2000～2011年前列腺脓肿诊治文献的循证评价

目的循证评价近十年前列腺脓肿诊治文献,为临床实践提供参考。方法依据循证医学原理,应用文献计量学方法,全面检索PubMed数据库2000年1月～2011年4月前列腺脓肿诊治研究,纳入合格文献并评估文献质量、提取有效数据后以OpenO ce.org 3.8 Calc建立数据库进行分析,系统评价前列腺脓肿诊治文献。结果①初检共获得文献205篇,最终纳入符合标准的文献81篇,合计388例(4.79例/篇)患者。患者年龄分布为10天～83岁,除2篇文献涉及诊断试验外,其余79篇文献均为外科干预性研究。②81篇文献中无一篇为临床对照试验,病例数≥5例的16个研究(共311例)均为回顾性病例分析,其余65个研究为个案报道。③美国共发表13篇文献居首位(占16.5%),欧美国家共发表36篇(占44.44%),我国大陆研究明显薄弱,仅发表2篇英文研究。④前列腺脓肿发病低龄化。病原体包括真菌、细菌两大类,后者以G+球菌(葡萄球菌属)为主,次为G–杆菌(克雷伯菌属),少见病原体亦有发病,病因复杂且不同地区差异明显。易感因素概括为局部与全身因素两类,以糖尿病、肝硬化与下尿路操作、尿路感染最常见。⑤诊断涉及症状评估、体格检查、病原体鉴定、影像学检查(TRUS、下腹或骨盆CT、MRI)等。治疗包括一般处理、抗生素疗法与外科引流;手术径路分为经皮经会阴、经直肠与经尿道;经会阴/经直肠行TRUS、EUS或CT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,部分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。⑥由于缺乏对比资料,未能获得不同术式孰优孰劣的结果。⑦除死于相关并发症外,结局良好。结论①前列腺脓肿文献丰富,但质量不高,均为回顾性研究或个案报道,且以欧美国家报道为主。②发病低龄化但任何年龄皆可发生,以G+球菌(葡萄球菌属)为主,次为G–杆菌(克雷伯菌属),地区差异明显。③易感因素以糖尿病、肝硬化与下尿路操作、尿路感染最常见。④在临床评估的基础上,以TRUS/盆腔CT/MRI与实验室检查确诊本病。⑤抗菌素使用宜有病原学依据,注意大肠埃希菌耐药性问题。视具体情况可个体化采用保守治疗、TRUS/EUS或CT引导下穿刺抽吸、留置导管引流或经尿道微创引流;若脓肿穿破前列腺包膜或穿透肛提肌则宜经会阴切开引流;术后应密切随访。

Evidence-Based Evaluation on Global Clinical Research Literatures about Prostatic Abscess in the Past Decade

Objective To review and evaluate the global clinical research literatures about the surgical manage- ment for prostatic abscess in the past decade, so as to provide useful information for clinical practice. Methods Based on the principles of evidence-based medicine, and the methods of bibliometrics, the PubMed database was searched from January 1st 2000 to April 10th 2011. The literatures about prostatic abscess were screened according to the predefined inclusion and exclusion criteria, the quality was assessed, the valid data were extracted and then systematical evaluation was performed after the establishment of the database with OpenOffice.org 3.8 Calc. Results a） A total of 205 articles were found initially and 81 were finally included with the total 388 cases involved （on average, 4.79 cases per paper）. The patients＇ ages ranged from 10 days to 83 years old. Two studies were diagnostic tests, and all the other 79 were surgical in- tervention studies; b） There was no controlled clinical trail. A total of 16 studies involving more than 5 cases for each and 311 cases in all which were retrospective case analyses, all the other 65 were individual case reports; c） American scholars published 13 papers （16.5%）, ranked as the first. American and European scientists published 36 papers （44.44%）. Chinese scholars published quite fewer studies, of which only 2 were in English; d） The incidence increased in younger patients gradually. The pathogens included fungi and bacteria. Most bacteria were gram-positive cocci （such as Staphylococci）, fol-lowed by gram-negative bacillus （such as Klebsiella）. There were also some minority pathogens. The pathogens were com- plex and quite diverse in different districts. The predisposing factors included both regional and systematic conditions, with diabetes mellitus, hepatocirrhosis, manipulations of lower urinary tract and urinary tract infections as the common; e） The diagnostic procedures included evaluation on symptoms and signs, physical examination, identification of pathogens, and medical imaging examinations （TRUS, CT, MRI）. The therapeutic options included routine managements, conserva- tive antibiotic therapies and surgical drainages. The surgical routes were transcutaneous, transperineal, transrectal, and transurethral. The fine needle aspiration, indwelling catheter drainage, or incision and drainage were performed under the guidance of TRUS, EUS or CT through transperineal or transrectal routes. The TUR, TURP or TUIP drainages were performed through transurethral route. The failed cases of fine needle aspiration were then treated by transurethral or transperineal incision and drainages, and some patients were also treated by urinary diversion; f） The best surgical method could not be concluded for lack of controlled data; and g） Few cases died from severe complications, and the outcomes of the majority cases were good. Conclusion a） The literatures about prostatic abscess are abundant but of low quality, with all retrospective studies or individual case reports, and most are published by American and European scholars; b） The prostatic abscess affects all ages but tends to increase in the young. Most pathogens are the gram-positive cocci （such as Staphylococci） ranked as the top and followed by gram-negative bacillus （such as Klebsiella）, and the pathogens are ob- viously diverse in different districts; c） The predisposing factors are commonly seen as diabetes mellitus, hepatocirrhosis, manipulations of lower urinary tract and urinary tract infections; d） The combination of TRUS, CT or MRI and labora- tory tests based on clinical evaluation is the standard diagnosis procedure; e） The application of antibiotic therapies should be conducted in line with the definite evidence of pathogens, and the problem of drug-resistant Escherichia coli should be closely concerned. The individualized therapies, such as conservative therapy, TRUS/EUS or CT guided needle aspiration, indwelling catheter drainage, or transurethral minimal invasive drainage, should be performed according to the individual condition. When abscess is seen in capsula prostatica and levator ani muscle, it is suggested to perform transperineal incision and drainage. The patients should be closely followed up.