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,中医附院泌尿外科,良性前列腺增生,(Benign proststic hyperplasia BPH),病 因,年龄,有功能睾丸,高危因素：,人种犹太人,糖尿病,性活动强度,泌尿系感染史,低身体质量指数,临床,组织学前列腺增生之发生率,尿流率下降之发生率,一、概述,1、良性前列腺增生症是老年男性常见病,2、BPH 的自然病史分为病理组织学期、临床期。,3、BPH的主要特点概括为三点如以下图,图 一,图 二,增 生 部 位,单纯中叶肥大 30%,单纯两侧叶肥大 14%,两侧中叶肥大 22%,后联合增生 14%,后联合增生侧叶增生 17%,中叶增生腺体不大但梗阻明显。长期梗阻形成膀胱小梁，假性憩室，肾积水，肾功损害。,1.膀胱出口梗阻(Bladder Outflow Obstruction,BOO)分为机械性和动力性因素；,BPH的病理生理改变可分为三个阶段,2.膀胱功能异常,1不稳定膀胱USB5080%BPH患者出现；,2低顺应性膀胱Low Compliance Bladder 与BOO合并存在产生持续膀胱内高压，成为加速上尿路损害的主要原因；,3高顺应性膀胱High Compliance Bladder高顺应性膀胱是手术解除梗阻后排尿依旧困难的主要原因。,3.上尿路积水、肾功能受损 大量剩余尿及膀胱内压持续40cmH2O是导致上尿路积水及肾功能受损的两个根本原因.,临 床 表 现,1、病症在50岁以上出现,2、梗阻病症,3、刺激病症,4、逼尿肌功能不稳定或失调,5、BPH、梗阻、刺激病症不一致,6、合并膀胱结石,7、血尿,8、泌尿系感染,9、慢性肾功能减退,10、并发腹股沟疝、脱肛、痔等,诊 断,病史：,除外神经系统、糖尿病、精神疾病、药物引起排尿困难,病症评估：,国际前列腺病症评分IPSS,小于7分为轻度，819分为中度，2035为重度,国际前列腺症状评分（I-PSS）,在过去1月您是否出现以下症状？,没有,少于1/5,少于1/2,大约1/2,多于1/2,几乎每次,评分,是否经常有尿不尽感？,两次排尿时间是否15ml/s,剩余尿60ml,有无结石，中叶凸出情况。,排尿困难由逼尿肌乏力引起应作尿流动力学检查。,超声检查前列腺时同时应注意双肾积水情况。,体格检查：双肾是否扪及，耻骨上是否充盈，直肠指诊前列腺大小、硬度、结节、球海绵体反射，下肢运动和感觉。,手 术 治 疗,化验检查,血常规和血小板,尿常规,出凝血时间,肝肾功,PSA,手 术 治 疗,术前发现以下情况时，选择前列腺增生切除手术要格外小心。,年龄小于50岁,以往前列腺增生手术失败者,伴有前列腺癌者,难以控制的糖尿病,骨盆手术和外伤史,服用可能影响膀胱功能的药物,手 术 治 疗,手术适应症,尿潴留一次以上,BPH伴反复血尿,BPH伴肾功不全,继发膀胱结石,尿路反复感染,剩余尿60ml,手 术 治 疗,手术方法的选择,前列腺50g以上选开放性切除,前列腺50g以下选TURP术,手 术 治 疗,手术并发症,早期：出血、排尿困难、尿路感染。,晚期：阳痿、逆向射精、尿失禁、膀胱及颈挛缩等。,手术效果,五年内复发占5,BPH手术以后仍可发生前列腺癌,治 疗,激光治疗,凝固,组织 内凝固,气化,高强度超声聚焦(经直肠超声聚焦),热疗 经外皮4250度,球囊扩张术,前列腺支架 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