探討綠光雷射汽化與經尿道前列腺切除醫療成效及醫療資源耗用分析

研究目的良性前列腺增生（BPH）是一種常見的老年疾病，在過去最有效的方式、黃金標準仍以經尿道前列腺切除（TURP）為主，但近年開始以綠光雷射 (PVP)手術來代替TURP，國內外臨床報告中亦已證實有效，但在台灣地區僅有少數在臨床報告，但在有關兩者成本效益及醫療費用分析較少，故引發動機，想藉此研究兩組醫療費用耗用分析及醫療成效，期望結果能給醫療團隊參考。研究方法以回溯性分析研究方法。收集南部某醫學教學中心及區域教學醫院於2008年1月至2011年3月，因前列腺增生患者接受綠光雷射汽化術與經尿道前列腺切除之病患個案數各124例，比較兩組在住院天數、手術時間、術後膀胱沖洗、留置導尿管時間、解尿狀態、併發症、傷口疼痛之間的差異性，進而討論醫療資源耗用，做描述性統計、推論性統計。研究結果 1.臨床醫療成效：手術後發現接受綠光雷射汽化術之病患( PVP)組比經尿道前列腺切除之病患(TURP) 組發生併發症比率比經尿道前列腺切除之病患(TURP)組高(P＝0.002），其中性功能障礙(P＝0.001）、手術後疼痛(P＝0.016），具有顯著差異且與手術時間有相關；尿道狹窄、逆行性射精、尿液感染(P＞0.05），無顯著差異。 2.臨床醫療資源耗用：兩組結果比較，接受經尿道前列腺切除之病患(TURP)組平均住院天數4.81±0.80天，而接受綠光雷射汽化術之病患( PVP)組平均住院天數為4.32±1.29天(P<0.001）；術後膀胱沖洗時間（TURP組45.60±14.85小時PVP組33.98±14.61小時；導尿管留置時間（TURP組58.88±16.48 PVP組39.56±16.39小時）綠光雷射汽化術之病患組( PVP)組明顯比TURP短，具有顯著差異(P<0.001）；而手術時間綠光雷射汽化術之病患( PVP)組比經尿道前列腺切除之病患(TURP)組時間長（TURP組75.65±29.67 PVP組125.89±51.66分），(P<0.001）具有顯著差異性；在醫療總費用，先扣除兩組手術費及特殊衛材後在去做比較後，發現經尿道前列腺切除之病患組(TURP)組醫療總費用30547±15691元，綠光雷射汽化術之病患( PVP)組33028±17790元，無顯著差異(P＞0.05）。結論與建議本研究醫療費用兩組比較雖無差顯著異性，但綠光雷射汽化術之病患( PVP)組比經尿道前列腺切除之病患組(TURP)組費用比率較高，影響的因素：手術、麻醉時間及住院天數、術後產生併發症有相關。TURP是目前臨床治療BPH之下泌尿道症狀黃金治療標準，而綠光雷射汽化術（PVP）優點是更短的住院天數及術後膀胱沖洗、導尿留置時間。因出血量少、安全性高，而成為有罹患共病症、高麻醉風險病患的首選手術，至於術後併發症比率較高，仍需要更多的證據來證實。

關鍵字

綠光雷射汽化；經尿道前列腺切除；醫療資源耗用；醫療成效

並列摘要

Purposes Benign prostate hyperplasia(BPH) is a common disease in elderly. Transurethral resection of prostate(TURP) is the most effective treatment and the gold standard in the past. However, photovaporization of the prostate(PVP) had replaced TURP gradually in recent years. Latest clinical reports had approved the effect of PVP. In Taiwan, there were only several cases reports. Due to the scarcity of analyses on cost- effectiveness and medical cost in Taiwan, we decided to design a study to compare the two methods on medical expenses and effect for bringing some different views to other medical teams. Objective: To compare the differences between the methods for BPH on medical Utilization Analysis Method This study is a retrospective analysis to collect 100 patients with BPH receiving PVP and another 124 patients receiving TURP from January 2008 to March 2011 in a academic medical center and a metropolitan hospital in southern Taiwan. We compared the hospitalization days, surgery time, postoperative bladder irrigation, the days of catheter indwelling, void state, complications, wound pain between these two groups. Discussion of the medical resource utilization, descriptive statistics and inferential statistics were made. Result Medical effect: Patients received green laser vaporization (PVP) had more complication rate than patients received transurethral resection (TURP) (P＝0.002). Included sexual dysfunction(P ＝0.001), post-operative pain (P＝0.016). A significant difference of more operative time was noted in patients received PVP. There was no significant difference in comparing of the rate of urethral stricture, retrograde ejaculation, and urinary infection (P> 0.05). Clinical medical resource utilization The hospital stays in PVP group and TURP group are4.32± 1.29(day) and 4.81 ± 0.8 0(day), (P <0.001), respectively.The duration of bladder irrigation ,catheterization time and were significantly shorter in PVP group.( bladder irrigation 45.60±14.85(h) vs33.98±14.61(h); catheterization time58.88±16.48(h) vs39.56±16.39(h) ,(P <0.001).The operation time was longer in PVP group.（75.65±29.67 min vs 125.89 ±51.66min）.The total health care costs, after deducting the two sets of surgery and special Eisai were not significant differences TURP group 30547 ± 15691 NTD ; PVP group 33028 ± 17790NTD (P> 0.05). Conclusions In this study there is no significant difference in the medical resource utilization of these two groups. But the PVP group have higher resource utilization which was attributed to the following factors: operation time, anesthesia ,hospital stays, and postoperative complication rate. TURP is the gold standard in the operation of BPH. PVP has the advantages of shorter hospital stay, less duration of bladder irrgation and shorter catheterization time. Owning to less intraoperative bleeding .PVP is the alternative treatment in patient with comorbidities and higer anesthesia risks. Regarding the higher postoperative complication rate of PVP group, the further study is warranted.