| Background:Benign prostatic hyperplasia is a common benign disease,which Easily leads to significant dysuria in middle and old aged male. The disease are characterized by hyperplasia of prostatic stromal and epithelial components according to histology, anatomically enlarged prostate, lower urinary tract symptoms as well as bladder outlet obstruction on the dynamics. Due to the restrictions of the prostate capsule, hyperplastic glands can only grow toward posterior urethra and bladder. So urethral resistance increase rapidly, resulting compensatory changes in bladder function. When the resistance of outflow tract is increasing, detrusor pressure is also elevating in order to maintaining the flow of urine. But this is at the cost of damaging to storage function of bladder. Both obstruction-related changes of function of detrusor muscle and age-related changes of function of bladder and nervous system lead to the most common symptoms of BPH,such as urinary frequency, urinary urgency, urinary pain.It is worthwhile to note that the incidence of histological BPH increase in direct ratio with age. Prostatic hyperplasia usually can occur after the age of40. More than half of60years old and83%of80years old has glandular hyperplasia.Be similar to histological features, the symptom of dysuria gradually aggravates, along with the growth of age. About50%histological diagnosis of BPH in men associate with moderate to severe lower urinary tract symptoms. Facing with such a high incidence of BPH, how to choose a reasonable and effective treatment measures is naturally the most important during the study of the disease. At present, treatments for BPH consists mainly includes watchful waiting, drug therapy and surgical therapy. The choice of treatment should be based on the patient’s symptoms, the supplementary examination, local medical condition and the patient’s compliance. If lower urinary tract symptom caused by severe benign prostatic hyperplasia has seriously affected the quality of life in patients, surgical treatment should be considered. In addition, surgical treatments are required as the following complications occur.1. repeated urinary retention (inability to urinate at least once after extubation or twice urinary retention);2. recurrent hematuria or those who won’t respond to5a-Reductase Inhibitors;3.recurrent urinary tract infections;4. vesical calculus;5. secondary hydronephrosis of upper urinary tract (with or without renal dysfunction);6. with bladder diverticulum, inguinal hernia, severe hemorrhoids or rectal prolapse. not relifing lower urinary tract obstruction is difficult to achieve a therapeutic effect.7.The significantly increased residual urine results in overflow incontinence in BPH patients. When urologists choose the treatments for patients, the wishes of the patients should be respected.Personal experience and views of patients, the size of the prostate, concomitant diseases as well as systemic conditions should be considered.The commonly used surgical method contains transurethral resection of the prostate(TURP),transurethral vaporization resection of the prostate,(TUVRP)and bipolar plasmakinetic transurethral resection of prostate(PKRP). The latter two techniques are evolved by TURP. In addition, there is also transrectal high-intensity focused ultrasound (HIFU) in the ablation of prostate which is developing rapidly. TURP is regarded as the "gold standard"treatment for benign prostatic hyperplasia. TURP is showed as no surgical incision, fewer traumas, shorter surgery time, less bleeding, faster recovery, less post-operative complications with open prostatectomy.But excessive absorption of irrigating fluid easily causes dilutional hyponatremia and transurethral resection syndrome(TURS).Compared with TUVRP and PKRP, the disadvantages of TURP are long operation times, especially for large-volume prostates, unclear surgery field, high incidence of complications such as TURS and bleeding. Therefore, TURP is gradually being replaced by TUVRP and PKRP. Since1994, TUVRP has been developed, which combines with advantages of transurethral vaporization of the prostate(TVP) and TURP. It can be used for cutting and vaporizing prostate simultaneously. Prostate tissue is rapidly vaporized by improved the electrode and then forms1～3mm solidified layer, so it can significantly reduce intraoperative blood loss in the cutting process. This compensates for its lack of hemostatic effect and not coagulating and cutting at the same time. Due to the use of fluid non-isotonic for irrigation, such as mannitol, it can neither reduce the occurrence of TUR syndrome,nor leave enough tissue for pathological examination. Subsequently, British Gyrus company took the lead in application of plasma technology in resection of prostate in1998.And PKRP is developed on the basis of the TUVRP and TURP.It is the third-generation electricity cut system, which has two advantages:first effective electricity cutting and secondly vaporization hematischesis. Therefore, it has a favorable safety and effectiveness. The bipolar plasma resectoscope consists of two electrodes:a working electrode and a return electrode. Dynamic plasma knife forms when high frequency electrical current passes through the two electrodes, by which macromolecules were rapidly broken down into small molecules such as H2, O2,CO2and so on.Therefore, electro-vaporization and coagulation effect were observed. Besides,saline as irrigation fluid can significantly reduces the incidence of prostate transurethral resection syndrome in theory.Furthermore, removed prostate tissue is complete enough for pathologic biopsy.HIFU is a kind of emerging treatment for BPH. Its treatment principle is that high-intensity ultrasound is emitted by ultrasonic generator, and gathers in the targeted area. The local temperature of the targeted area suddenly rises to80℃～100℃,which leads to coagulative necrosis in this region. Finally, the targeted cell was killed. The clinical application of HIFU begun in1993, but is almostly transabdominal approach.Sonablate500transrectal HIFU therapeutic instrument has not been introduced in china until Until December2002. At present, there are only a handful of units carried out a transrectal high intensity focused ultrasound in the treatment of prostate disease.At present, there are only a handful of units carried out a transrectal high intensity focused ultrasound in the treatment of prostate disease.Sonablate-500HIFU made by American Focus Sugery Company belongs to the third generation, which is the latest generation of HIFU devices. There are two ways for HIFU:transrectal and transabdominal approach. The transrectal ultrasonic is easier to focus on the targeted area of prostate,while transabdominal ultrasonic cannot maximize the effect of ablation for the treatment as a result of blocking of the pelvic. Therefore, the treatment of transrectal approach is superior to transabdominal approach. It’s not yet clear that which is best among the four operative methods.And there is lack of retrospective analysis of large sample. The long-term curative effect of HIFU needs to be verified.Objection:1.To compare the clinical effective of transurethral resection of the prostate(TURP), transurethral vaporization resection of the prostate(TUVRP), bipolar plasmakinetic transurethral resection of prostate(PKRP) and high intensity focused ultrasound(HIFU) for the treatment of benign prostatic hyperplasia.2. The long-term curative effect of HIFU to treat BPH was observed and its effectiveness was confirmed.Methods and materials:We reviewed patients who accepted TURP, TUVRP, PKRP, HIFU in the General Hospital of Guangzhou Military Command of Urology From January2000to October2011The objects of study were screened by strict inclusion and exclusion criteria.Inclusion criteria included the following:1.patients whose preoperative PSA was unusually high or who could be touched nodules by rectal touch undergoing prostate biopsy had been excluded prostate cancer;2.The quality of life of patients,whose IPSS score and QOL score were no less than7points and4points respectively, were seriously affected;3. The patients with moderate and severe BPH accompanied by obvious symptoms of lower urinary tract obstruction;4. All of BPH patient were checked by transrectal ultrasound whose prostate volume were in the range of20-100ml. Prostate cancer and intraepithelial neoplasia which was diagnosed by preoperative prostate biopsy or postoperative pathological report were excluded.According to the operation in different ways,601cases of BPH were divided into four groups:TURP(n=130), TUVRP(n=102), PKRP(n=225), HIFU (n=144). And the general situation and complications as well as incidence of complications of each group were compared with each other such as operative time (min), intraoperative amount of blood loss (ml), time of continuous bladder irrigation (d), time of postoperative indwelling catheter (d), hospitalization time (d), cost ($),postoperative Qmax (ml/s), postoperative residual urine (ml), postoperative prostate volume (PV)(ml), international prostate symptom score (IPSS)(points), quality of life score (QOLS)(points). The data was used for statistical analysis by spss13.0statistical software. Measurement data were expressed as mean±standard deviation (X±S), three-sample t test was used to observation index of homogeneity of variance,while non-parametric test was used to observation index of unequal variances.All statistical tests were taken a two-sided test, inspection standards for a=0.05.Results:There was no significant difference of pretherapy factors between the four groups (P>0.05). Incidence of incontinence and epididymitis were also no significant difference(P>0.05). Qmax, RUV, PV, IPSS, QOL were significantly improved in each group after the procedure(.P<0.05). The amount of bleeding and blood transfusion in TURP were different from TUVRP and PKRP group(P<0.05). Incidence of TUR Syndrome in PKRP group was superior to that of TURP and TUVRP group(P<0.05). There was no significant difference among TURP, TUVRP and PKRP group in the area of Qmax、RUV、PV、IPSS、QOLS at24months after surgery(P>0.05). HIFU was different from TURP, TUVRP and PKRP group in terms of operative time, amount of bleeding, continuous bladder irrigating time, time of indwelling urinary catheter, hospital stay, cost and occurrence of complications(P<0.05). Qmax、RUV、PV、IPSS、QOLS at24months after surgery in HIFU group were different from TURP, TUVRP and PKRP group(P<0.05). The subjective and objective symptoms further improved after2years in HIFU group, but was still lower than that of TUVRP and PKRP group.Conclusion:1. TURP, TUVRP and PKRP were as effective as each other for treatment of BPH, but the security of PKRP was higher than that of TURP and TUVRP.2. Compared with above three transurethral surgerys, maximal security was observed in HIFU. But the effectiveness of HIFU was not good as transurethral surgery s.3. HIFU was effective for the treatment of BPH at24months after surgery. |
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