簡國龍chien, kuo-liong臺灣大學:預防醫學研究所楊登凱Yang, Teng-KaiTeng-KaiYang2010-06-022018-06-292010-06-022018-06-292009U0001-0608200922001700http://ntur.lib.ntu.edu.tw//handle/246246/184842背景與目標：經尿道前列腺刮除術(TURP)一直是良性攝護腺肥大患者最標準、最主要的手術之一。光選擇性攝護腺組織汽化術(PVP)由於穩定度高，副作用少，近來成為風行的替代性治療方式。由於一些限制，新一代的高功率綠光雷射 (The Greenlight HPSTM) 便因應而生，但相關的文獻評估並不完整。本研究的目的，是要整理高功率綠光雷射患者的術後資料，進一步與經尿道前列腺刮除術作比較，評估其療效及安全性。法: 一百一十五位病患的選取來自一段期間內的一家醫院。手術種類的選擇經醫師詳細解說後，由病患自行決定。主要結果設定為國際攝護腺症狀指數、生活品質指數、最大尿流速及解後殘尿量的改善程度，各個主要結果與潛在干擾因子作多變數模型分析。另外利用包括年齡、身體質量指數、攝護腺體積及攝護腺特異抗原等因子作次族群分析。果：兩組的基本特徵在身高、體重、教育程度及年收入上有差異。主要結果方面，相較於TURP，國際攝護腺症狀指數(13.6 比上 11.7，P=0.046)及生活品質指數(2.91 比上 2.5，P=0.034)在PVP組改善程度較大；術中及術後的觀察發現，PVP組的失血量，鈉離子的改變量及平均住院天數都較少，平均12個月的追蹤後，發現TURP組的尿道狹窄的發生率較高(3.3% 比上14.5%，P=0.033)，多變數模型的分析在校正IPSS基礎值、年齡、身體質量指標、年收入、教育程度及攝護腺特異抗原密度後，手術種類仍是國際攝護腺症狀指數的預測因子(β=2.70, 95信賴區間為 0.71到4.69)。在次族群的分析結果，則發現在校正後，年輕和身體質量指數較高的患者，在接受PVP手術後，IPSS的改善較為明顯。四個次族群和主要結果沒有發現有交互作用的存在。論：經比較TURP後，我們的初步結果顯示，以高功率綠光雷射來治療良性攝護腺肥大，是一個有效及安全性高的方式，而進一步的療效及可能的副作用，則需要更長時間的追蹤來釐清。Background and objectives: Transurethral resection of the prostate (TURP) has been the most commonly used procedure for benign prostatic hyperplasia. Photoselective vaporization of the prostate (PVP) has been evolved as an alternative. Our objectives are to evaluate the effectiveness and safety of the new high power PVP procedure.ethods: The one hundred and fifteen patients were enrolled from a single hospital at the same period, and they choose the preferred procedure after the advantages and disadvantages were informed. The major outcomes include improvements of international prostatic symptom score (IPSS), IPSS quality of life scores, maximum flowrate and postvoided residuals, and multivariate models analysis with potential confounders adjustments were used to evaluate the strength of the relationships between the major outcomes and the 2 different procedures. The subgroup for age, body mass index, prostate volume and prostatic specific antigen were analyzed for interaction.esults: The basic demographics were listed, and the parameters including height, weight, education level and annual income were significantly different between the 2 groups. Compared to TURP, the PVP group had better outcomes in IPSS improvements(13.6 versus 11.7, P=0.046), quality of life score change (2.91 versus 2.5, P=0.034). After 12 months of follow up duration, the TURP group showed higher urethral stricture rates (3.3% versus 14.5%, P=0.033). The multivariate analysis resulted in, after adjusted, PVP was a prediction factor for IPSS improvements versus TURP(estimate coefficient=2.70, 95 confidence interval=0.71 – 4.69).. The subgroup analyses showed younger and high BMI patients receive greater IPSS effects after PVP therapyonclusions: Our results showed that PVP offers effectiveness for BPH and advantageous over TURP with regard to operative safety. The long term follow up is needed to evaluate the durability and possible morbidity.目錄一章 緒論 11-1 研究背景 11-2 PVP和TURP文獻結果比較 12二章 BPH基礎理論、診斷與治療 18-1 自然史 18-2 危險因子 20-2-1種族 20-2-2 男性荷爾蒙 20-2-3 家族遺傳史 21-2-4 攝護腺癌 21-2-5 其他 21-3 BPH的診斷方法 22-3-1 前言 22-3-2 病史 23-3-3 美國泌尿科協會症狀評分表 24-3-4 血中PSA 25-3-5 最大尿流速 25-3-6 殘尿的測量 26-4 測量指標的依據 26-4-1 主觀指標IPSS 27-4-2 客觀指標：最大尿流速Qmax及解後殘尿量Post void residual 30-4-3 膀胱掃瞄儀 32-4-4 內部變異性within-patient variability 32-4-5 使用測量指標之共識 33-5 BPH的治療 35-5-1 治療的適應症 36-5-2 口服藥物治療 37-6 侵入性治療 40-6-1 TURP 40-6-2 開腹式攝護腺切除術Open prostatectomy 41-6-3 經尿道攝護腺切開術(Transurethral incision of the prostate) 42-6-4 電汽化Electrovaporization(TVP) 43-6-5 微創手術Minimally invasive procedures 43-7 雷射攝護腺切除術LASER PROSTATECTOMY 44-7-1 雷射手術的發展 44-7-2 光選擇性攝護腺組織汽化術PVP 46-8 影響手術結果的干擾因子 51-8-1 年齡 51-8-2 社經地位 51-8-3 攝護腺體積 51-8-4 PSA 52-8-5 主要結果的術前基礎值 52-8-6 BMI 53-8-7 手術時間 53三章 研究目的與假說 55-1 研究目的 55-2 研究假說 55四章 材料與方法 56-1 資料收集 56-2 術前評估 56-2-1 病史及理學檢查 56-2-2 主要結果的測量 57-2-3 次要結果的測量 58-3 雷射手術之進行 58-3-1 The GreenLight HPS™ 高功率綠光雷射操作 58-3-2 手術步驟 59-4 資料的呈現及統計分析 60-4-1 年齡及社經地位 61-4-2 攝護腺體積 61-4-3 身體質量指標 和PSA 62-4-4 手術時間 62-5 次族群分析 63-6 樣本數的估計 63五章 結果分析 65-1 病患的術前資料與特徵 65-2 術後結果POSTOPERATIVE EVENTS 66-3 影響手術結果的因素 67-4治療後的追蹤 69六章 討論 70-1 本研究主要療效與文獻之比較 70-2 PVP的安全性 72-3 PVP次族群的分析 74-4 本研究的優勢 76-5 本研究的限制 76-6 未來的展望 76-7 結論 77ABLE 78ABLE 1 LITERATURE REVIEW FOR LASER PROSTATECTOMY V.S TURP 78ABLE 2 THE NORMALITY TEST FOR STUDY VARIABLES 81ABLE 3 PREOPERATIVE DEMOGRAPHICS FOR PATIENTS RECEIVE PVP OR TURP 82ABLE 4. THE OPERATION-RELATED CLINICAL OBSERVATION OF PERIOPERATIVE AND POSTOPERATIVE PARAMETERS FOR ENROLLED PATIENTS (N=115) 84ABLE 5. THE 8 SUBJECTIVE AND OBJECTIVE VOIDING OUTCOMES FOR THE ENROLLED PATIENTS 85ABLE 6-1 THE UNIVARIATE PREDICTION FOR IPSS CHANGE IN THE STUDY POPULATION 86ABLE 6-2 THE ESTIMATED COEFFICIENT AND 95 PERCENT CONFIDENCE INTERVAL(CI) FOR IPSS CHANGE IN THE MODEL OF PVP COMPARED WITH TURP 87ABLE 7 THE ESTIMATED COEFFICIENT AND 95 PERCENT CONFIDENCE INTERVAL(CI) FOR LOGIPSS CHANGE IN THE MODEL OF PVP COMPARED WITH TURP 88ABLE 8 THE ESTIMATED COEFFICIENT AND 95 PERCENT CONFIDENCE INTERVAL(CI) FOR QUALITY OF LIFE SCORE CHANGE IN THE MODEL OF PVP COMPARED WITH TURP 89ABLE 9 THE ESTIMATED COEFFICIENT AND 95 PERCENT CONFIDENCE INTERVAL(CI) FOR LOG VALUE OF QUALITY OF LIFE SCORE CHANGE IN THE MODEL OF PVP COMPARED WITH TURP 90ABLE 10 THE ESTIMATED COEFFICIENT AND 95 PERCENT CONFIDENCE INTERVAL(CI) FOR POSTVOIDED RESIDUAL CHANGE IN THE MODEL OF PVP COMPARED WITH TURP 91ABLE 11 THE ESTIMATED COEFFICIENT AND 95 PERCENT CONFIDENCE INTERVAL(CI) FOR LOG VALUE OF POSTVOIDED RESIDUAL CHANGE IN THE MODEL OF PVP COMPARED WITH TURP 92ABLE 12 THE ESTIMATED COEFFICIENT AND 95 PERCENT CONFIDENCE INTERVAL(CI) FOR MAXIMUM FLOWRATE CHANGE IN THE MODEL OF PVP COMPARED WITH TURP 93ABLE 13 THE ESTIMATED COEFFICIENT AND 95 PERCENT CONFIDENCE INTERVAL(CI) FOR LOG VALUE OF MAXIMUM FLOWRATE CHANGE IN THE MODEL OF PVP COMPARED WITH TURP 94ABLE 14 THE DIFFERENCE OF THE 4 OUTCOMES BETWEEN 2 AGE GROUPS (AGE<76 VERSUS AGE>76) 95ABLE 15 THE DIFFERENCE OF THE 4 OUTCOMES BETWEEN 2 BODY MASS INDEX (BMI) GROUPS (BMI<24 VERSUS BMI>=24) 96ABLE 16 THE DIFFERENCE OF THE 4 OUTCOMES BETWEEN 2 PROSTATE VOLUME (PV)GROUPS (PV<57 VERSUS PV>=57) 97ABLE 17 THE DIFFERENCE OF THE 4 OUTCOMES BETWEEN 2 PSA GROUPS (PSA<5.1 VERSUS PSA>5.1) 98ABLE 18 COMPARISON OF PREOPERATIVE AND POSTOPERATIVE EVENTS DURING AVERAGED 12 MONTHS OF FOLLOW UP 99ABLE 19 COMPARISON OF EFFICACY (IPSS AND MAXIMUM FLOWRATE) OF PVP VERSUS TURP IN SELECTED SERIES FROM THE LITERATURE 100IGURES 101IG 1 532 NM KTP雷射吸收的原理 101IG 2 FLOW DIAGRAM OF PATIENTS ENROLLMENT FOR PVP AND TURP 102IG 3 THE BOXPLOTS OF THE IPSS CHANGE FOR THE 4 SUBGROUPS, ADJUSTED FOR BASELINE IPSS, AGE, BMI, EDUCATION LEVEL, ANNUAL INCOME AND PROSTATIC SPECIFIC ANTIGEN DENSITY, PVP COMPARED WITH TURP 103IG 4 THE BOXPLOTS OF THE QUALITY OF LIFE SCORE CHANGE FOR THE 4 SUBGROUPS, ADJUSTED FOR BASELINE QUALITY OF LIFE SCORE, AGE, BMI, EDUCATION LEVEL, ANNUAL INCOME AND PROSTATIC SPECIFIC ANTIGEN DENSITY , PVP COMPARED WITH TURP 104IG 5 THE BOXPLOTS OF THE POSTVOIDED RESIDUAL CHANGE FOR THE 4 SUBGROUPS, ADJUSTED FOR BASELINE POSTVOIDED RESIDUAL, AGE, BMI, EDUCATION LEVEL, ANNUAL INCOME AND PROSTATIC SPECIFIC ANTIGEN DENSITY , PVP COMPARED WITH TURP 105IG 6 THE BOXPLOTS OF THE MAXIMUM FLOWRATE CHANGE FOR THE 4 SUBGROUPS, ADJUSTED FOR BASELINE MAXIMUM FLOWRATE, AGE, BMI, EDUCATION LEVEL, ANNUAL INCOME AND PROSTATIC SPECIFIC ANTIGEN DENSITY , PVP COMPARED WITH TURP 106IG 7 THE GREENLIGHT HPS™雷射系統的機型外觀 107IG 8-1 KTP 雷射手術術中圖 108IG 8-2 雷射手術完成圖 109考文獻 110application/pdf1066265 bytesapplication/pdfen-US光選擇性攝護腺組織汽化術國際攝護腺症狀指數療效安全性Photoselective vaporization of the prostateinternational prostatic symptom scoreeffectivenesssafetythesishttp://ntur.lib.ntu.edu.tw/bitstream/246246/184842/1/ntu-98-P96846001-1.pdf