保留尿道前列腺切除术360例报告

目的：探讨前列腺增生症（ＢＰＨ）的理想术式。方法：采用保留尿道前列腺切除术治疗ＢＰＨ３６０例,其中作耻骨后保留尿道前列腺切除术（Ｍａｄｉｇａｎ术）３２５例,作耻骨上经膀胱保留尿道前列腺切除术３５例。结果：两种术式术中视野显露良好,操作准确、简易,术后恢复快,出血少,并发症少,随访３￣６０个月,疗效满意。结论：保留尿道前列腺切除术是治疗ＢＰＨ较为理想的开放术式。     

保留前叶的经尿道前列腺切除术及解剖学依据

目的：评价保留前叶的经尿道前列腺切除术的疗效及其对术后尿失禁的避免作用,并初步探讨本术式的解剖学依据。方法：在86例BPH患者中,32例行保留前叶的经尿道前列腺切除术（1组）,54例行传统的经尿道前列腺切除术（2组）;并对比两组各临床参数,结合尿道括约肌的解剖学特征进行分析。结果：1组术后排尿通畅,剩余尿量均小于5ml,无尿失禁发生。2组中有29例发生各种尿失禁。1组术后后尿道长度大于2组。结论：保留前叶的经尿道前列腺切除术疗效满意,并可有效避免对前列腺前方尿道括约肌的损伤,在一定程度上保留后尿道长度,从而有效避免术后尿失禁的发生。     

前列腺增生术后排尿困难原因分析(附14例报告)

目的:分析前列腺增生术后排尿困难的原因,为预防和治疗提供依据.方法:回顾性分析14例前列腺增生术后出现排尿困难病例的临床资料.结果:9例耻骨上前列腺切除术病例中,膀胱颈梗阻6例,尿道外口狭窄、腺体残留和后尿道炎性粘连狭窄各1例;5例经尿道前列腺电切术病例中,腺体残留3例,血块堵塞和前尿道狭窄各1例.结论:膀胱颈口梗阻为耻骨上前列腺切除术后引起排尿困难的主要原因,而腺体残留则为经尿道前列腺电切术后排尿困难的重要原因.     

前列腺增生术后排尿困难原因分析

目的；分析前列腺增生术后排尿困难的原因，为预防和治疗提供依据。方法：回顾性分析１４例前列腺增生术后出现排尿困难病例的临床资料。结果：９例耻骨上前列腺切除术病例中，膀胱颈梗阻６例，尿道外口一残留和后尿道为性粘连狭窄各１例，５例经尿道前列腺电切术病例中，腺体残留３例，血块堵塞和前尿道狭窄各１例。     

耻骨后解剖性根治性前列腺切除术的技术改进

目的探讨耻骨后解剖性根治性前列腺切除术的技术改进,减少手术并发症。方法前列腺癌患者98例,平均年龄64岁。术前PSA 2．0～108．6 ng／ml,平均18．5 ng／ml。A期6例、B期68例、C期24例。耻骨后解剖性根治性前列腺切除术改进步骤包括：保留耻骨前列腺韧带;应用集束血管钳协助完成耻骨后血管复合体（耻骨前列腺韧带＋背静脉复合体）的结扎切断;采用“4＋1”方法行膀胱尿道吻合术（“4”指重建的膀胱颈与尿道黏膜对黏膜2、5、7和10点4针吻合、“1”指将缝扎耻骨后血管复合体的2-0缝线于重建的膀胱颈12点、距吻合缘0．5～1．0 cm处浆肌层穿过,将重建膀胱颈与耻骨后血管复合体固定）。结果98例手术顺利,平均手术时间3 h。术中平均出血量约400 ml,输血37例。3例发生直肠损伤,术中行直肠修补,均Ⅰ期愈合。术后病理报告：盆腔淋巴结阳性12例,切缘阳性12例,精囊浸润13例。术后随访3～68个月。术后3个月内PSA下降至≤0．2 ng／ml者95例。保留尿管2～3周,术后6个月有Ⅱ度以下尿失禁者8例,7例于6个月内恢复控尿,1例于术后12个月时仍有Ⅰ度尿失禁。术后发生尿道狭窄4例,通过腔内治疗治愈。3例复发后给予间断全激素阻断治疗者分别于术后57、60、64个月死于肿瘤复发与转移。结论改进的耻骨后解剖性根治性前列腺切除术可缩短手术时间、减少手术并发症,可有效切除肿瘤,同时保留控尿功能。     

保留尿道前列腺摘除术疗效观察(附31例报告)

为提高前列腺切除术的治疗效果，寻找一种既符合解剖生理特点、减少出血量及并发症的发生，又能使患者痛苦小、恢复快的手术方式，对31例前列腺增生患者采用保留尿道前列腺摘除术予以治疗，手术平均时间97．5min，术中平均输血250ml。随访0．5～2年，疗效满意。强调术前留置导尿管或术中放置尿道扩张器的必要性，认为采用睑板拉钩和缝扎牵拉腺体予以暴露，应用脑膜剪刀锐性分离前列腺与尿道、膀胱颈之间的组织和前列腺包膜，切除前列腺腺体，保留完整的尿道膀胱颈粘膜十分有效。     

经尿道前列腺切除术后并发症14例分析

目的探讨经尿道前列腺切除术后常见并发症的原因、预防和处理方法。方法2002年8月～2005年8月。我院经尿道前列腺电切术、经尿道前列腺电汽化术治疗良性前列腺增生症73例，出现14例并发症，包括术中严重出血2例，术后尿潴留5例，尿道狭窄2例，尿失禁2例，包膜穿孔致电切综合征2例，下肢深静脉血栓1例。结果1例严重出血者中转开放手术，无再次出血；1例经放置三腔单囊尿管，持续盐水或冰盐水膀胱冲洗，配合止血药物治疗，也未再次发生出血，术后排尿顺畅。5例术后尿潴留，其中2例再次经尿道前列腺电切手术，3例经尿道扩张术结合口服对症药物，5例均无再次尿潴留，术后1—3个月复查，尿流率〉15ml／s。2例尿道外口狭窄者定期尿道扩张1个月，排尿顺畅。2例尿失禁行永久膀胱造瘘术。2例包膜穿孔致电切综合征经迅速结束手术，积极对症治疗，生命体征平稳，术后排尿顺畅。1例下肢深静脉血栓2周后治愈。结论尿潴留、尿道狭窄是经尿道前列腺切除术后常见并发症，严格掌握手术指征，熟练细致地操作，及时有效地处理可以避免出现严重后果。     

改良的Madigan前列腺切除术

目的　对Madigan前列腺切除术 (MPC术 )进行改良 ,提高手术疗效。　方法　对 52例前列腺增生 (BPH)患者行MPC术 ,并进行手术改良。包括 :(1)显露膀胱颈及尿道起始部以避免或减少尿道损伤 ;(2 )联合膀胱顶部小切口以治疗中叶增生显著和 (或 )合并膀胱病变的BPH。结果　尿道完整或基本完整者 48例 ,术中出血较少 ,平均手术时间 12 0min。其中 3 5例获随访 ,随访时间 1～ 12个月 ,术后平均最大尿流率 18 9ml/s;8例患者手术前后行排尿期膀胱尿道造影 ,证实术后前列腺部尿道及膀胱颈完整 ,尿道较术前明显增宽。　结论　改良的MPC术减少了尿道损伤的发生 ,扩大了MPC术的适应证 ,手术操作简便、并发症少 ,疗效确切     

改良Madigan前列腺切除术50例体会

１９９３年１１月－１９９４年１２月对５０例良性前列腺增生症患者采用改Ｍａｄｉｇａｎ前列腺切除术。本手术特点在于钝性分离前列腺与尿道之间的组织，切除整个增生的腺体组织，同时也能将突入膀胱内中叶予以切除，而且保留完整尿道与膀胱颈，术后渗血少，膀胱冲洗后冲洗液很快清亮，并发症术。     

结扎膀胱下动脉改良Madigan前列腺切除术在临床的应用

为了探讨预防Madigan前列腺切除术中出血的方法，自1994年2月至1997年2月，在Madigan前列腺切除术中结扎膀胱下动脉35例，未结扎膀胱下动脉30例，术后57例随访3～36个月，结果显示结扎组术中出血明显减少，并认为改良术式具有不损伤尿道、保留性功能、简单易行的优点。对前列腺血管神经外科解剖及术中方法进行了讨论。     

Urethral injury secondary to pelvic fracture: anatomical and functional classification

OBJECTIVE: To develop a new functional and anatomical classification of urethral injury secondary to pelvic fracture. MATERIAL AND METHODS: Fifty-six male patients (20 children, 36 adults) with urethral injuries secondary to pelvis fracture were evaluated. Clinical examination, retrograde urethrogram immediately after the accident, operative findings in the emergency state, subsequent combined retrograde urethrography and suprapubic cystography, operative findings during urethral reconstruction and postoperative follow-up were critically reviewed retrospectively. RESULTS: A new classification of urethral injury secondary to pelvic fracture is proposed as a result of our findings: Type 1. Injury to the prostate; 1a. Proximal avulsion of the prostate; 1b. Incomplete or complete trans-prostatic rupture. Type 2. Stretching of the membranous urethra. Type 3. Incomplete or complete pure rupture of the prostatomembranous junction, supradiaphragmatic. Type 4. Incomplete or complete rupture of the bulbomembranous urethra, infradiaphragmatic. Type 5. Variable combined urethral injuries affecting more than one level of the urethra, prostatic and membranous or prostatomembranous and bulbomembranous, injury to proximal sphincteric mechanism combined with prostatic and/or membranous urethral injury. CONCLUSIONS: This anatomical and functional classification includes all types of urethral injuries secondary to pelvic fracture; moreover, it directs the attention towards evaluation of the urethral sphincteric mechanism, which is essential for the therapeutic and medicolegal aspects.     

双镜联合应用微创治疗尿道损伤

目的 探讨联合应用软性和硬性输尿管镜在微创治疗尿道损伤中的方法和疗效.方法 回顾性分析2003年6月至2011年12月在联合应用软性和硬性输尿管镜下 对16例尿道损伤患者实施腔内尿道会师术的临床资料.结果 16例患者中7例为球部尿道完全断裂,均会师成功,9例为膜部尿道断裂,7例成功,2例失败.随访5 ～ 48个月,2例膜部尿道断裂患者出现尿道狭窄,3例出现勃起功能障碍.结论 联合双镜行腔内尿道会师术,具有损伤小、并发症少、恢复快、手术操作简单等优点,是治疗尿道损伤安全有效的方法.     

改良Madigan前列腺切除术的并发症及防治

报道行改良Ｍａｄｉｇａｎ前列腺切除术１０７例的临床资料。年龄４８～８７岁，平均６９岁。术中和术后并发症有尿道损伤２５例，膀胱颈损伤２例，直肠粘膜损伤１例，精囊损伤１例，术中大量出血１例达６００ｍｌ。术后排尿不畅１例，轻度尿失禁５例，耻骨后间隙感染１例。对并发症的防治进行了讨论     

Urethral complications following ischiectomy in spinal cord injury patients: a urethral pressure study

Ischial ulcers are the most common pressure sores in spinal cord injury patients and ischiectomy often is used in the over-all management. Because a high percentage of spinal cord injury patients with total ischiectomy had complications of the membranous and proximal bulbous urethra, we evaluated urodynamically 15 ischiectomy patients in the supine and sitting positions to determine if pressure usually borne by the ischial tuberosities was transmitted to the membranous and proximal bulbous urethra. Of the 8 patients with a complete ischiectomy at least on 1 side 5 had problems of the membranous and proximal bulbous urethra, and the average urethral pressure increase from the reclining to the sitting position was 111 cm. water. The increase in urethral pressure was not related to any change in bladder or abdominal pressure. The average urethral pressure increase in the nonischiectomy patients was only 16 cm. water and none had any problems of the membranous and proximal bulbous urethra. Some retrospective clinical studies have implicated ischiectomy in the development of these urethral complications. Our urodynamic data lend some direct evidence that a more complete ischiectomy results in excessive urethral pressure with the patient in the sitting position, thereby predisposing the membranous and proximal bulbous urethra to problems related to ischemia. Five of the 8 patients with more complete ischiectomy and 1 with bilateral partial ischiectomy had high urethral pressures and complications, such as pseudodiverticulum, diverticulum and dilatation. More incomplete ischiectomy should be used to obviate this urethral damage.     

Brunn's nests and glandular metaplasia: normal urothelial variants in the supramontanal prostatic urethra

Sections of 292 transurethral prostatic resection specimens and 52 intact prostatic urethral specimens from male patients 10 to 89 years old were examined for the presence of Brunn's nests and glandular metaplasia in the urothelium of the supramontanal prostatic urethra. The complex pitted urethral mucosa at and below the verumontanum was not assessed. Either or both lesions were present focally in 211 transurethral prostatic resection specimens (72 per cent) and in 51 intact urethral specimens (97.5 per cent). Brunn's nests and glandular metaplasia consisted chiefly of transitional cells but in 47 transurethral prostatic resection cases glandular metaplasia contained prostatic acinar-type cells and in 1 case intestinal-type goblet cells were noted. Brunn's nests and glandular metaplasia were associated with inflammation in only 27 per cent of the cases and were not associated with dysplasia or urethral tumors except for 1 benign papilloma. We conclude that Brunn's nests and glandular metaplasia are so common in the supramontanal prostatic urethra that they represent normal urothelial variants in this segment of the urinary tract.     

前尿道损伤早期处理的治疗体会

目的 探讨前尿道损伤早期处理方式的选择.方法 回顾性总结2001年9月至2011年6月我科47例尿道损伤患者的临床资料,分析术后并发症及排尿情况.结果 47例患者随访41例,随访时间1～84个月,术后2～6周拔除尿管;采用膀胱穿刺造瘘术3例,留置导尿8例,输尿管镜尿道置管术18例,腔镜下尿道会师术4例,尿道修补术或断端吻合术14例(术后会阴伤口感染2例,尿漏2例),术后31例排尿良好,尿道狭窄10例,失访6例.结论 前尿道不全断裂首选输尿管镜尿道置管术,不成功时行腔镜下尿道会师术,而对于前尿道断裂仍宜行尿道断端吻合术.     

DOES PROSTATE TRANSITIONAL CELL CARCINOMA PRECLUDE ORTHOTOPIC BLADDER RECONSTRUCTION AFTER RADICAL CYSTOPROSTATECTOMY FOR BLADDER CANCER?

Purpose

We determined if urethral preservation and orthotopic bladder replacement in patients with transitional cell carcinoma within the prostatic urethra or prostate placed these patients at risk for urethral recurrence or death.

Materials and Methods

The clinical course of all patients undergoing urethral preservation and orthotopic bladder replacement was reviewed. The urethra was sacrificed only if the distal prostatic urethral margin was positive for transitional cell carcinoma. The pathological T stage and the grade of the primary malignancy, local recurrence, site of recurrence (urethral, pelvic, distant) and death were documented.

Results

Of 81 patients, 70 were evaluated (June 1996) with a mean followup of 35 months. Of the 70 patients 48 were alive without evidence of disease for a mean of 38 months (range 8 to 107) and 5 died without evidence of disease. Eight of these 53 patients (15%) had prostatic involvement (carcinoma in situ in 6, intraductal carcinoma in 1 and stromal invasive transitional cell carcinoma in 1). Of the 70 patients 17 had disease recurrence (13 died of disease and 4 are alive, 1 of whom had urethral recurrence without initial prostatic transitional cell carcinoma). Of the 17 patients (35%) 6 had transitional cell carcinoma prostatic involvement (carcinoma in situ in 4 and stromal invasion in 2), and 5 of these 6 died, none with or of urethral recurrence but of the primary bladder pathology. Of these 5 patients 1 had stromal invasive transitional cell carcinoma of the prostate and experienced a bulbar urethra recurrence at 1 month and a pelvic recurrence at 3 months, and died at 5 months. Death was not secondary to the urethral recurrence. Thus, of the 14 patients who had prostatic transitional cell carcinoma, only 1 had urethral recurrence (7%), and this recurrence did not present as the cause of death.

Conclusions

The guidelines for urethral resection can be relaxed, increasing the opportunities for orthotopic reconstruction, without placing the patients at increased risk for death of transitional cell carcinoma.     

What is the ratio of urethral recurrence risk after radical cystoprostatectomy for bladder cancer?

Objective: There is always a risk of urethral recurrence after radical cystoprostatectomy in patients with bladder transitional cell cancer. Taking these risk factors of urethral recurrence into account, orthotopic neobladders or urinary diversions without using the urethra are performed. But urethral tumour recurrence occurs much less than the expected. We assessed the etiological factors that affect the urethral recurrence in orthotopic and nonorthotopic urinary diversion cases. Methods: Sixty-four patients with bladder cancer who underwent radical cystoprostatectomy and urinary diversion between 1994 and 2002 were included this study. Conventional risk factors effecting the selection of operation type and urethral recurrence were evaluated in these patients. Cystoscopy and biopsy were done and pathologic specimen was obtained preoperatively, and cystoscopy and urethral washout cytology were done postoperatively. Routine bladder biopsies were done in uncertain cases at follow-up. Risk factors increasing the urethral recurrence are as follows: papillary and multiple tumours, tumour invading bladder neck and trigone, extensive CIS, prostatic stromal and urethral invasion, positive surgical margin and history of upper urinary tract tumour. In 31 patients having one or more of these criteria, continent nonorthotopic urinary diversion was performed, but 33 patients without these risk factors underwent orthotopic urinary diversion. Simultaneous urethrectomy was not done in any of these patients. Results: Among the patients who underwent radical cystoprostatectomy, none was with positive surgical margin in the distal end of the prostatic urethra. In preoperative cystoscopy, tumoural mass was seen near to collum in eight patients and in the prostatic urethra in three patients. Histopathological examination of cystoprostatectomy specimen displayed transient epithelial cell carcinoma of prostatic urethra in three patients, transient epithelial cell metaplasia inside the prostate in five patients and invasion to the urothelium of bladder neck in three patients. There were not any transient epithelial cell cancer metastases in prostatic stroma in any of these patients. One patient underwent urethrectomy, since atypical cells were observed in postradical prostatectomy urethral washout cytology but there was no tumour found in pathological examination of the specimen. Therefore, urethral tumour recurrence did not occur after 25 months follow up. Conclusion: These findings suggest that some of the conventional risk factors of urethral recurrence were exaggerated. We may also conclude that there is no need for prophylactic urethrectomy unless there is urethral cancer or cancer in the surgical margin. But if utilization of urethra is planned, evaluation of prostatic stroma by TUR biopsies and urethral anastomose margin by frozen section during the operation is necessary.     

The nature of urethral injury in cases of pelvic fracture urethral trauma

PURPOSE: We examine the urethral injury associated with pelvic fracture that is said to be due to a shearing force through the membranous urethra which inevitably destroys the urethral sphincter mechanism. MATERIALS AND METHODS: A total of 20 asymptomatic cases were prospectively studied, including symptomatically, radiologically, endoscopically and urodynamically, 1 to 4 years after an apparently successful anastomotic repair of a pelvic fracture urethral distraction defect. RESULTS: There was evidence of urethral sphincter function, including urodynamically in 11 (55%), endoscopically in 13 (65%) and functionally in 17 (85%) patients. CONCLUSIONS: These findings, coupled with surgical observation, suggest that the urethral injury associated with pelvic fracture is avulsion of the membranous urethra from the bulbar urethra rather than a shearing through the membranous urethra, and that some degree of urethral sphincter function is preserved in a significant percentage of patients.     

排尿期尿道压力测定在膀胱出口梗阻疾病诊断中的应用

目的　研究排尿期尿道压力测定 (MUPP)在膀胱出口梗阻 (BOO)疾病诊断中的应用。方法　下尿路梗阻患者 4 5例 ,其中良性前列腺增生 (BPH) 38例 ,前尿道狭窄 3例 ,女性尿道狭窄 4例。对照组为健康志愿者 4例。按常规方法行压力 流率测定 ,静态尿道压力测定 (UPP)及MUPP。以压力下降梯度计算梗阻程度。数据分析采用t检验。研究不同疾病梗阻患者尿道压力下降点及下降梯度 ,MUPP对梗阻部位的诊断价值 ,MUPP与压力 流率研究对可疑梗阻诊断的比较 ,MUPP与压力 流率研究判断梗阻程度的比较。　结果　对照组 2例男性 ,外括约肌以上尿道内压与膀胱内压力相等 ,尿道压在外括约肌处快速下降 ;2例女性 ,膀胱压与全部尿道压几乎相等 ,尿道末端 1cm处尿道压下降。 38例BPH患者最大排尿压增高 ,平均为 (99.33± 4 1.0 9)cmH2 O(1cmH2 O =0 .0 98kPa) ,尿道压力在膀胱颈或前列腺尖部下降。 3例前尿道狭窄患者后尿道近端压力与膀胱压相等 ,球部及远端尿道压力下降。 4例女性远端尿道狭窄患者尿道压力在狭窄远端区域下降。BPH、前尿道狭窄、女性远端尿道狭窄平均MUPP压力下降梯度分别为 (71.6 3± 37.4 1)cmH2 O、(43.5 1± 15 .71)cmH2 O、(41.4 8± 17.34)cmH2 O ,与正常对照组的 (2 4 .2 5± 2 .99)cmH2 O相比 ,差别有