| 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. |
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