科收治的合并糖尿病BPH患者,分別行TUERP或TURP治療,對(duì)比分析兩種術(shù)式的臨床療效、圍手術(shù)期并發(fā)癥發(fā)生情況以及對(duì)患者生活質(zhì)量的影響。綜合評(píng)價(jià)TUERP在腔內(nèi)微創(chuàng)治療BPH的實(shí)際應(yīng)用效果,驗(yàn)證該術(shù)式的安全性、有效性及可行性,為TUERP在臨床應(yīng)用的進(jìn)一步推廣提供科學(xué)依據(jù)。研究目的探討TUERP和TURP兩種術(shù)式對(duì)合并糖尿病的BPH患者臨床療效、可行性及安全性,以及對(duì)患者生活質(zhì)量的影響,為合并糖尿病的BPH患者治療方法選擇及臨床應(yīng)用推廣提供理論依據(jù)。研究方法收集2015年1月至2016年6月本院收治合并有糖尿病的BPH患者,根據(jù)納入及排除標(biāo)準(zhǔn)選擇符合要求的研究對(duì)象。所有患者均行直腸指檢,直腸超聲檢測(cè)前列腺體積,尿動(dòng)力學(xué)檢測(cè)最大尿流率(maximum flow rate,Qmax)、殘余尿量,并進(jìn)行生活質(zhì)量評(píng)分(QOL)、國際前列腺癥狀評(píng)分(IPSS)、焦慮自評(píng)量表(Self-Rating Anxiety Scale,SAS)以及抑郁自評(píng)量表(Self-Rating Depression Scale,SDS)調(diào)查評(píng)估。納入研究的患者均為良性前列腺增生,診斷明確,且患有2型糖尿病,符合納入標(biāo)準(zhǔn),行TUERP或TURP治療。應(yīng)用隨機(jī)對(duì)照、單盲試驗(yàn)設(shè)計(jì)及隨機(jī)均衡分組。觀察組患者40例,行TUERP治療;對(duì)照組患者40例,行TURP治療。對(duì)比分析兩組圍手術(shù)期和術(shù)后的各個(gè)觀察指標(biāo),術(shù)后3月及6月進(jìn)行首次對(duì)患者進(jìn)行隨訪,隨訪采用電話隨訪、門診復(fù)查等方式進(jìn)行調(diào)查。收集的數(shù)據(jù)均采用SPSS21.0軟件行統(tǒng)計(jì)學(xué)分析,將P0.05定義為差異有統(tǒng)計(jì)學(xué)意義。(1)術(shù)前研究觀測(cè)指標(biāo)收集所有患者的年齡、病程、BMI、最大尿流率(maximum flow rate,Qmax)、是否合并基礎(chǔ)疾病、前列腺特異性抗原(PSA)、前列腺體積(prostate volume,PV)、殘余尿量(post void residual,PVR)、國際前列腺癥狀評(píng)分(IPSS)、生活質(zhì)量評(píng)分(QOL)、焦慮自評(píng)量表(SAS)、抑郁自評(píng)量表(SDS)調(diào)查。入院后對(duì)所有納入患者行QOL、IPSS、SAS及SDS調(diào)查。(2)術(shù)中研究觀測(cè)指標(biāo)記錄兩組患者的術(shù)中出血量、手術(shù)時(shí)間、術(shù)中是否需輸血及輸血量、切除腺體重量,術(shù)后住院時(shí)間、術(shù)后膀胱持續(xù)沖洗時(shí)間、術(shù)后留置導(dǎo)尿管時(shí)間以及術(shù)后并發(fā)癥發(fā)生情況,有無副損傷,包括膀胱、尿道損傷,是否出現(xiàn)經(jīng)尿道電切綜合癥(TURS)、有無前列腺包膜穿孔,以及是否術(shù)中轉(zhuǎn)開放手術(shù)。(3)術(shù)后觀察指標(biāo)記錄兩組患者的術(shù)后住院時(shí)間、術(shù)后膀胱持續(xù)沖洗時(shí)間、術(shù)后留置導(dǎo)尿管時(shí)間以及術(shù)后并發(fā)癥發(fā)生情況。(4)隨訪觀察指標(biāo)術(shù)后第3月及6月時(shí)可評(píng)價(jià)臨床療效,術(shù)后第3月及6月時(shí)進(jìn)行首次對(duì)患者進(jìn)行隨訪,隨訪內(nèi)容包括:術(shù)后早期有無出現(xiàn)排尿癥狀,如尿頻、尿急、尿痛、排尿困難、肉眼血尿等,以及術(shù)后恢復(fù)狀況,復(fù)查B超及尿流動(dòng)力學(xué)檢測(cè),包括檢測(cè)PVR和Qmax,并做QOL評(píng)分、IPSS評(píng)分、SAS及SDS調(diào)查,詢問患者有無出現(xiàn)尿線變細(xì)、尿失禁、尿不盡感、尿后滴瀝、排尿困難等癥狀,以及是否需藥物進(jìn)行輔助治療。術(shù)后的客觀癥狀指標(biāo)主要包括術(shù)后3月及6月的PVR、Qmax,以及術(shù)后并發(fā)癥發(fā)生率;術(shù)后3月及6月的QOL評(píng)分、IPSS評(píng)分、SAS及SDS調(diào)查則作為評(píng)估患者術(shù)后的主觀感受指標(biāo)。研究結(jié)果共納入80例合并糖尿病的BPH患者,所有患者均順利完成手術(shù)治療,無中轉(zhuǎn)開放手術(shù)患者,術(shù)中徹底止血,均未行輸血治療。(1)術(shù)前的觀察指標(biāo)包括年齡、BMI、病程、是否合并高血壓、糖化血紅蛋白、殘余尿量、最大尿流率、術(shù)前IPSS評(píng)分、QOL評(píng)分、前列腺體積、tPSA等,組間差異無統(tǒng)計(jì)學(xué)意義(P0.05),提示兩組患者分布均衡,組間具有可比性。(2)與TURP治療患者相比較,TUERP治療患者的手術(shù)時(shí)間、膀胱沖洗時(shí)間、尿管留置時(shí)間及術(shù)后住院時(shí)間均明顯更短,出血量明顯更少,而切除前列腺腺體重量明顯更多,組間差異具有統(tǒng)計(jì)學(xué)意義(P0.05),提示TUERP可縮短手術(shù)時(shí)間,減少術(shù)中出血,加快術(shù)后康復(fù)等特點(diǎn)。(3)兩組患者術(shù)前及術(shù)后3月及6月隨訪觀察指標(biāo)主要包括:Qmax、PVR、IPSS評(píng)分、QOL評(píng)分問卷評(píng)分、SAS及SDS調(diào)查,所有患者在術(shù)前和術(shù)后3月及6月均行Qmax和PVR的檢測(cè),給予IPSS評(píng)分、QOL評(píng)分,以評(píng)估患者的臨床癥狀改善情況和生活質(zhì)量,并進(jìn)行SAS及SDS調(diào)查,以了解患者的精神心理狀況,包括焦慮和抑郁。與手術(shù)治療前相比,所有患者在術(shù)后3月及6月的Qmax明顯升高,術(shù)后3月及6月的PVR、IPSS評(píng)分、QOL評(píng)分問卷評(píng)分、SAS及SDS調(diào)查評(píng)分均明顯降低,組間差異具有統(tǒng)計(jì)學(xué)意義(P0.05);通過比較觀察組和對(duì)照患者不同時(shí)間段(包括術(shù)前和術(shù)后3月及6月)各項(xiàng)隨訪指標(biāo),組間差異具有統(tǒng)計(jì)學(xué)意義(P0.05),而術(shù)后3月與術(shù)后6月各項(xiàng)指標(biāo)均無統(tǒng)計(jì)學(xué)差異,表明相比TURP,TUERP可顯著改善術(shù)后尿流率、下尿路癥狀,明顯提高患者生活質(zhì)量、緩解患者焦慮和抑郁心境狀態(tài)。(4)TUERP治療40例患者中共有4例患者出現(xiàn)并發(fā)癥,并發(fā)癥發(fā)生率為10%,包括1例術(shù)中包膜穿孔,3例術(shù)后尿失禁;而TURP治療的40例患者中共有13例患者出現(xiàn)并發(fā)癥,并發(fā)癥發(fā)生率為32.5%,包括3例術(shù)后繼發(fā)性出血、6例包膜穿孔、2例術(shù)后尿失禁、2例尿道狹窄,觀察組患者的并發(fā)癥發(fā)生率明顯更低,其中兩組患者的包膜穿孔率明顯更低,組間差異具有統(tǒng)計(jì)學(xué)意義(P0.05),提示TUERP治療合并糖尿病的BPH患者術(shù)后并發(fā)癥較少,安全性更高。結(jié)論TUERP和TURP治療合并糖尿病的BPH患者的臨床療效均比較確切,其中與TURP相比,TUERP的優(yōu)勢(shì)為創(chuàng)傷較小,術(shù)后恢復(fù)較快,安全性較高,明顯改善術(shù)后排尿癥狀及生活質(zhì)量,值得臨床進(jìn)一步推廣應(yīng)用。
[Abstract]:Background benign prostatic hyperplasia (benign prostatic hyperplasia, BPH), one of the most common benign diseases in middle-aged and elderly men, often causes difficulty in urination, and is also one of the most common diseases of the urinary system. The main clinical symptoms of.BPH are the symptoms of Urination Obstruction and overactivity of the bladder, and the main symptoms of obstruction. Urine retention, urine line thinning, beginning urination time, intermittent urination, urinating, urgent incontinence, filling urinary incontinence, urinary incontinence, urinary drip incontinence and so on. Bladder hyperactivity is manifested by the increase of nocturia, frequency of urine, urgent incontinence and urgency of urine. The main clinical symptoms are mainly lower urinary tract symptoms and patient's daily routine. Activities, social contacts and sleep are seriously affected by these symptoms, which often further cause depression, anxiety and other bad mood, which greatly damage the physical and mental health of the patients. The quality of life of the patients is greatly reduced. At present, the most commonly used methods of BPH treatment include drug treatment, observation and surgery. Treatment, as BPH is a progressive and progressive disease of lower urinary tract symptoms, with the increase of the course of the disease, the symptoms of the lower urinary tract and the complications in the majority of the patients are often aggravated, and the oral medication is not effective. Finally, the surgical treatment for the surgical treatment of.BPH is mainly to remove the hyperproliferative gland tissue. The classic surgical procedures include transurethral bipolar plasma prostatectomy, transurethral resection of the prostate, and open prostatectomy, of which, TURP is still a "gold standard" for BPH clinical surgery. On the basis of this operation, transurethral bipolar plasma prostatectomy (transurethral resection) Of the prostate, TURP) for the third generation technology and equipment for BPH intracavitary surgery, it has the characteristics of precise cutting, saline as flushing fluid, shallow heat penetration and high focus. Based on the above characteristics, the safety and clinical efficacy of the operation are greatly improved. With the continuous improvement of the surgical equipment of the cavity mirror and the operation of the treatment of BPH Methods to develop and improve, Professor Liu Chunxiao, a Chinese scholar, combined the advantages and characteristics of open surgery and intracavity minimally invasive surgery, and first carried out the transurethral enucleation resection of the prostate, TUERP in the transurethral bipolar plasma prostatic enucleation (TUERP). It has the advantages of minimally invasive endovascular resection and open prostatectomy, which not only has the advantages of open prostatic extraction, but also has the advantages of non recurrence and less bleeding in minimally invasive surgery, high safety and postoperative recovery. The effect of fast and small trauma is a major breakthrough in the surgical treatment of BPH. In addition, the number of people with diabetes in our country is more than forty million, which has seriously threatened human health. At the same time, the incidence of diabetes and BPH is increasing with the increase of the number of elderly people in our country, the increasing degree of aging, the incidence of diabetes and the incidence of BPH. The increasing trend, among them, the number of BPH patients with diabetes in old men is also increasing. Although the treatment of diabetes is improving and improving, the therapeutic effect of BPH is getting better and better. However, the technique of surgical treatment of BPH patients with diabetes still needs to be further improved. The disorder of the patient's body metabolism and the decline of resistance lead to poor tolerance and high risk of BPH operation. Therefore, appropriate surgical procedures are of great significance to improve the clinical efficacy. The patients with diabetic BPH were treated with TUERP or TURP respectively. The clinical efficacy of the two kinds of surgical procedures, the perioperative complications and the quality of life of the patients were compared and analyzed. The practical application of TUERP in the intracavitary minimally invasive treatment of BPH was evaluated, and the safety, effectiveness and feasibility of the operation were verified for TUERP in the future. The further promotion of bed application provides scientific basis. The purpose of this study is to explore the clinical efficacy, feasibility and safety of two kinds of TUERP and TURP methods for patients with diabetic BPH, as well as the influence on the quality of life of the patients, to provide a theoretical basis for the choice of treatment methods and clinical application of diabetic BPH patients. 5 years from January to June 2016, BPH patients with diabetes were admitted to the hospital. The subjects were selected according to the inclusion and exclusion criteria. All patients underwent rectal examination, rectal ultrasound examination of prostate volume, urodynamic test maximum urinary flow rate (maximum flow rate, Qmax), residual urine volume, and quality of life score (QOL). The prostatic symptom score (IPSS), the Self-Rating Anxiety Scale (SAS) and the self rating Depression Scale (Self-Rating Depression Scale, SDS) were evaluated. All the patients enrolled were benign prostatic hyperplasia, with a definite diagnosis, and with type 2 diabetes, which met the inclusion criteria and performed TUERP or TURP. A randomized controlled trial was used. The blind trial design and random equilibrium grouping. 40 patients in the observation group were treated with TUERP; 40 cases in the control group were treated with TURP. The peri operative and postoperative observation indexes of the two groups were compared and analyzed, and the patients were followed up for the first time in March and June after the operation. The follow-up was followed by telephone follow-up, and the outpatient reexamination was conducted. All the data collected were collected. All data collected were collected. Statistical analysis was performed by SPSS21.0 software. (1) the age of all patients, the course of disease, the course of disease, the BMI, the maximum urinary flow rate (maximum flow rate, Qmax), the combination of the basic disease, the prostate specific anti primitive (PSA), the volume of the prostate (prostate volume, PV), the residual urine volume (post), were collected before the operation. D residual, PVR), International Prostate Symptom Score (IPSS), quality of life score (QOL), self rating Anxiety Scale (SAS), and self rating Depression Scale (SDS) survey. All the patients were investigated for QOL, IPSS, SAS and SDS after admission. (2) intraoperative bleeding volume, operation time, operation time, blood transfusion and blood transfusion were recorded during the study. The weight of the gland, the time of postoperative hospitalization, the time of continuous bladder irrigation after the operation, the time of indwelling catheter after operation, and the postoperative complications, there were no side injuries, including bladder, urethral injury, urethral resection syndrome (TURS), the perforation of the prostatic membrane, and whether the operation was open or not. (3) the observation index The time of postoperative hospitalization of the two groups, the duration of postoperative bladder irrigation, the time of indwelling catheter after operation and the postoperative complications were observed. (4) the clinical efficacy was evaluated at third months and June after the follow-up observation, and the patients were followed up for the first time in third months and June after the operation. The symptoms of urination, such as frequency of urination, urination, urination, dysuria, dysuria, hematuria, and postoperative recovery, review the B-ultrasound and urodynamic test, including the detection of PVR and Qmax, and do QOL score, IPSS score, SAS and SDS investigation, and ask if the patients have symptoms such as urine thinning, urinary incontinence, urinary inconsistency, urine drop Lek, dysuria and other symptoms, and whether or not PVR, Qmax, and postoperative complications occurred in March and June after the operation; the QOL scores in March and June after operation, IPSS score, SAS and SDS survey were used to evaluate the subjective perception of patients after operation. The results were included in 80 patients with diabetes mellitus, all of which were included in all patients. The surgical treatment was completed successfully. There was no transfer to open surgery patients. No blood transfusion was performed during the operation. (1) preoperative observation indexes included age, BMI, course of disease, combined hypertension, glycated hemoglobin, residual urine volume, maximum urine flow rate, preoperative IPSS score, QOL score, prostate volume, tPSA and so on, there was no significant difference between groups (P0 .05), it was suggested that the two groups were evenly distributed and comparable between the groups. (2) compared with the patients treated with TURP, the operation time of the patients with TUERP, the time of bladder irrigation, the indwelling time of the urinary catheter and the time of hospitalization after the operation were significantly shorter, the amount of bleeding was significantly less, and the weight of the glandular gland was significantly increased, and the difference between the groups was statistically significant (P0. 05) suggested that TUERP could shorten the time of operation, reduce intraoperative bleeding and accelerate postoperative rehabilitation. (3) the indexes of follow-up and observation in two groups of patients before and after operation in March and June were mainly included: Qmax, PVR, IPSS, QOL score, SAS and SDS, all patients were tested for Qmax and PVR before and after operation, March and June, and IPSS scores, Q The OL score was used to assess the patient's clinical symptoms improvement and quality of life, and to conduct a SAS and SDS survey to understand the mental state of the patient, including anxiety and depression. Compared with the operation before the operation, all the patients were significantly elevated in March and June after the operation, PVR, IPSS score, QOL score, SAS and SDS in March and June after the operation. The difference between the groups was statistically significant (P0.05), and the difference between the observation group and the control patients in different time periods (including pre operation and March and June) was statistically significant (P0.05), but there was no statistical difference between March and June after the operation, indicating that TUERP could be compared with TURP. Improving the postoperative urinary flow rate and lower urinary tract symptoms, obviously improving the quality of life and relieving the state of anxiety and depression. (4) there were 4 cases of complications in 40 patients treated with TUERP, the incidence of complications was 10%, including 1 cases of intraoperative perforation and 3 cases of postoperative urinary incontinence, and 13 patients in 40 patients treated with TURP. Complications, complication rate was 32.5%, including 3 cases of postoperative secondary bleeding, 6 cases of perforation of capsular, 2 cases of urinary incontinence, 2 cases of urethral stricture, the incidence of complications in the observation group was significantly lower, of which the two groups were significantly lower in the envelope perforation rate, and the difference between the groups was statistically significant (P0.05), suggesting that TUERP treatment combined diabetes BP. H patients have less postoperative complications and higher safety. Conclusion the clinical efficacy of TUERP and TURP in the treatment of BPH patients with diabetes is more accurate. Compared with TURP, the advantage of TUERP is less trauma, the postoperative recovery is faster, the safety is higher, and the postoperative urination symptoms and quality of life are obviously improved. It is worthy of further clinical application.

【學(xué)位授予單位】：南方醫(yī)科大學(xué)
【學(xué)位級(jí)別】：碩士
【學(xué)位授予年份】：2017
【分類號(hào)】：R699.8;R587.1

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