前列腺脓肿外科处理的系统评价

目的：系统评价近10年前列腺脓肿诊治，为临床提供参考。方法：检索PubMed2000．0l～2011．04前列腺脓肿诊治文献，纳入合格文献，系统评价其外科处理。结果：病例数≥5例16个研究纳入行定量荟萃分析，均为回顾性病例分析，研究质量低。总计311例（5～77）患者，年龄分布10天～83岁，发病低龄化。病原体包括真菌、细菌两类，后者以G＋球菌（葡萄球菌属）为主，次为p杆菌（克雷伯菌属），少见病原体亦有发病．地区差异明显。易感因素概括为局部与全身因素两类，分别以糖尿病、肝硬化与下尿路操作、尿路感染最常见。诊断涉及症状评估、体格检查、病原体鉴定、影像学检查（TRUS、骨盆CT、MRI）等。治疗包括一般处理、抗生素疗法与外科引流。手术径路有经皮经会阴、经直肠与经尿道。经会阴／经直肠行EUS、TRUS或c’F引导下细针穿刺抽吸、留置导管引流或切开引流；经尿道行TUR、TURP或TuIP引流；穿刺抽吸失败转为经尿道或经会阴切开引流；部分病例行尿流改道。无对比研究而未能比较何种术式更优。除死于严重并发症外，均结局良好。结论：应基于临床评估，结合TRUS／盆腔CT与实验室检查确诊前列腺脓肿。抗生素使用宦有病原学依据。视具体情况个体化处理：保守治疗；EUS、TRUS或CT引导下穿刺抽吸、留置导管引流；经尿道微创引流；若脓肿穿破前列腺包膜或肛提肌宜经会阴切开引流。外科引流以“准确、彻底、无残留”为原则。术后应密切随访。

A Systematic Review of Surgical Management for Prostatic Abscess

Objective:To systematic review surgical management of prostatic abscess literatures in the past decade based on PubMed.Methods:All literature retrievals were updated from January 1st 2000 to April 10th 2011 in PubMed database.Articles were screened according to the predefined inclusion and exclusion criteria.The characteristics of literature.diagnosis and management were reviewed.Results:16 studies(≥5 patients) which included 311 patients(range from 5 to 77 cases)were included,and metaanalysis were performed.All were retrospective cases analysis, and the qualities were low.The patients’ ages ranged from 10 days to 83 years old.The incidence increased in younger patients.The pathogens included fungi and bacteria,the most of later was gram-positive cocci (such as Staphylococci),the second one was gram-negative bacillus(such as Klebsiella),there were also some minority pathogens,and the differences of districts were quite obvious.The predisposing factors were summed up to regional and systematic conditions,the most were diabetes mellitus and hepatocirrhosis,manipulations of lower urinary tract and urinary tract infections respectively.Diagnostic procedures included evaluating of symptoms and signs,physical examination,identifying of causative agents,medical imaging examinations(TRUS.pelvis CT. MRI).Therapeutic options included routine managements,antibiotic therapies and surgical drainages.EUS.TRUS or CT guided fine needle aspiration or indwelling catheter for drainages,incision and open drainages were performed by transperineal or transrectal routes.TUR.TURP or TUIP for drainages were performed by transurethral approaches.The failed cases of needle aspiration received transurethral mini-invasive drainages or transperineal open drainages.Some patients received urinary diversions simultanely.The best modus operandi could not be concluded because of there were no enough comparative data.Except for few cases died from severe complications.the outcomes of the majority cases were good.Conclusions:The standard diagnostic programs of prostatic abscess are combination the TRUS,pelvis CT examinations and laboratory tests based on clinical assessment.The application of antibiotic therapies should base on definite evidence of pathogens.According to individual conditions,conservative treatment.EUS,TRUS or CT guided fine needle aspiration,indwelling catheter or transurethral mini-invasive operations for optimal drainages should be performed.Transperineal incision and open drainage should be consid- ered when the abscess has penetrated beyond the prostatic capsule or penetrated through the levator ani muscle. Whichever procedure would be carried out,abscess drainage must be exact.thorough and with no residual.The patients should be close followed up.