【作者】 李三祥；

【导师】 刘春晓；

【作者基本信息】 南方医科大学 ， 泌尿外科（专业学位）， 2014， 博士

【摘要】 背景前列腺增生症是泌尿外科最常见的疾病之一,经尿道前列腺电切术(transurethral resection of the prostate, TURP)是目前治疗前列腺增生症的“金标准”。近年来,由刘春晓教授自行创立经尿道前列腺等离子剜除术(plasma kinetic enucleation of the prostate, PKEP)等使用双极等离子电切系统治疗BPH的新方法,现已在临床上广泛采用并取得良好效果。泌尿外科医生在尝试PKEP术式的开展时,由于PKEP术学习曲线长,难度较大,临床上难以大范围的推广该术式。因此在开展PKEP初期,在熟练掌握经尿道前列腺等离子切除术(plasma kinetic resection of the prostate, PKRP)的基础上,尝试一种将PKEP与PKRP有机的结合起来的术式,吸取两种术式的优点,降低手术难度,为逐步开展PKEP建立良好的基础,有望成为从PKRP到PKEP术的过渡术式。与普通电切相比,经尿道等离子电切在手术创伤、出血、术后相关并发症等方面都有了一定的改善,同时因为可以使用等渗盐水作为术中膀胱灌洗液,较传统的TURP更安全,但仍有诸多不足(PKRP)之处,主要有以下几方面：①术中及术后出血多。前列腺血供丰富,由浅入深没有层次的电切导致术中出血多；前列腺组织切除不充分导致术后出血量及出血几率增加,这样术中术后两方面的因素造成手术总出血量较多。②前列腺外科包膜穿孔。PKRP术的理想目标是完整的前列腺外科包膜下切除,但由于出血、操作技术等各方面原因导致解剖层次不完全清楚,过多和过深的电切很容易切穿包膜导致前列腺穿孔。③腺体切除不彻底。由于该术式为逐层切除,所以很难达到各叶均完整切除至包膜的理想状态,直接影响手术后的排尿改善情况,也为术后再出血、感染、梗阻、残留腺体再增生等并发症埋下隐患。④观赏性差。由于主客观各种因素的影响,电切在一定程度上不易准确的识别外科包膜,导致电切后前列腺窝凸凹不平,这些都大大的影响了手术的观赏性。2002年由我国学者提出了经尿道前列腺剜除术。经尿道前列腺前列腺剜除术根据开放前列腺摘除术的原理,采用现有的电切设备进行微创手术,有如下优点：①出血较少。前列腺外科包膜保留完整,血管显示清晰,便于止血,明显减少术中出血量；剜除腺体时从精阜到膀胱颈血管纹理清楚,遇有血管或点状出血都可直视下电凝止血,起到关掉血管总开关的作用,这样在电切前列腺组织时由于阻断了血供很少出血。②不易穿孔。由于是直视包膜下的钝性镜体剜除,前列腺增生组织与外科包膜层次清楚,没有接近包膜时的试探性电切,所以手术操作中包膜不易穿孔。③切除彻底。由前列腺外科包膜直接剥离增生组织,使腔内泌尿外科手术达到开放手术的效果,切除组织量明显多于PKRP,减少残余腺体再次增生的可能性；由于是根据解剖结构完整钝性分离,充分完整的腺体剜除大大提高了手术后的排尿效果。④括约肌损伤几率小。剜除到前列腺尖部时,主要采用钝性分离,手术操作是由远及近,首先通过仔细识别尿道外括约肌和前列腺尖部,可有效降低由于最后修切前列腺尖部时损伤尿道外括约肌的可能性。⑤适用范围广,手术时间短。随着前列腺腺体积增大,传统电切手术时间及风险相应增加,相比而言剜除术适合切除较大体积前列腺而不明显增加手术风险。阻断腺体血运,腺体无明显出血,手术野清晰,大大缩短手术时间。⑥观赏性强。清晰的手术视野及明晰的解剖层次,平整的前列腺窝,使经尿道剜除术具有较好的观赏性。PKEP虽有许多优势,但尤其对于初学者来说亦有一些不足,总结为以下几点：①前列腺内外腺之间粘连明显、界限不清时往往使用钝性剥离困难,容易造成剥离时前列腺包膜撕裂或其他副损伤；②整体剥离的腺体充满前列腺窝,常常会使新学者不知如何处理,导致解剖标志辨认不清或迷失方向,进而影响手术操作及手术安全性。③在剜除剥离前列腺的过程中,前列腺组织充满后尿道,当出现包膜穿孔、出血较多等意外情况时,因为操作空间狭小造成处理困难,也不易改为普通电切治疗,使初学者手忙脚乱,不知如何处理。④前列腺12点位往往前列腺组织与外科包膜粘连较重,不易剥离出外科包膜界限,强行剥离时易引起穿孔,引起较多出血。⑤PKEP术学习曲线长,手术操作技术难度较大,对于初学者来说不易掌握。⑥尿失禁。PKEP术由于不易损伤括约肌,所以一般不会产生真性尿失禁,但对于初学者来说,前列腺尖部的钝性撕开很难掌握要领,容易损伤尿道外括约肌。综合PKRP及PKEP的优缺点,根据前列腺的局部解剖结构,我们尝试将两者结合起来,各取其优点,进一步解决上述两种术式的不足,同时期待降低开展PKEP的技术门槛,成为从PKRP术到PKEP术的过渡术式。目的和意义随着医疗新技术和器械的不断发展,出现了经尿道等离子前列腺电切术(PKRP)及经尿道等离子前列腺剜除术(PKEP)等使用双极等离子体电切系统治疗良性前列腺增生(BPH)的新方法,目前我国也已在临床上广泛采用,并取得较好的治疗效果,但把两种术式结合起来的术式尚缺乏进一步研究,我们初步尝试把两种术式的优点结合起来,扬长避短,进行前列腺增生症患者的治疗。由于PKEP是在PKRP的基础上发展起来的,所以探索一种术式将两者有效的结合起来,在开展这两种术式的联合术式过程中逐步掌握PKEP手术技能,从而降低PKEP的学习难度,更有利于PKEP术式的全面推广。方法1.资料与方法1.1临床资料本研究选择从2011年11月至2012年10月就诊于内蒙古自治区人民医院的良性前列腺增生患者72例,按照患者入组顺序,按随机数字表分为观察组和对照组各36例,分别采用PKRP与PKEP联合术式(观察组)和PKRP术式(对照组)进行手术治疗。1.2手术方法两组均采用日本Olympus等离子电切镜系统,电切功率120-180W,电凝功率60-80W。生理盐水持续膀胱冲洗,冲洗液高度为60-80cm,常规连续硬膜外麻醉,取截石位,直视下经尿道置入电切镜,观察精阜、增生前列腺及膀胱内全貌,充盈膀胱,中等以上大小前列腺常规行耻骨上膀胱穿刺造瘘接引流管。①观察组：直视下经尿道置入电切镜,观察尿道与前列腺中叶及两侧叶增生情况,前列腺与膀胱颈及双侧输尿管口关系。采用精阜近端标识法,即将电切镜退至精阜水平,观察尿道外括约肌位置,在其近端精阜远端之间以电切环沿尿道点切一圈,可见有环状沟及凝血块形成,以此点作为前列腺切除远端标志,避免初学者损伤外括约肌。标志形成后,在膀胱颈口4-5点和7-8点处与精阜间定切除起终点,切除深至外科包膜,充分止血,初步阻断前列腺尿道组动脉,减少术中出血。同样方法完全切除前列腺前叶至外科包膜,以上3条沟形成冲水通道,并将剩余前列腺组织按解剖学分成3叶,即前列腺中央叶及两侧叶。在精阜前方标志处通过点切的方式找到外科包膜界限,用逆推方式以电切镜鞘像前列腺开放手术一样进行剥离。在逆行剥离的过程中可以看到前列腺腺体向膀胱游离出来,由于前列腺外科包膜非常致密,在电切镜下表现为环形纤维,如果切穿或者剜除导致包膜穿孔,可见包膜外为一些疏松的结缔组织,并可见一些分支状的血管丛。在剜除的过程中,外科包膜剥离面可见明显走形的前列腺营养血管,部分可见前列腺囊肿,电凝血管断面止血,与钝性剥离配合点切纤维粘连带。剜除3叶中的一叶仅留下部分腺体与膀胱颈有部分相连,形成一个仅由膀胱颈部少量腺体与膀肤颈部相连的完整腺体,血供大部分己断,周围标志清晰,按序将已剥离的腺体快速、由浅入深地切碎,剩余2叶按同样方法剜除后切除、冲出。最后切平修整创面,在膀胱空虚状态下仔细止血,以ELLIC冲吸出残余破碎前列腺组织。②对照组：先电切5、7点处作为标志沟,电切深达前列腺外科包膜,充分止血,初步阻断前列腺中叶大部分血供,然后以标志沟为标准顺行和逆行切除前列腺组织直达12点处会合,然后修整前列腺尖部和膀胱颈部并予以彻底止血,注意勿损伤尿道外括约肌及输尿管开口。用ELLIC冲吸出残余破碎前列腺组织,留置F22三腔导尿管一根,拔除膀胱造瘘管,术后两组患者均三腔导尿管持续膀胱冲洗。2.观察指标2.1包括术前患者一般情况、手术时间、切除组织重量、术中出血量、术后膀胱冲洗时间、术后拔尿管时间、术后住院天数、术后3个月IPSS、Qmax、RU、并发症等疗效指标。2.2术中出血量测定将术中膀胱持续冲洗液标本用无菌蒸镏水稀释,蒸镏水会对出血进行溶血,然后采用微量游离血红蛋白测定法测定冲洗液血红蛋白浓度。根据公式：术中出血量(L)=冲洗液用量(L)x术后冲洗液血红蛋白浓度/术前血中血红蛋白浓度,计算出术中的出血量。3.统计学分析使用SPSS16.0统计软件进行数据分析。计量资料以x±s表示,计数资料用例数、百分数表示；计量资料比较采用独立样本t检验(方差齐性)或t’(方差不齐)检验,若不服从正态分布则采用非参数检验(Mann Whitney U);计数资料组间比较采用PearsonX2检验或者Fisher’s exact检验,P<0.05为差异有显著性。结果术前两组患者的一般情况统计学无显著性差异(P>0.05)；观察组切除前列腺组织较对照组更多,术中出血更少,术后膀胱持续冲洗时间、术后拔尿管时间、术后住院天数更短,较之对照组有显著差异(P<0.05)。观察组手术时间与对照组相比无显著性差异(P>0.05)。两组术后患者随访3-6个月,3个月随访结果均提示IPSS明显下降,最大尿流率显著提高,残余尿明显减少,而两组间比较无显著差异(P>0.05)。对照组术后6例出现再次出血,给与继续膀胱冲洗或经再次清除血块后治愈；观察组2例对照组3例出现排尿困难,为尿道外口狭窄,经尿道扩张后好转；两组间并发症比较差异有显著性差异(P<0.05)。观察组和对照组都无死亡、输血病例。结论1.采用PKRP与PKEP联合术式,与PKEP相比,在掌握PKRP术的基础上,避开剜除术的难点,具有简单易学的优点。2.联合术式与等离子电切比较切除前列腺更多更彻底。3.联合术式出血更少,住院时间短,相应降低手术风险。4.联合术式不影响远期效果,并发症无明显增多。5.联合术式期待成为从PKRP术到PKEP术的过渡术式,让更多的泌尿外科医生在轻松掌握该过渡术式的基础上能逐步掌握PKEP术。背景近年来,随着新技术和器械的不断发展,出现了经尿道等离子前列腺电切术(PKRP)等使用双极等离子电切系统治疗BPH的新方法,现已在临床上广泛采用,取得良好的治疗效果。第一章的研究中我们初步探索应用PKRP联合PKEP术治疗前列腺增生症的患者,取得较好效果。泌尿外科医生一般习惯于经尿道前列腺切除术后5到7天拔除导尿管,这样就造成患者术后住院时间较长,尿路感染发生率高、费用相对增加等结果。在本研究中,我们初步尝试在应用PKRP联合PKEP术治疗前列腺增生症患者后,24到48小时拔除导尿管,拔除后观察一天后患者可出院,真正体现微创手术住院时间短、恢复快的优越性。BPH是泌尿外科最常见的老年男性疾病之一,严重影响患者生活质量,手术治疗前列腺增生症的“金标准”是TURP。近年来,应用PKRP等使用双极等离子电切系统治疗BPH的新方法,现已在临床上广泛采用。由于TURP切割温度高,导致局部组织形成凝固层且达到显著的止血效果,但对尿道周围组织有一定的损伤作用,诱发手术后下尿路症状,创面愈合较慢。相对于TURP, PKRP切割组织时表面温度低,具有切割范围精确、热穿透表浅、对周围组织破坏轻微等特点,所以手术后下路症状较TURP明显减少。TURP切割面一般形成焦痴或者碳化较PKRP明显,其术后近期创面有发生感染、再次出血的可能性较PKRP要高,术后痴皮脱落一般需要3个月左右,术后切割面修复速度PKRP明显快于TURP,这就为PKRP术后早期拔除导尿管创造了条件。不论应用哪种经尿道前列腺切除手术,术后要常规留置三腔导尿管进行持续膀胱冲洗,及时冲出出血,以免形成血块堵塞导尿管。导尿操作是尿路感染的最常见直接原因之一,完整的尿道黏膜是一个屏障,它可以有效的防止微生物入侵,导尿管的插入可以破坏这个屏障,且导尿管对于人体来说为异物,会刺激尿道及膀胱黏膜,削弱了膀胱及尿道对细菌的防御作用,是引起尿路感染的人为直接因素。留置导尿管不但会引起尿路感染的发生,还会引起病人出现血尿,在前列腺增生的病人发生血尿的几率更高,主要是在导尿管留置期间加重下尿路感染成为出血的一个诱因,同时导尿管作为机体的一种异物刺激尿道粘膜,使尿道粘膜的血管舒张,同时导尿管的机械摩擦作用使尿道或膀胱更易出血,所以尽量缩短导尿管留置时间也是降低尿路出血的有效方法。目的和意义留置导尿管的并发症较多,如感染、出血、尿道狭窄等,其中尿路感染与留置导尿管的时间有直接的关系,经尿道手术后都要常规留置导尿管,为降低上述的并发症,如何做到尽早拔除导尿管在经尿道手术中具有重要的意义。不论应用经尿道前列腺切除的哪一种手术方式,从病理学来说,术后创面上皮修复一般至少需要3周左右,3个月以上才能达到完全上皮化,术后前列腺窝的创面敞开浸泡于尿液当中,在术后一段时间后,水肿、坏死组织就会脱落,取而代之的是上皮组织重新生长覆盖,加上导尿管的刺激损伤,血尿、膀胱刺激症状较重,远期可出现后尿道愈合引起疤痕狭窄,前列腺腺体再增生等情况。所以早期拔除导尿管可以降低血尿、感染等并发症的发生率。从上述尿道创面的恢复规律可以看出,留置导尿管1周创面根本就没有愈合,所以留置导尿管的作用只是为了膀胱冲洗的功能。在应用了等离子前列腺电切后,术后继发性出血的发生率低,为早期拔除导尿管创造了条件。基于以上经尿道等离子切除的优越性以及联合剜除术式的优点,且根据前列腺等离子切除后创面愈合及修复的理论基础,我们尝试应用PKRP和PKEP联合术式治疗前列腺增生术后早期拔除导尿管,与常规拔除导尿管进行比较,在不影响治疗效果的前提下,降低前列腺增生患者术后并发症的发生。方法1.资料与方法1.1临床资料本研究选择从2012年10月至2013年11月就诊于内蒙古自治区人民医院的良性前列腺增生患者84例进行前瞻性研究,本试验按照患者入组顺序,采用区组随机方法,区段长度设为4。试验组和对照组按照1：1分配患者,各42例。采用PKRP(经尿道前列腺等离子电切术)与PKEP(经尿道前列腺等离子剜除术)联合术式进行治疗,术后常规应用抗菌素3-5天,观察组视冲洗液情况在1-2天拔除导尿管,对照组按常规5-7天拔除,观察两组围手术期及拔除导尿管后各项指标,比较其临床疗效。1.2手术方法两组均采用日本Olympus等离子电切镜系统,电切功率120-180W,电凝功率60-80W。介质冲洗溶液为生理盐水,冲洗液高度为60-80cm,常规连续硬膜外麻醉,取截石位,直视下经尿道置入电切镜,中等以上大小前列腺常规行耻骨上膀胱穿刺造瘘接引流管。观察尿道与前列腺中叶及两侧叶增生情况,前列腺与双侧输尿管口关系。采用精阜近端标识法,即将电切镜退至精阜水平,观察尿道外括约肌位置,在其近端精阜远端之间以电切环沿尿道点切一圈,可见有环状沟及凝血块形成,以此点作为前列腺切除远端标志,避免初学者损伤外括约肌。标志形成后,在膀胱颈口4-5点和7-8点处与精阜间定切除起终点,切除深至外科包膜,充分止血,初步阻断前列腺尿道组动脉,减少术中出血。同样方法完全切除前列腺前叶至外科包膜,以上3条沟形成冲水通道,并将剩余前列腺组织按解剖学分成3叶,即前列腺中央叶及两侧叶。在精阜前方标志处通过点切的方式找到外科包膜界限,用逆推方式以电切镜鞘像前列腺开放手术一样进行剥离。在逆行剥离的过程中可以看到前列腺腺体向膀胱游离出来,由于前列腺外科包膜非常致密,在电切镜下表现为环形纤维,如果切穿或者剜除导致包膜穿孔,可见包膜外为一些疏松的结缔组织,并可见一些分支状的血管丛。在剜除的过程中,外科包膜剥离面可见明显走形的前列腺营养血管,部分可见前列腺囊肿,电凝血管断面止血,与钝性剥离配合点切纤维粘连带。剜除3叶中的每一叶仅留下部分腺体与膀胱颈有部分相连,形成一个仅由膀胱颈部少量腺体与膀肤颈部相连的完整腺体,血供大部分己断,按序将已剥离的腺体快速地切碎,剩余2叶按同样方法剜除后切除、冲出。最后切平修整创面,在膀胱空虚状态下仔细止血,术毕膀胱冲洗液充盈膀胱,行排尿试验,检查尿道通畅程度及尿道括约肌功能。术后置F22Foley三腔导尿管,气囊注水30m1,视情况膀胱持续冲洗,切除组织吸出后用天平称重,并常规家属看标本后送病理检查。2.观察指标2.1术中观察指标(1)患者的呼吸、脉搏、血压、神志及心电、血氧饱和度；对于手术时间较长的患者必要时术中行动脉血气分析。(2)患者耻骨上膀胱区充盈情况,下腹部紧张度；耻骨上膀胱造瘘的患者观察造瘘管是否通畅,一旦堵塞及时疏通；(3)手术时间、前列腺切除组织重量、术中出血量。(4)切穿前列腺外科包膜时注意腹部情况,必要时急查离子及血气分析。2.2术后观察指标(1)患者的呼吸、心率、血压、神志及心电血氧饱和度监护；(2)冲洗液颜色、冲洗液速度、冲洗液引流情况；(3)电解质、血常规、尿常规；(4)记录持续膀胱冲洗时间、拔除导尿管时间、术后住院时间；(5)术后并发症：如膀胱痉挛、暂时尿失禁、再次出血、尿路感染、急性附睾炎、肺感染等；(6)术后3-6个月IPSS、QOL、Qmax、RU、尿道狭窄、尿失禁等指标。RU采用导尿管置入收集尿液准确计量。3.统计学分析使用SPSS16.0统计软件进行数据分析。计量资料以x±s表示,计数资料用例数、百分数表示；计量资料比较采用独立样本t检验(方差齐性)或t’(方差不齐)检验,若不服从正态分布则采用非参数检验(Mann Whitney U);计数资料组间比较采用PearsonX2检验或者Fisher’s exact检验,P<0.05为差异有显著性。结果1.两组患者术前情况根据术前纳入研究患者情况的详细记录及最后随访结果,两组共84例病例术前及术后所有资料完整,无退出研究病例。两组患者术前的年龄、前列腺质量、最大尿流率(Qmax)、膀胱残余尿量(RU)、国际前列腺症状评分(IPSS),生活质量评分(QOL),两组间比较各项指标差异无显著性意义(P>0.05)。2.两组患者术后情况比较两组患者均手术顺利,术中均未输血,未发生TURS、死亡、闭孔神经反射、膀胱损伤、直肠损伤的病例。观察组术后5例,对照组4例出现暂时性尿失禁,两组间比较无显著差异(P>0.05)；观察组术后尿路感染例数较对照组少；观察组术后膀胱痉挛、再次出血出现例数较对照组少,对照组术后6例出现再次出血,给与继续膀胱冲洗或经再次清除血块后治愈,两组间比较有显著性意义(P<0.05)；3.两组患者术后3个月随访情况两组术后患者随访3-6个月,3个月随访结果均提示PSS及QOL明显下降,最大尿流率显著提高,残余尿明显减少,两组间比较无显著差异(P>0.05)。两组均未出现尿失禁。观察组3例对照组5例出现排尿困难,为尿道外口狭窄,经尿道扩张后好转,两组间尿道狭窄发生率无显著性意义(P>0.05)。结论1.PKRP联合PKEP术式术后1-2天早期拔除导尿管可显著缩短术后住院时间,从而降低患者费用。2.联合术式术后早期拔除导尿管可降低术后尿路感染率。3.联合术式术后早期拔除导尿管可减少发生膀胱痉挛及再次出血的发生率。4.联合术式术后早期拔除导尿管不影响手术效果,远期并发症发生率无明显提高,值得提倡推广。更多还原

【Abstract】 BackgroundBenign prostatic hyperplasia (BPH) is one of the most common diseases in urology; transurethral resection of the prostate (TURP) method is the "gold standard" for the treatment of BPH. In recent years, plasma kinetic enucleation of the prostate(PKEP) founded by professor Liu Chunxiao using bipolar plasma cutting system as new treatment for BPH, has been widely used in clinic and achieved good results. Preliminary try PKEP operation in our department, but PKEP learning curve is too long, operation skills are difficult, and it’s difficult to grasp the operation skills in a short time. In carrying out early, so we try to fall together PKEP with plasma kinetic resection of the prostate(PKRP), absorbing the advantages of the two kinds of operation, reducing the operation difficulty, in order to establish the good foundation for develop PKEP, is expected to become the transition operation from PKRP to PKEP.Compared with TURP, plasma cutting in surgical trauma, bleeding and postoperative complications have certain to improve, at the same time, because you can use isotonic saline as intraoperative bladder douche, which is more safer than traditional TURP, but there are still some shortcomings (PKRP), mainly has the following several aspects:(1) More bleeding. Prostate blood supply is rich, more levels of electricity cutting cause intraoperative hemorrhage; Insufficient removal of prostate tissue lead to increased risk of blood loss and postoperative bleeding, so the total blood loss added by surgery in the two aspects.(2) Prostatic capsule perforation. Ideal goal of PKRP is prostate surgery subcapsular resection completely, but because various aspects reason lead to that anatomical level is not entirely clear, too much and too deep electric cutting lead to prostate perforation.(3) Gland resection is not complete. Due to the surgery for removal step by step, so it is difficult to achieve complete resection to coated the ideal state of each leaf, which directly affect the urination improvement after surgery, also for postoperative complications such as bleeding, infection, obstruction again.(4) Appreciation. Because of the subjective and objective factors, it is not easy to cut within a certain range accurately, lead to prostate fossa bumpy after cutting, which greatly affected the look of the surgery.According to the principle of open prostate gland excision technique, professor Liu Chunxiao proposed transurethral prostatic enucleation in2002.The operation of transurethral prostatic enucleation has the following advantages:(1) Less bleeding. Because of gouging out glands from verumontanum to bladder neck,vascular texture clear, in case of blood vessels or dotted hemorrhage,look straight down an electrocautery unit of blood, which have the effect of main switch to turn off blood vessels, which cause little bleeding due to blocked prostate tissue blood supply.(2) No easy perforation. Because it is direct subcapsular gouge with blunt the lens body, level clear, no tentative cutting while approach coated capsule, it is not easy for operation in the capsular perforation.(3) Remove completely. Because it is full blunt separation according to the anatomic structure, fully complete tear glands after undergoing surgery, improve the effect of urination greatly.(4) A small risk of sphincter damage. Operation is by far and near, first of all, through careful identification to the tip of the prostate and urethral sphincter, we can effectively reduce damage of urethral sphincter when cutting tip of the prostate due to the repair.(5) Wide application scope. With prostate gland volume increasing, the time and risk of the traditional electric cut operation increase, comparing to enucleation, it is not to increase the risk of surgery for removal of large volume prostate.(6) Ornamental value. Clear operation visual field and anatomical level, the level of prostatic fossa, make prostatic enucleation to have a better view.Although PKEP has many advantages, but especially for beginners also has some defects, we summarized as the following:(1) Serious adhesion between inner and outer gland of prostate, which often strip difficultly when line is not clear, it’s easy to cause stripping prostate capsular tear or other vice-injury;(2) The overall stripping glands with prostate fossa lead to a new academic overwhelmed, view is not clear or lost, thus affect the operation.(3)In the process of enucleation of the prostate, when there is a capsular perforation and prostate tissue full of posterior urethral, bleeding more unexpected situations, as space processing is difficult, it’s not easy to convert to ordinary cutting treatment.(4)Tended to be adhesion heavier, it’s not easy to peel12points from surgical coated line, which cause more bleeding after perforation.(5) To the doctors who carry out the business first time, the demand is higher for surgical skills; it is not conducive to the operation of comprehensive promotion.Comprehensive the advantages and disadvantages of PKRP and PKEP, according to the local anatomy of prostate, we try to combine the two each advantages and further solve the shortage of the above two kinds of operative methods, at the same time look forward to reduce the technical threshold of PKEP, hope to become the transition from PKRP to the PKEP technique step by step.Purpose and meaningWith the continuous development of medical technology and equipment, as new treatment for BPH,PKRP and PKEP using bipolar plasma cutting system has been widely used in clinic at present our country, and achieved good therapeutic effect, but combining two kinds of surgical operation is still a lack of further study, we preliminary attempt to combine the advantages of two kinds of operative methods to treat the BPH patients through fostering strengths and circumventing weaknesses.Because the PKEP is developed on the basis of PKRP, so we combine both effective and reduce degree of difficulty of learning PKEP for PKEP operation comprehensive promotion.Observed group absorb the advantages of two kinds of operative methods in this study, and complement each other.The verumontanum proximal identification method is adopted in observation group, this point as a marker of distal resection of the prostate avoided external sphincter beginners’ damage. We blocked the prostatic urethra arteries at first with bladder neck4-5, and7-8points between verumontanum resection, applied enucleation method at the same time. Comparing with the control group, it significantly reduced intraoperative hemorrhage.Complete removal of the anterior lobe of the prostate at the same time; it avoided increasing intraoperative blood loss for enucleation application simply stripping12point because of adhesion seriously.3ditch formed, as a blunt water channel, the remaining prostate tissue is separated into3leaf anatomy which is prostate central lobe and side lobe,it make the new scholars at a loss when they strip the glands with prostate fossa. We use sheath make glands retrograde in the direction of bladder neck dissection on the middle and both sides leaf, it reach the thoroughness of prostate condition, but the difficulty of surgery is reduced.So that we can make plans to carry out that the PKEP surgery on the basis of the mastery of plasma cutting gradually transit to enucleation in surgery, which create conditions for PKEP universal access. Methods1. Materials and methods1.1Clinical data72patients with benign prostatic hyperplasia in November2011to October2012in the Inner Mongolia autonomous region people’s hospital who are divided into observation group and control group36cases according to the patients with operation sequence number and random number table, we adopt PKRP and PKEP joint surgery (observation group) and PKRP surgery (control group) for surgical treatment respectively. Patients aged between55and90who are tested preoperative routine urine flow mechanics, neurogenic bladder cases are excluded; TPSA<10.0ng/ml, patients suspected of prostate cancer will be prostate biopsy. Preoperative and postoperative prostate symptom score (IPSS), quality of life score (QOL), residual urine (RU), maximum urinary flow rate (Qmax) record. B ultrasound check and calculate the prostate volume (volume=AxBxC×0.52) and weight (weight=volumex1.05). Surgical indications:a repeated urinary retention; Merge the bladder calculi; Conservative treatment is invalid to recurrent hematuria; Secondary upper tract water (with or without renal impairment); Recurrent urinary tract infections.1.2Surgical method Two groups patients adopt Japan Olympus plasma electric cutting system, electric power120-180W,60-80W electric coagulation power. Physiological saline continuous bladder irrigation, flushing fluid height of60-80cm, conventional continuous epidural anesthesia, lithotomic position, looking straight at the transurethral into electricity cutting mirror, observation of verumontanum and bladder, then fill bladder, prostate above medium size use bladder colostomy,then link to the pubic bladder puncture drainage tube.(1) Observation group:the verumontanum proximal identification method is adopted, the electricity cut mirror back to the level of verumontanum, observe urethral sphincter, cut a circle cutting ring along the urethra between urethral sphincter and verumontanum, so we can see annular groove and coagulate blood clot formation, this point as a marker of distal resection of the prostate, it can avoid beginners external sphincter damage. Logo, then it format resection area between the bladder neck mouth4-5,7-8points and verumontanum, remove to surgical capsule, sufficient to stop the bleeding. Same way complete removal of the anterior lobe of the prostate to surgical capsule, above3ditch water channel formation, and the remaining prostate tissues is separated the anatomy into three leaves, that is prostate central lobe and on both sides of the leaf. Find surgical coated boundaries, will be in the middle and on both sides of the leaf retrograded the direction of bladder neck in sheath, and adopt the method of stripping and bleeding at the same time.(2) Control group:first cutting5,7points as a symbol of ditch, electric cutting as deep as prostate surgery capsular, fully hemostatic, preliminary block most of the prostate blood supply, and then on the basis of sign ditch anterograde and retrograde excision prostate tissue to meet12points, then trim the tip of the prostate and bladder neck and radically hemostatic, pay attention to don’t damage urethral sphincter and urethral openings. Suck out with ELLIC residual broken prostate tissues, making three cavity catheters a lien, pulling the bladder fistula, postoperative three cavity catheter continuous bladder irrigation.2. Observation data2.1Including operation time, removing tissue weight, intraoperative blood loss, postoperative bladder washing time, postoperative urine tube time, postoperative hospitalization days, after3months IPSS, Qmax, RU, complications etc.2.2Intraoperative blood loss determination Rinses specimens use sterile distilling water to dilute hemolytic processing, using trace determination of free hemoglobin to measure rinses hemoglobin concentration. Dosage of intraoperative blood loss (L)=Rinses dosage (L)×rinses postoperative rinses hemoglobin concentration (L)/preoperative hemoglobin concentrations in the blood.3. Statistic analysisSPSS16.0statistical software is used for data analysis. Measurement data use x±s,the count data cases expressed as percentage; Measurement data comparing with independent samples t/t’ test, if they do not obey the normal distribution is using nonparametric test (Mann Whitney U);Comparison between count data set using Pearson chi-square test or Fisher’s exact test, P<0.05for the difference is significant.ResultsAll patients were successfully completed surgery, compared two groups of patients with preoperative, intraoperative and postoperative of the indicators.Results show that the observation group to remove the prostate tissue more than the control group, less intraoperative bleeding, postoperative bladder irrigation duration and postoperative urine tube time and postoperative hospitalization days shorter, compared with the control group there were significant differences (P<0.05). Compared with the control group, preoperative general situation and operation time of observation group there was no significant difference (P>0.05).Two groups of postoperative patients were followed up for3to6months,3months follow-up results suggest IPSS decline obviously, maximum urinary flow rate is significantly increased, residual urine decreased significantly, and the comparison between the two groups have no significant difference (P>0.05).Control group in6cases bleed again in post-operation, cured by continuous bladder irrigation or eliminating blood clots again; Observation group2cases and control group in3cases appear dysuria, for urethral mouth narrow, improved after urethral expansion; Complications comparing differences between two groups have significant difference (P<0.05).Observation group and control group were no deaths, blood transfusion. Conclusions1. Compared with PKRP, on the basis of the master PKRP operation, PKRP and PKEP combined surgery has the advantages of easy to learn.2. The combined surgery compared with PKRP is more thoroughly.3. The combined operation has less hemorrhage, shorter hospitalization time, and reduces the risk of surgery accordingly.4. The combined operation does not affect long-term outcomes, complications have no obvious increase.5. The combined operation is looking forward to become the transition from PKRP to the PKEP technique, let more urinary surgeons in transition easily master the operation on the basis of gradually mastered PKEP technique, so as to be benefit to more patients with BPH. BackgroundIn recent years, with the continuous development of new technology and equipment, the plasma kinetic resection of the prostate (PKRP),using bipolar plasma cutting system a new method of treatment of BPH, has been widely used in clinic, and achieve good therapeutic effect. In the study of the first chapter we preliminary explored application of combined PKEP and PKRP surgery patients with hyperplasia of prostate, achieved good effect. Urological surgeon general used to remove urethral catheter about5to7days after transurethral resection of the prostate, thus patients stay hospital longer, cause high incidence of urinary tract infection and relative cost results, In this study, we preliminary attempt on the application of combined PKEP and PKRP treatment of prostatic hyperplasia patients, removing urethral catheter in24to48hours, the patients can be discharged from the hospital a day after pulling, truly reflect the advantages of minimally invasive surgery which hospital time is short, recovery is fast.BPH is one of the most common diseases in older men in urology which seriously affect the patients quality of life, TURP is the "gold standard" of treatment of prostatic hyperplasia. In recent years, the application of PKRP using bipolar plasma cutting system as a new method of treatment of BPH has been widely used in clinic.Due to TURP cutting temperature is high, local tissue form solidified layer and achieve remarkable hemostatic effect, but it has certain damage tissue around the urethra, can induce the urinary tract symptoms after surgery, and wound heal slowly. Relative to TURP, the surface temperature is low when PKRP cut tissue, with a precise cutting range, the heat penetration is shallow and mild characteristics such as damage to surrounding tissues, so dramatically reduce symptoms than TURP surgery. TURP is obvious usually formed coke delusion or carbide to PKRP, its surface has the possibility of infection, bleeding again higher than PKRP recently, postoperative coke peel off period about3months, repairing PKRP significantly faster than TURP postoperative surface, which will create conditions for early postoperative removing urethral catheter.No matter apply what kind of transurethral resection of the prostate surgery, postoperative routine continuous bladder irrigation with three cavity catheter, rushed out of the hemorrhage in time, so as not to form a clot to block the catheter. Urethral catheterization operation is one of the most common direct cause of urinary tract infections, complete urethral mucosa is an important barrier for preventing microbial invasion, catheter insertion destroyed the natural barrier urinary mucosa, and catheter is a kind of the foreign matter for the human body, stimulates the urethra and bladder mucosa, weaken the defense function of bladder and urethra to bacteria, is direct cause of urinary tract infection.Urethral catheter will not only cause the occurrence of urinary tract infection, but also can cause the patient appear bleed in the urine, patients with prostatic hyperplasia bleeding in the urine have higher risk, mainly in the indwelling catheters increase during lower urinary tract infection as a cause of bleeding, catheter as a foreign matter to the body can stimulate the urethra mucous membrane at the same time, make vasodilatation of urethra mucous membrane, and the mechanical friction function of catheter urethra or bladder more bleeding, so shortening the catheter indwelling time is an effective way to reduce urinary tract bleeding.Purpose and meaningComplications of indwelling catheter is more, such as infection, hemorrhage, urethral stricture, especially urinary tract infection with urethral catheter time has a direct relationship, transurethral surgery should be routine urethral catheter, in order to reduce the complications, how to do it as soon as possible removing urethral catheter is of great importance in the transurethral surgery. Regardless of which application of transurethral resection of the prostate operation method, the pathology, postoperative wound epithelial repairing generally requires at least3weeks,3months or more to achieve full epithelium, postoperative prostate fossa wound soaked in urine, edema, falls off necrotic tissue, epithelial tissue grew cover again, until the scars heal, and stimulate the damage of catheter, recent blood in the urine, frequent urination urgency, urinary pain and urinary irritation symptoms is heavier, the forward can appear urethral scar stricture, and hyperplasia, and so on. Early removing urethral catheter can reduce the blood in the urine and the incidence of complications such as infection. Which an be seen from the urethra wound recovery rule, urethral catheter1week wound is no healing, so the action of the urethral catheter is only for the function of bladder irrigation. After the application of plasma cutting of prostate, the incidence of postoperative hemorrhage is lower, which create conditions for early urethral catheter.Based on the above advantages of transurethral plasma resection and combined enucleation in addition to the advantages of the operation, according to plasma resection of the prostate and the theoretical basis for wound healing and repair, we try to remove urethral catheter early, comparing with conventional removing urethral catheter, and reduce complications postoperatively in patients with hyperplasia of prostate in not affect the treatment effect.Methods1. Materials and methods1.1Clinical data This study choose84patients with benign prostatic hyperplasia from October2012to November2012in the Inner Mongolia autonomous region people’s hospital to do prospective study, this test in the patient group order, using the block random method, segment length is set to4. Experimental group and control group accord to1:1allocation of patients,42cases every group. Using combined PKRP (plasma kinetic resection of the prostate) and the PKEP (plasma kinetic enucleation of the prostate) surgical treatment, postoperative routine application of antibiotics for3to5days, the observation group flush fluid in1-2days urethral catheter according to the condition, the control group remove out5-7days according to the convention, after observing two groups of preoperative and urethral catheter indicators, compare the clinical curative effect.1.2Surgical method Two groups adopt Japan Olympus plasma cutting system, electric power120-180w,60-80w electric coagulation power. Medium for saline rinse solution, washing fluid height of60-80cm, conventional continuous epidural anesthesia, lithotomic position, looking directly into urethra, under the above medium size prostate colostomy after the line on the pubic bladder puncture drainage tube. The middle and side lobe were observed. The verumontanum proximal identification method is adopted, the electricity cut loop back to the level of verumontanum, observe urethral sphincter position, distal proximal verumontanum cut a circle cutting ring along the urethra, annular groove and coagulate blood clot formed, this point as a marker of distal resection of the prostate, avoid beginners damage external sphincter. Logo, after the formation of the bladder neck mouth4-5, and7-8points between verumontanum resection on the finish, remove to surgical capsule, fully hemostatic, preliminary blocked prostatic urethra group arteries, reduce intraoperative hemorrhage. Same way complete removal of the anterior lobe of the prostate to surgical capsule, above3ditch water channel formation, and the remaining prostate tissue into three leaves according to the anatomy, that is prostate central lobe and on both sides of the leaf. Find surgical coated boundaries in front verumontanum, hyperplasia gland was cleared with surgical in reverse way, electricity cutting sheath like prostate open surgery in the doctor’s fingers for stripping, stripping process of visible glands in the direction of the bladder, prostate surgery coated for dense circular fiber, capsule of loose connective tissue and branching vascular plexus, surgical coated strip surface can see bare supply blood vessels, glands partially can see retention of prostatic fluid overflow, fiber adhesive tape, prostate stones, etc. Using electric coagulation of blood vessels on the cutting section, point cut fiber adhesive tissue and prostate calculi with cutting ring blow away. Gouge out each leaf leaving only parts with bladder neck glands are linked together, bladder neck small gland is connected with dark skin and neck glands, complete blood supply most broken, sequential will have stripped the glands chopped quickly and remaining2leaves on the same terms and gouge method after resection, rushed out. Finally cut flat dressing wounds, in the condition of bladder empty carefully hemostatic, intraoperative urination test. Place three cavity Foley catheter, airbag filling30ml, depending on the situation of the bladder was irrigated, removing tissue after sucked out and weighed, and after conventional families specimens and the pathological examination.2. Observation data2.1Intraoperative index (1) The patient’s respiration, pulse and blood pressure, consciousness and ECG, blood oxygen saturation;(2) Patients with bladder on pubic area density and bladder filling, lower abdomen; if bladder fistula is obstructed to colostomy patients, once the blockage in a timely manner;(3) The operation time, intraoperative blood loss, resection of prostate tissue weight.(4)Pay attention to the abdomen, urgent check ion and blood gas analysis when cutting wear prostate surgery capsular.2.2Postoperative index(1) The patient’s breath, pulse, blood pressure, consciousness and ECG and blood oxygen saturation monitoring;(2) The washing liquor color, rinses speed, flushing fluid drainage situation;(3) Electrolyte, blood routine, routine urine;(4) Record the bladder flushing duration and urethral catheter time, hospital stay;(5)The postoperative complications, such as the bladder spasm, temporary incontinence, bleeding, urinary tract infection, acute epididymitis again, etc.(6)3-6months after operation, IPSS, QOL, Qmax, RU, urethral stricture, urinary incontinence, etc. RU use urine catheter placement to collect accurate measurement.3. Statistic analysisSPSS16.0statistical software is used for data analysis. Measurement data use x±s,the count data cases expressed as percentage; Measurement data comparing with independent samples t/t’ test, if they do not obey the normal distribution is using nonparametric test (Mann Whitney U);Comparison between count data set using Pearson chi-square test or Fisher’s exact test, P<0.05for the difference is significant.Results 1. Two groups of patients with preoperative conditionAccording to the results of the final follow-up, the two groups were complete clinical data of84cases, two groups of patient’s age, prostate quality, maximum urinary flow rate (Qmax), bladder residual urine (RU), the international prostate symptom score (IPSS), quality of life (QOL) score, comparison between the two groups before the indicators there was no significant difference (P>0.05).2. Two groups of postoperative situationTwo groups of patients were operation smoothly and has not been intraoperative blood transfusion, TURS, no death, obdurate nerve reflex, bladder injury, rectal injury. Observation group5cases postoperatively, the control group4cases with temporary incontinence, comparison between the two groups had no significant difference (P>0.05); Observation group of postoperative urinary tract infection cases less than the control group; Observed group of postoperative bladder spasm, rebleeding cases less than the control group, control group6cases with postoperative bleeding again, to continue to bladder irrigation or cured by again removing blood clots, comparison between the two groups have significant meaning (P<0.05).3. Follow-up after3monthsTwo groups of postoperative patients were followed up for3to6months,3months follow-up results suggest IPSS and QOL declined obviously, maximum urinary flow rate is significantly increased, residual urine decreased significantly, the comparison between the two groups had no significant difference (P>0.05). No incontinence occurred in both groups. Observation group3cases and control group5cases appear dysuria for urethral stricture, mouth after urethral expansion, urethral stricture rate between the two groups have no significant (P>0.05).Conclusions 1. Early postoperative removing urethral catheter can significantly shorten the length of hospital stay, reducing cost to the patients using PKRP combine PKEP after1-2day operation.2. The combined operation early postoperative removing urethral catheter can reduce postoperative urinary infection risk.3. The combined operation early postoperative removing urethral catheter can reduce the chance of bladder spasm; reduce the incidence of postoperative recurrence of bleeding.4. The combined operation early postoperative removing urethral catheter does not affect the operation effect, is worth promoting.更多还原