雷射尿道造口術可能對閉塞性尿道狹窄有助益


  Aug. 19, 2004 - 根據八月號泌尿科學誌(Urology) 刊載的結果顯示,鈥雷射尿道造口術(HolCTU)對創傷、閉塞性尿道狹窄而言是安全及簡單的治療。
  
  全印度新德里藥學的自然科學協會P. N. Dogra指出,與骨盆破裂相關的尿道外傷,其中最嚴重的後遺症之一,是受傷害部位大量纖維化而導致完全的閉鎖;最近的幾個研究,包含我們中心的一些已經顯示,使用釹釔鋁榴石雷射穿越核心的外科手術之效果。
  
  從2002年6月到20033月,29位球膜尿道的閉鎖性尿道狹窄的男性接受穿越核心的外科手術,所有患者的狹窄部位長度為2.5公分或小於2.5公分,其手術部位尿道兩端的精準度相當好,閉鎖纖維化組織藉由鈥雷射的金屬探針經由上恥骨通道被蒸發。
  
  平均手術時間是40分鐘(範圍在30-90 分鐘),且平均住院時間為8個小時(範圍在6-48小時),其中一位患者發展較輕微,只有部分的液體外滲,除此之外沒有其他手術後併發症;手術後6個星期,患者移除導管並做排尿膀胱攝影,一個月後以尿道鏡檢視法追蹤。
  
  經過15個月的後續追蹤(範圍在1 0-19個月),29位患者中有19 位(65.51%)患者有極佳的效果,另有9位(31.03%)患者有可以接受的效果;不過,後面幾組無法以尿道造口術維持好的流動,為了穩定流速,需要一至兩次內部的尿道造口術/內視鏡擴張術(最大流速為5 mL/s 或更大);有1位(3.44%)患者雖然重複接受內部尿道造口術,但是一再發生阻塞,患者最後需要經正規的恥骨尿道成形術,全部患者可在不影響性功能的情況下控制排尿。
  
  研究人員表示,雖然在研究中,受試者樣本數少且追蹤期短,但我們相信HolCTU將會像對創傷後閉鎖性尿道狹窄的最初治療般受到重視,因為這項手術過程簡單、傷口較少,同時也較少導致其他病變、不需要輸血,且患者較不需要花時間離開工作;我們不否定穿越核心的外科手術與一般外科手術相比,有較高的失敗率,但無論如何,手術失敗將不會阻礙傳統的尿道成形術。
  
  美國加州Irvine大學Joel Gelman醫師在社論中指出,尿道鏡檢視法是在導尿管拔除後一個月執行,讓復發不再發生。
  
  Gelman醫師指出,他不認為復發是可以接受的,且他也相信復發是手術失敗的結果,除非用完全一致的成功及失敗的定義,且包括受試者的資訊及充分的追蹤,否則將無法比較開放及內視鏡手術治療狹窄疾病的結果。
  
  在最佳的情況下,目前使用尿道造口術有高於利用開放重建手術至少六倍的失敗率;他的結論是,從此研究得知,雷射尿道造口術不如開放性重建手術,且開放性切除修復手術仍是尿道斷裂後期的一個選擇。

Laser Urethrotomy May Be Helpf

By Laurie Barclay, MD
Medscape Medical News

Aug. 19, 2004 — The holmium laser core-through urethrotomy (HolCTU) is a safe and simple treatment for traumatic obliterative urethral strictures, according to the results of an interventional case series published in the August issue of Urology.

"One of the most unpropitious sequelae of urethral trauma associated with fracture to the pelvis is extensive fibrosis resulting in complete obliteration at the site of the injury," write P. N. Dogra, from the All India Institute of Medical Sciences in New Delhi, and colleagues. "Recently, several studies, including some from our center, have shown results of a core-through procedure using the neodymium:yttrium-aluminum-garnet laser on par with the results of open surgery."

From June 2002 to March 2003, 29 men with obliterative strictures of the bulbomembranous urethra underwent the core-through procedure. The length of the stricture was 2.5 cm or shorter in all patients, with good alignment between the two urethral ends. The obliterative fibrotic tissue was vaporized by a holmium laser guided by a metal sound introduced through the suprapubic tract.

Mean operating time was 40 minutes (range, 30-90 minutes), and mean hospital stay was eight hours (range, 6-48 hours). One patient developed a small, local extravasation of fluid, but there were no other perioperative complications. At six weeks after the procedure, patients had catheter removal and voiding cystourethrography, followed by urethroscopy one month later.

At a mean follow-up of 15 months (range, 10-19 months), 19 (65.51%) of 29 patients had excellent results, and nine patients (31.03%) had acceptable results. HolCTU failed to maintain good flow in the latter group, necessitating internal urethrotomy/endoscopic dilation once or twice for stabilization (maximal flow rate 15 mL/s or greater). One patient (3.44%) had recurrent obstruction despite repeated internal urethrotomy, which finally required formal transpubic urethroplasty. All of the patients were continent, with no change in potency status.

"Although in our study the number of patients was small and follow-up short, we believe that HolCTU should be considered as an initial treatment for obliterative post-traumatic urethral strictures," the authors write. "The procedure is simple, less traumatic, and less morbid, without a blood transfusion requirement, and the patient will require less time away from work. We do not deny that the core-through procedure has a slightly greater rate of failure compared with open surgery. However, failure of the procedure does not prevent conventional urethroplasty if required."

In an accompanying editorial, Joel Gelman, MD, from the University of California, Irvine, notes that urethroscopy was performed one month after catheter removal, making it possible for recurrences to be missed.

"I do not consider recurrence acceptable and believe that recurrence is a failure of the procedure. It is not possible to compare the outcomes of open versus endoscopic treatment for stricture disease unless uniform definitions of success and failure are used and the follow-up is sufficient and includes objective data," Dr. Gelman writes. "At best, the failure rate reported in the current study using urethrotomy is at least six times the failure rate with open reconstruction using modern techniques. My conclusion from this study is that laser urethrotomy is inferior to open reconstruction, and that open excisional repair remains the procedure of choice for posterior urethral disruptions."

Urology. 2004;64:232-236

Reviewed by Gary D. Vogin, MD

    



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