55章良性前列腺增生.ppt

2019/11/1,the first hospital of xinxiang medical college,1,良性前列腺增生 benign prostatic hyperplasia,bph,2019/11/1,the first hospital of xinxiang medical college,2,前列腺的位置,2019/11/1,the first hospital of xinxiang medical college,3,概述,bph又稱為前列腺肥大(prostate enlargement) bph是指腺上皮細胞的增多，而非細胞的肥大 bph是老年男性常見疾病 北方地區(qū)的發(fā)病率高于南方 通常前列腺從3540歲開始增生，50歲出現(xiàn)癥狀，60歲需要進行有效的治療,2019/11/1,the first hospital of xinxiang medical college,4,病因,前列腺發(fā)育依賴于功能性睪丸的存在 “雙氫睪酮(dht) ”學說(70年wilson提出) 基質(zhì)與上皮的相互作用 性激素與基質(zhì)-上皮間的相互作用,雙氫睪酮學說示意圖,2019/11/1,the first hospital of xinxiang medical college,5,病理,通常將前列腺分為移行帶(尿道周圍腺體、占5%)、外周帶、中央帶 增生的部分主要是尿道周圍腺體 增生的腺體壓迫外周帶成為外科包膜 增生結(jié)節(jié)：基質(zhì)型、腺泡型、混合型,2019/11/1,the first hospital of xinxiang medical college,6,病理,增生使前列腺段尿道彎曲、伸長、狹窄，導致膀胱出口（boo）梗阻 梗阻代償期：膀胱逼尿肌肥厚 梗阻失代償期：充溢性尿失禁、上尿路積水擴張、代謝產(chǎn)物潴留、尿毒癥 增生的程度與梗阻程度不一定成正比,2019/11/1,the first hospital of xinxiang medical college,7,臨床表現(xiàn),尿頻：最早出現(xiàn)的癥狀 排尿困難：最重要的癥狀 尿潴留：梗阻加重的表現(xiàn) 其他：血尿、感染、結(jié)石、腎積水、疝、痔等(實物標本),bph,boo,luts,2019/11/1,the first hospital of xinxiang medical college,8,國際前列腺癥狀評分(i-pss),i-pss：score(035),2019/11/1,the first hospital of xinxiang medical college,9,i-pss means,2019/11/1,the first hospital of xinxiang medical college,10,生活質(zhì)量評分,生活質(zhì)量評分：l(06),2019/11/1,the first hospital of xinxiang medical college,11,診斷,50歲以上男性，進行性排尿困難 直腸指診(digital rectal exam,dre)觸及增生前列腺 增生：雞蛋大小 增生：鴨蛋大小 增生：鵝蛋大小 客觀指標：殘余尿、尿流率、psa測定 膀胱鏡檢或b超檢查：直接測定前列腺大小,2019/11/1,the first hospital of xinxiang medical college,12,鑒別診斷,膀胱頸纖維化(膀胱頸攣縮)：慢性炎癥所致，發(fā)病年齡較輕 前列腺癌：前列腺堅硬，表面不平，psa 膀胱癌：指膀胱頸附近的膀胱癌，膀胱鏡檢可以鑒別 神經(jīng)原性膀胱尿道功能障礙：有神經(jīng)系統(tǒng)損害的病史和體征 尿道狹窄：有尿道損傷、感染病史,2019/11/1,the first hospital of xinxiang medical college,13,治療,目的：緩解增生腺體所致的膀胱出口梗阻 膀胱出口梗阻(boo)的原因： 增生腺體擠壓尿道所致的機械性梗阻 增生腺體平滑肌張力所致的動力性梗阻 治療方法：很多,2019/11/1,the first hospital of xinxiang medical college,14,藥物治療,-受體阻滯劑 ：降低前列腺平滑肌張力 非選擇性-受體阻滯劑 ：酚卞明 選擇性1-受體阻滯劑 ：hytrin(高特靈) 高選擇性1a-受體阻滯劑：哈樂 5-還原酶抑制劑：proscar(保列治)阻止睪酮轉(zhuǎn)變?yōu)閐ht，長期服用可使前列腺體積縮小 花粉類制劑：舍尼通 等,2019/11/1,the first hospital of xinxiang medical college,15,手術(shù)治療,適應癥： 殘余尿量大于50ml 曾經(jīng)出現(xiàn)過急性尿潴留 大量出血或反復肉眼血尿 病人迫切要求，身體狀況能耐受手術(shù),手術(shù)方法： 恥骨上前列腺增生腺體摘除術(shù) 恥骨后摘除術(shù) 經(jīng)會陰摘除術(shù) 經(jīng)尿道前列腺電切或電汽化術(shù),2019/11/1,the first hospital of xinxiang medical college,16,經(jīng)尿道增生腺體切除術(shù),目前，在全世界范圍內(nèi)，這種治療方法被公認為治療bph的“金標準” (gold standard),2019/11/1,the first hospital of xinxiang medical college,17,2019/11/1,the first hospital of xinxiang medical college,18,2019/11/1,the first hospital of xinxiang medical college,19,經(jīng)尿道增生腺體切除術(shù),2019/11/1,the first hospital of xinxiang medical college,20,前列腺電汽化術(shù)tuvp transurethral vaporization of the prostate,2019/11/1,the first hospital of xinxiang medical college,21,前列腺電切除術(shù)turp transurethral resection of the prostate,2019/11/1,the first hospital of xinxiang medical college,22,電切除的前列腺碎片,2019/11/1,the first hospital of xinxiang medical college,23,前列腺鈥激光切除術(shù),2019/11/1,the first hospital of xinxiang medical college,24,laser ablation of the prostate,2019/11/1,the first hospital of xinxiang medical college,25,前列腺兩側(cè)葉、中葉增生合并膀胱結(jié)石,2019/11/1,the first hospital of xinxiang medical college,26,treatment of bph,placebo watchful waiting pharmacotherapy alpha-blockers 5alpha reductase inhibitors phytotherapy surgery turp tuvp tuip open prostatectomy,m