医学精品课件：（参考翻译）14.3 BPHnephrosis

何卫阳

重庆医科大学附属第一医院泌尿外科UrinaryObstruction尿路梗阻&BenignProstaticHyperplasia良性前列腺增生(BPH)IntroductionEtiologyClinicalManifestationDignosisTreatmentBenignprostatichyperplasia(BPH)AnatomyandphysiologyTheprostate前列腺

isapartofthemalereproductivesystem生殖系统Functionistostoreandsecreteaclearfluid(Prostaticfluid前列腺液)thatconstitutes10-30%ofthevolumeoftheseminalfluid精液Passwayofurine

locatedbelowthebladder膀胱Infrontoftherectum直肠surroundingtheurethra尿道AnatomyandphysiologyDefinitionBPHisanonmalignant非恶性的enlargementoftheprostateglandcausedbycellularhyperplasia细胞增生ofbothglandular腺andstromalelements基质元素thatleadstotroublesome麻烦的

lowerurinarytractsymptoms(LUTS)insomemenItisthemostcommonbenigntumorinmenandisnotaprecancerouscondition癌前病变

Zonal带状Anatomy(McNeal-1972)

PeripheralZone边缘带70%oftheyoungadult(60-70%ofCaP)CentralZone中央带25%(5-10%CaP)TransitionZone过渡带5%(10-20%CaP)BPHEtiologyofBPHAndrogens雄激素AgeingLifestyleHereditary遗传的(genetic)/Race种族Androgen(Functionaltesticle睾丸):theprostateisanandrogendependentorgan,thusthehyperplasiaofprostaterelyonfunctionaltesticle.Theeunuch太监

Ageing:Maleelderthan50aremoreliable有倾向的toBPH,andtheincidenceincreasesastheageincreases.LifeStyle&Race

Menwholeadawesternlifestylehaveamuchhigherincidenceofsymptomatic症候的BPHthanmenwholeadatraditionalorrurallifestyle

Animalprotein,Greentea,tomato,bean

Americanblacks>whites>Africablacks>Asians(prostatacancer前列腺癌)AdaptedfromNordlingJetal.InBenignProstaticHyperplasia.Plymouth,UnitedKingdom:HealthPublication,2001:107-166.PathophysiologyofClinicalBPH:OverlappingbutIndependentFeaturesSlideI.2LUTSEnlargedprostateBOOLUTS:lowerurianrytracksymptom下尿路症状BOO:bladderoutletobstruction膀胱出口梗阻LowerUrinaryTractSymtoms-LUTSVoiding排泄/Obstructivesymptoms:Hesitancy犹豫Intermittency间歇Incompletevoiding排泄不完全Weakurinarystream弱尿流Straining竭力topassurineProlongedmicturition长时间排尿Terminaldribbling尿末滴沥LowerUrinaryTractSymtoms-LUTSStorage储存/Irritative刺激symptoms:Frequencyofurination尿频Nocturia夜尿Urgency急迫(compelling强迫needtovoidthatcannotbedeferred推迟)Urgeincontinence急迫性尿失禁ClinicalManifestation

Irritationsymptoms:

nocturia夜尿frequency尿频urgency尿急urgentincontinence尿失禁

TheeffectivevolumeofthebladderdecreaseLowbladdercompliance顺从forlongtimeobstructionObstructionsymptoms:

Hesitancy犹豫Intermittency间歇Incompletevoiding不完全排尿Weakurinarystream弱尿流Strainingtopassurine竭力排尿Prolongedmicturition排尿延长Terminaldribbling尿末滴沥

Complications:

InfectionCysticcalculusHematuriaHydronephrosisChronicrenalfailureInguinalhernia&AnalprolapseDiagnosisHistory:(LUTS).UseIPSS国际前列腺症状评分PhysicalExamination:digitalrectalexam直肠指检prostatitis前列腺炎:tenderness,soft,bogginess泥沼样;prostatecancer:harder;Abdominalexam-distendedbladder膀胱膨胀Urinalysis尿分析-bydipstick量油计androutinemicroscopy常规显微镜,urinecultureandsensitivitytoinfectionsandhematuria血尿SerumPSA前列腺特异抗原-optionaltoProstateCancerDiagnosisUppertractimaging(IVP静脉肾盂造影,CT,U/S超声检查)onlyinpresenceof提示concomitant伴随urinarytractdiseaseorcomplications-hematuria,UTI尿路感染,renalinsufficiency肾功能不全,stonediseaseCystometrograms膀胱内压测量图andurodynamicprofile尿动力学概要-forpatientswithsuspectedneurologicdiseaseorthosewhofailedprostatesurgeryFlowrate流量,post-voidresidualurinedetermination排泄后余尿量测定andpressureflow逆流IPSSMild(score0-7)Moderate(score8-19)Severe(score20-35)DifferentialDiagnosis

Pre-prostatic前列腺前的Urethralstricture尿道狭窄Bladderneckcontracture膀胱颈挛缩BladdertumorsNeurogenicbladder神经性膀胱功能障碍Bladdercalculi结石UrinarytractinfectionsProstaticProstatitis前列腺炎ProstateCancer前列腺癌ManagementofBPHGoal-rapidandsustained持续的reliefofsymptoms:Decreasebladderoutlet出口obstructionImprovebladderemptying排空ReverserenalinsufficiencyPreventfutureepisodes发作ofgrosshematuria肉眼血尿,UTIandurinaryretention尿潴留Qualityoflifeandsexuality性欲Managementdependsonseverity严重程度TreatmentofBPHLifestylemodification改变生活方式WatchfulWaitingMedicalTherapyPhytotherapy植物疗法(alternative)SurgicalTreatment:Conventional传统的SurgicalorMinimallyInvasiveTreatment微创手术治疗LifestyleChangesEnricheddietwithampleamountsoffreshfish,fruitsandvegetablesReducestressregularExercise

WeightwithinnormallimitsLimitfluidintake,decreasebladderirritants-caffeine咖啡因,alcohol;avoidanticholinergicdrugs抗胆碱药物,narcotics麻醉剂andskeletalmusclerelaxants肌松药Seeyourdoctorifyoudevelopnocturia夜尿Beawareofinteraction相互作用ofbotanical植物/中药andmedical药物/西药treatmentWatchfulWaitingTheriskofprogressionorcomplicationsisuncertainInmenwithsymptomatic有症状的BPH,progressionisnotinevitable并非不可避免的andsomemenundergospontaneous自发性improvementorresolution解决oftheirsymptomsAppropriatemanagementofmenwithmildsymptomscores(0-7)MedicalTreatmentAlphablockersAlpha-blockersareaclassofdrugsconsideredtobefirst-linetreatmentforBPH.Alpha-blockersworkbyblockingthealpha-1areceptorintheprostateandthebladder.Alpha-blockersrelaxthemusclesofthebladderneckandprostate.Alpha-blockersareveryeffectiveinthetreatmentofBPH;roughly50percentofmenseeanimprovementinsymptomswithinthefirst48hourstooneweekaftertherapyinitiation开始.However,patientsmayonlyretainsymptomreliefforupto4years,andalpha-blockersdonotshrink收缩theprostateorslowdownBPHprogression.Alpha-blockersarealsousedtotreathighbloodpressure.Examplesofalpha-blockersusedinthetreatmentofBPHinclude:Examplesofalpha-blockersusedinthetreatmentofBPHinclude:

Terazosin

特拉唑嗪

(Hytrin

高特灵)Doxazosin

多沙唑嗪

(Cardura

可多华,

CarduraXL)Alfuzosin

阿夫唑嗪

(Uroxatral)Tamsulosin

坦索罗辛

(Flomax)Silodosin

西洛多辛

(Rapaflo)CompanyLogo5α-Reductase还原酶inhibitorsCombinationTherapyCompanyLogoSurgicalTreatment

Forpatientwhodonotexperienceresponsetomedicaltreatmentin12-24months;forthosewhosesymptomsprogressTURP(transurethralresectionoftheprostate经尿道前列腺电切术)-GoldstandardSurgicalTreatment

SurgicalTreatment

OpenProstatectomyNotdoneroutinelyWhenprostatetoolargeforTURP(>100mL)MinimallyInvasive

SurgicaltreatmentTUMT-transurethralmicrowavetherapy经尿道微波热疗TUNA-transurethralneedleablation经尿道射频消融UrinaryStents尿道支架LaserProstatectomy-Holepholmiumlaserenucleationoftheprostate钬激光前列腺剜除术MinimallyInvasive

SurgicaltreatmentTUMT(transurethralmicrowavetherapy)Performedasasingleoutpatient门诊的visitunderlocalanesthesiaandanoralanalgesic口服镇痛药.Improvessymptomscoresandurinaryflowrates尿流率MinimallyInvasive

SurgicaltreatmentTUNA

(transurethralneedleablation)Anofficeprocedureperformedunderlocalanesthesia-improvessymptomscoresandurinaryflowratesItusesspeciallydesignedcatheter导管throughwhichinterstitial间隙的radio-frequencyneedlesaredeployed展开fromthetip尖端ofit.Theywillheatthetissueresultingincoagulativenecrosis凝固性坏死Theentireprocedurelasts30-60minutes

Acatheterisleftfor1-4daysaftertheprocedureMinimallyInvasive

SurgicaltreatmentIntraurethralStentLimitedlongtermexperienceIncreasesurineflowratesbutcausessecondaryobstructionbyexuberant丰富granulationtissue肉芽组织growththroughandaroundthestentDifficulttoremoveit;formationofbladdercalculiin50%ofpatientsUsuallyforpatientswithlimitedlifeexpectancy预期寿命thatarenotgoodsurgicaloranestheticcandidates候选AbandonedbymosturologistsMinimallyInvasive

SurgicaltreatmentLaserTherapy-“Thewaveofthefuture”Neodymium:yttrium-aluminium-garnet(Nd:YAG)-VisualLaserablationoftheProstateThefinalresultiscoagulativenecrosisoftheprostaticurethraandadjacentinnerprostatictissue.Theobstructivetissuestartstoslough4-8weekspost-opleadingtoanopenprostaticurethra

Greenlightlaser-LaserVaporization气化

ofProstate-causesrapidvaporizationofthesuperficialtissue,withaminimalrim(2mm)ofcoagulationAdvantage:immediateTUR-likeefectoftheprostaticurethra,resultinginshorterdurationofFoleycatheterizationintheinitialpost-opperiodHolmium-YAG-Laserresection切除术-prostaticlobesareresectedintomultiplesmallprostatechipsthatfallintothebladder,similartostandardelectrocauteryTURPAdvantage:immediateanatomicalpatencyoftheprostaticurethra,resultinginshorterdurationofFoleycatheterizationandhigherpeakflowratesintheinitialpost-opperiod

InSummaryBPH(Benignprostatichyperplasia)becomesincreasinglycommonasmenageManymenwithBPHareasymptomatic无症状的

orhaveonlymildsymptoms,andmaynotrequiretherapyMenwhodevelopupperorlowertractinjurywillrequiresurgeryAlpha-adrenergicantagonistsprovideimmediatetherapeuticbenefitsandarefirstlinetreatmentforsmallerprostates<40mLandmildsymptoms5-a