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单击此处编辑母版标题样式,单击此处编辑母版文本样式,第二级,第三级,第四级,第五级,*,*,*,单击此处编辑母版文本样式,第二级,*,*,*,单击此处编辑母版标题样式,超声引导经会阴前列腺穿刺活检术,“,小腺体，大问题,”,-,“,生命腺,”,前列腺癌,(,PCa,),：发病率逐年上升，危害大,2024/11/3,2,Hsing,AW,et al.,Int,J Cancer,2000,85:60-7.,USA,2024/11/3,3,Jemal,A,et al.Cancer statistics,2010.CA Cancer J,Clin,2010,60(5):277-300.,Worldwide,Estimated new cases,Estimated Deaths,2024/11/3,4,Jemal,A,et al.Global cancer statistics.CA Cancer J,Clin,.2011.61(2):69-90.,中国,(,上海,),2024/11/3,5,肿瘤,:,上海市市区,1983-2007,年恶性肿瘤发病率,.2010,(7):595.,1.9/10,万,25.87/10,万,我国部分主要城市,PCa,发病率变化,2024/11/3,6,全国肿瘤防治研究办公室,/,全国肿瘤登记中心,中国肿瘤登记年报,2009:,军事医学科学出版社，,2010.6,PCa,发病率随着经济发展迅速增长,2024/11/3,7,Singapore,Chinese,Incidence,*,68-02,GDP(Singapore Dollars),GDP(Hong Kong Dollars),*Age standardized incidence rate,Source:Hong Kong Cancer Registry,Singapore MOH,World Market Monitor,Osaka Cancer Registry,Cancer Incidence in Five Continents,Vol,III-VIII(WHO),Hong Kong,Incidence,*,:83-05,Osaka,Japan,Incidence,*,68-02,Japan GDP(USD MM),我国,PCa,诊治现状,发病数,死亡率,2024/11/3,8,International Agency for Research on Cancer,（,estimated for 2000,）,叶定伟,等,.,前列腺癌发病趋势的回顾和展望,2007,17(3).,我国,PCa,诊治现状(08年),2024/11/3,9,All Prostate Cancer,19,820,Radical Prostatectomy,Advanced,Locally advanced,Early,Watchful Waiting,Radical Prostatectomy,Castration,Surgical,Medical(LHRH),MAB with AA,MAB with AA,AA,Watchful Waiting,Castration,Surgical,Medical(LHRH),MAB with AA,MAB with AA,Watchful Waiting,Castration,Surgical,Medical(LHRH),15%,35%,50%,20%,58%,21%,85%,15%,77%,9%,14%,45%,35%,65%,86%,14%,36%,64%,88%of all castration patients,Source:,Mckinsey,Team Estimation,Professional mgt&Team estimation,PCa,为什么不易早期诊断？,大多数,PCa,潜伏期很长；,早期常无症状；,国内多数地区普遍缺乏,PSA,筛查意识。,LUTS,、排尿困难、尿潴留、血尿等，缺乏认识，误诊为,BPH,；,转移灶症状（骨转移）。,2024/11/3,10,Zhang HF,，,et al.Mass screening of 12027 elderly men for prostate carcinoma by measuring serum PSA.CMJ,2004,117:67,70.,我们何去何从？,CUA,共识（,2011.10,，南京）,:,男性,50,岁,有,LUTS,，常规,PSA,和,DRE,检查；,PCa,家族史，,45,岁；,DRE,异常、有临床征象,(,如骨痛、骨折等,),或影像学异常。,2024/11/3,11,PCa,早期诊断方法,经直肠指检（,DRE,）；,前列腺特异性抗原（,PSA,）筛查；,影像学,(TRUS/MRI/CT/,骨扫描,),；,前列腺穿刺活检,“,金标准,”,。,2024/11/3,12,前列腺穿刺活检术,穿刺目的,前列腺组织学定性诊断：,前列腺癌？,病理,分级,(Gleason Score),前列腺穿刺活检,指征,（,CUA,指南,2011,）,DRE,发现结节，任何,PSA,值,;,B,超发现前列腺,低回声结节,或,MRI,发现,可疑信号,，任何,PSA,值,;,PSA10ng/ml,，任何,f/t,PSA,或,PSAD;,PSA4-10ng/ml,，,f/tPSA,(16%),或,PSAD(0.15),。,前列腺穿刺活检,时机,（,CUA,指南,2011,）,(PSA),抽血后；,盆腔,MRI,检查后,(,胆碱,+,肌酐,/,枸椽酸盐,0.86,),2024/11/3,15,前列腺穿刺活检,（手指引导）,手指引导下前列腺穿刺活检,-,“,盲穿,”,2024/11/3,16,对无明显结节的早期,PCa,诊断效率低。,手指和穿刺针反复进出直肠，操作复杂，时间长，病人疼痛明显；,损伤尿道等并发症；,穿刺点难保证均匀分布。,前列腺穿刺活检,（经直肠超声引导）,经会阴前列腺穿刺,经直肠前列腺穿刺,2024/11/3,17,经直肠前列腺穿刺,经会阴前列腺穿刺,阳性率,实际上各家报道结果不一,理论上经会阴穿刺率高，因为是纵向穿过整个外周区,是否需麻醉,大部分不需麻醉,少部分饱和穿刺需麻醉,需要经会阴皮下穿刺麻醉,有无模板,无法应用模板,可以应用模板，保证穿刺的准确性和可重复性,学习曲线,相对较短,比较复杂，相对较长,感染机率,大,小,前列腺穿刺,穿刺针平行超声探头,2024/11/3,18,PCa,与前列腺外周带,2024/11/3,19,Chen,M.E,et al.Detailed mapping of prostate carcinoma foci:biopsy strategy implications.,Cancer.,2000.89,1800-9.,前列腺,系统穿刺活检,2024/11/3,20,传统,6,点穿刺：,10,点穿刺,:,12,点穿刺,:,13,点穿刺,:,饱和穿刺,:,前列腺穿刺,术前准备,清洁灌肠，排空粪便；,术前,1-3,天口服预防性抗菌药物（灭滴灵,200mg,tid,）；,口服阿司匹林等抗凝药物者，停药一周以上；,2024/11/3,21,前列腺穿刺,体位,&,麻醉,2024/11/3,22,利多卡因胶浆,+,碘伏,+,利多卡因胶浆,“,三明治法,”,穿刺技术,见手术视频,前列腺穿刺,并发症及预防,血尿,便血,血精,发热，败血症,2024/11/3,24,正确引导，克服不必要的恐惧心理,病理分级（,Gleason,评分,）,2024/11/3,25,分为,1,5,级；,1,级分化良好，,5,级分化差；,Gleason,评分,=,主要分级区,+,次要分级区。,高分化：,2-4,分；中分化：,5-7,分；低分化：,8-10,分,PCa,危险因素分析,:,指导治疗和判断预后,2024/11/3,27,低危,中危,高危,PSA,（,ng,/ml,）,10,10,20,20,Gleason,评分,6,7,8,临床分期（,TNM,）,T2a,T2b,T2c,前列腺穿刺,设备,2024/11/3,28,多科室联合，共同抗击前列腺癌,检验科：,PSA,，,f/tPSA,影像科：,MR,超声科：,技术支持,病理科：,Gleason+,免疫组化,放疗科：,适形及调强放疗,泌尿外科：,-,门诊初筛,-,穿刺活检,-,手术,&MAB,谢谢,
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