二極體雷射攝護腺汽化切割手術於良性攝護腺肥大病人術後膿尿及泌尿道感染之研究

Pyuria and Post-operation Urinary Tract Infection following Diode Laser Vaporesection of the Prostate for Benign Prostate Obstruction

楊旻鑫(Ming-Hsin Yang)

指導教授 ： 李宗賢

中山醫學大學/醫學院/醫學研究所/碩士(2018年)

摘要

研究目的：對於良性攝護腺肥大病人的手術治療，傳統的「單極電燒經尿道攝護腺刮除術」是手術治療的黃金準則，但這個手術仍伴隨著可能致命的風險，例如術中出血及稀釋性低血鈉症引發腦水腫的風險。較新的手術方式「二極體雷射攝護腺切除手術」有較深的熱穿透能力，可以降低術中出血以及低血鈉的風險，較為安全。但是多項文獻證據顯示二極體雷射有較深的熱傷害，可能造成較長的發炎反應。本研究旨在以比較「術後膿尿持續時間」及「尿路感染相關事件」，藉此了解二極體雷射所帶來的熱傷害是否會造成後續併發症。
研究方法及資料：本研究採回溯世代的設計方式，納入自2011年七月至2015年九月，因為攝護腺阻塞接受二極體雷射攝護腺汽化切割術及單極電燒攝護腺刮除術的病人。實驗組為接受二極體雷射攝護腺汽化切割術的病人，對照組則為接受單極電燒攝護腺刮除術的病人。兩組資料包括術前、術中、術後，皆從單一醫學中心的電子病歷系統紀錄下來，作為分析比較。術後膿尿持續時間以存活分析作比較，相關的危險因子並以Cox回歸分析。術後尿路感染事件，包括泌尿道感染、副睪炎、攝護腺炎、尿路感染相關住院，也於兩組之間比較。
研究結果：共有112位病人接受二極體雷射攝護腺切除手術，81位病人接受單極電燒攝護腺刮除術，所有手術皆由同一位醫師完成。除了術前使用抗凝血劑比例在實驗組較高以外(18.5% vs 7.4 %, p=0.028)，兩組在術前的其他基本特色沒有顯著差異。手術時間是實驗組明顯較長(62.8±20.6 vs 47.4±22.1分鐘, p<0.001)，但是在術後尿管沖洗時間則是對照組較長(2.1±0.3 vs 2.5±0.9天, p<0.001)。術後膿尿持續時間在實驗組明顯長於對照組，有統計學上差異(16 vs 12 weeks, p=0.0014)。相關的風險因子包括，手術方式使用二極體雷射攝護腺切除手術 (HR: 1.828, p=0.003)、及年紀(HR: 0.665, p=0.040)。術後感染事件則是實驗組較易產生副睪炎(10.2% vs 1.2%, p=0.013)及因為尿路感染問題住院(8.3% vs 1.2 %, p=0.031)。雖然實驗組產生泌尿道感染比例看似較高(11.1% vs. 4.9%, p=0.131)，但沒有統計差異。
結論與建議：根據本研究，二極體雷射攝護腺切除手術有較多尿路感染相關事件。但其與較深的熱傷害及較長的術後膿尿之間有無因果關係，則須更多的研究證據來證實。

關鍵字

良性攝護腺增生 ； 二極體雷射攝護腺切除術 ； 單極電燒攝護腺刮除術 ； 膿尿 ； 泌尿道感染

並列摘要

Objective：Monopolar transurethral resection of prostate (m-TURP) remains the golden standard for benign prostate obstruction (BPO). Recently evolved laser surgical technique provides less perioperative complications with equivalent outcomes. New developed diode laser vaporesection (DiLRP) offers better hemostasis, shortens catheterization duration, and hospital stay. However, deep thermal penetration might cause prolong prostatic urethra inflammation and subsequent complication. We conduct a retrospective study to compare the pyuria duration and post-operative urinary tract infection sequelae (POUTIs) between DiLRP and m-TURP.
Methods and Materials：From July 2011 to September 2015, we retrieved medical records on patients with lower urinary tract symptoms due to prostate obstruction underwent m-TURP and DiLRP. Demographic characteristics were recorded from a single center computerized database, including history of the underlying disease, use of anticoagulant or antibiotic before operation, the duration of indwelling catheter, PSA level, history of transrectal ultrasound biopsy, perioperative and postoperative details, hospitalization period. The duration of pyuira after operation was compared by kapalan-meire analysis; and risk factors were evaluated by Cox regression analysis. The POUTIs which include urinary tract infection, epididymitis, prostatitis, and infection related hospitalization were compared as well.
Results：One hundred and twelve patients underwent DiLRP and 81 received m-TURP with the same surgeon at the same period. The mean age of the patients was 72±7.3 years in DiLRP group and 70±7.6 years in m-TURP group (p=0.069). There was more percentage of anticoagulant used in DiLEP group than in m-TURP group (18.5% vs 7.4 %, p=0.028). Operation time was longer, but post-operation normal saline irrigation interval was shorter in DiLRP in comparison with m-TURP respectively (62.8±20.6 vs 47.4±22.1 mins, p<0.001; 2.1±0.3 vs 2.5±0.9 days, p<0.001).
The difference of post operation infection between groups is statistically significant in epididymitis (10.2% vs 1.2%, p=0.013) and POUTIs related hospitalization (8.3% vs 1.2 %, p=0.031). The DiLRP resulted in longer pyuria period (16 vs 12 weeks, p=0.0014), with factors including operative method by DiLRP (HR: 1.828, p=0.003) and age (HR: 0.665, p=0.040).
Conclusion and Suggestion：According to our study, DiLRP associated with more POUTIs possibly caused by longer pyuria period. Further larger prospective study is necessary for the evaluation the association between post-operative pyuria and POUTIs.

並列關鍵字

benign prostate hyperplasia ； diode laser vaporesection of prostate ； monopolar transurethra resection of prostate ； pyuria ； urinary tract infection

參考文獻

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