摘要:经尿道前列腺电切 (transurethral resection of the prostate,TURP) 术后前尿道狭窄是临床中常见的尿 道狭窄,本文对TURP术后前尿道狭窄流行病学、病因学、处理策略以及预防等进行总结分析。TURP术后前尿 道狭窄的常见部位是舟状窝、阴茎阴囊交界处、尿道球部。TURP术后前尿道狭窄的可能的病因包括机械损伤、 电损伤、感染和留置尿管等。TURP术后前尿道狭窄的治疗一般包括内镜下微创治疗和开放重建手术。内镜下微 创治疗的效果无法保证,尤其是对于长段或严重狭窄的患者,狭窄复发率很高。尿道成形手术包括端端吻合、口 腔黏膜修复、会阴区皮瓣修复和尿道会阴造口等术式。针对TURP术后前尿道狭窄的相关基础和临床研究均较为 匮乏,面对临床上的具体病例,往往是在尿道狭窄处理原则的基础上制定个体化诊疗方案。
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九十余年来,使用单极电切镜进行的经尿道前 列腺电切术 (monopolar transurethral resection of the prostate,M-TURP) 被认为是治疗由良性前列 腺增生导致的下尿路症状的“金标准”,临床效果确 切且符合成本效益原则[1-4] 。随着技术的进步,双极 电切镜的出现或许为TURP手术提供了一种更好的设 备选择,即双极TURP(Bipolar TURP,B-TURP)。 相比于 M-TURP,B-TURP 使用生理盐水作为冲 洗液,疗效相近的同时明显降低了术中并发症的发生 率[2-4] 。然而,无论使用何种能量平台,前尿道狭窄 仍是 TURP 术后主要的晚期并发症之一[5-6] 。本文旨 在收集和总结 TURP 术后前尿道狭窄的流行病学、病因学和处理策略等。
1 流行病学
2 病因学
2.1 机械损伤
2.2 电损伤
2.3 感染
2.4 留置尿管
2.5 其他
3 处理策略
3.1 尿道扩张术和尿道内切开术
3.2 尿道重建术
3.2.1 短段的球部尿道狭窄
3.2.2 长段的球部尿道狭窄
3.2.3 阴茎部尿道狭窄
3.3 尿道会阴造口术
4 TURP 术后尿道狭窄的预防
4 TURP 术后尿道狭窄的预防
TURP 术后前尿道狭窄对接受 TURP 手术的患 者来说是一个无法忽视的问题,但患者往往没有充 分意识到潜在的终身后果。20世纪的医疗器械技术 依赖于利用大功率的电流或激光能量进行前列腺组 织切除或消融,通常需要一个大尺寸镜鞘,这是尿 道损伤和术后狭窄形成的主要原因。进入 21 世纪, 微创的创新性设备和技术更广泛的应用于临床,希 望尺寸更小金属镜鞘和更短的手术时间将降低功能 并发症和尿道狭窄的发生率[41] 。
TURP 相关前尿道损伤是医源性尿道狭窄的主 要原因,临床上对此类患者的诊治具有挑战性。临 床医生应该了解这类问题的确切病因,思考在TURP 术中如何保护尿道黏膜的完整性。关于 TURP 术后 前尿道狭窄的治疗方式并无统一意见,内镜下微创 治疗的效果无法保证,尤其是对于长段或严重狭窄的患者,狭窄复发率很高。实际上,口腔黏膜移植 物,包括颊黏膜和舌黏膜,是最常用的前尿道成形 术补片材料。对于患有多种基础病和严重或全尿道 狭窄疾病的老年患者,尿道会阴造口术不仅是临床 上重要的治疗手段,而且往往是为这些患者恢复正 常排尿功能的明智选择。
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