Jepsen J V, Bruskewitz R C
Department of Surgery, University of Wisconsin Hospital and Clinics, Madison 53792, USA.
Urology. 1998 Apr;51(4A Suppl):23-31. doi: 10.1016/s0090-4295(98)00052-1.
A new era in the surgical management of benign prostatic hyperplasia (BPH) has emerged in the past decade. A variety of less invasive treatment modalities have been introduced and well-established surgical treatments are being reassessed. Although progress has been made in the management of BPH, the substantial economic burden to the healthcare system caused by BPH emphasizes the importance of cost-effective treatment. Open prostatectomy is the most efficient BPH treatment for relieving symptoms and improving uroflow, but it is also the most invasive and morbid. Transurethral resection of the prostate (TURP) is still the "gold standard" for treatment of BPH, but open prostatectomy has been reported to have a lower perioperative mortality than TURP, and low retreatment rates reduce the long-term cost. The morbidity associated with TURP, such as impotence or urinary incontinence, has been reduced in recent years while new features, such as performing TURP under local anesthesia and bipolar electrosurgical techniques, have been introduced. Transurethral electrovaporization of the prostate (TVP) is a recent modification of TURP that has rapidly gained popularity. TVP greatly reduces TURP syndrome, provides good hemostasis, and may reduce catheterization and hospitalization times. Transurethral incision of the prostate (TUIP) is another safe and inexpensive procedure that is well-documented and comparable to TURP in long-term efficacy. TUIP is an underused procedure with which the newer, less invasive treatments should be compared. Whereas the well-established surgical treatments primarily relieve obstruction by tissue ablation, some of the newer treatment modalities may ameliorate lower urinary tract symptoms (LUTS) with minimal urodynamic change. In some of the newer nonresection treatments, no major significant postoperative reduction in prostate volume can be demonstrated. Laser treatments are based on a broad variety of techniques, generators, and fibers, of which most have initially demonstrated promising results. Well-known techniques include visually laser-assisted prostatectomy (VLAP) and interstitial laser coagulation (ILC). The laser techniques are generally not as effective as TURP, but are safe under local anesthesia on an outpatient basis with low complication rates. Transurethral microwave thermotherapy of the prostate (TUMT) and radiofrequency transurethral needle ablation (TUNA) are minimally invasive, safe new therapies. There is some evidence that the procedures create long-term, alpha-adrenoceptor-like blockade. Complications, except for transient catheterization in up to 40% of patients, may be practically nonexistent. The cost is difficult to estimate and the long-term outcome is still to be assessed. If the newer, less invasive treatment modalities provide stable long-term results and competitive costs, they will be tempting alternatives to prostate resections and may also challenge medical therapy.
在过去十年中，良性前列腺增生（BPH）的外科治疗进入了一个新时代。各种侵入性较小的治疗方式已被引入，同时人们也在重新评估已成熟的外科治疗方法。尽管BPH的治疗已取得进展，但BPH给医疗系统带来的巨大经济负担凸显了成本效益治疗的重要性。开放性前列腺切除术是缓解症状和改善尿流最有效的BPH治疗方法，但它也是侵入性最强、并发症最多的。经尿道前列腺切除术（TURP）仍然是BPH治疗的“金标准”，但据报道，开放性前列腺切除术的围手术期死亡率低于TURP，且再次治疗率低可降低长期成本。近年来，与TURP相关的并发症，如阳痿或尿失禁，已有所减少，同时还引入了一些新特点，如在局部麻醉下进行TURP和双极电切技术。经尿道前列腺电汽化术（TVP）是TURP的一种最新改良术式，已迅速普及。TVP可大大减少TURP综合征，止血效果良好，并可能缩短导尿和住院时间。经尿道前列腺切开术（TUIP）是另一种安全且费用低廉的手术，有充分的文献记载，其长期疗效与TURP相当。TUIP是一种未得到充分利用的手术，应将其与更新的、侵入性较小的治疗方法进行比较。虽然已成熟的外科治疗主要通过组织切除来缓解梗阻，但一些更新的治疗方式可能在尿动力学变化最小的情况下改善下尿路症状（LUTS）。在一些更新的非切除治疗中，术后前列腺体积并无明显显著缩小。激光治疗基于多种技术、发生器和光纤，其中大多数最初都显示出了有前景的结果。知名技术包括直视下激光辅助前列腺切除术（VLAP）和间质激光凝固术（ILC）。激光技术一般不如TURP有效，但在门诊局部麻醉下操作安全，并发症发生率低。经尿道前列腺微波热疗（TUMT）和射频经尿道针刺消融术（TUNA）是微创、安全的新疗法。有证据表明，这些手术可产生长期的α -肾上腺素能受体样阻滞作用。除了高达40%的患者会出现短暂导尿外，几乎不存在其他并发症。成本难以估计，长期疗效仍有待评估。如果更新的、侵入性较小的治疗方式能提供稳定的长期效果且成本具有竞争力，它们将成为前列腺切除术颇具吸引力替代选择，也可能对药物治疗构成挑战。
