Analysis of multiple factors affecting bleeding during holmium laser enucleation of the prostate
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摘要: 目的 评价经尿道钬激光前列腺剜除术(HoLEP)术中出血量的情况，探讨影响出血量的相关因素。方法 回顾性分析299例良性前列腺增生(BPH)患者的临床资料，其中268例行HoLEP，31例行经尿道前列腺电切术(TURP)。在手术前和术后第1天晨测量血红蛋白和红细胞比容，并记录术后的输血情况。分析年龄、糖尿病、高血压病、血清PSA、泌尿系感染、膀胱结石、术前留置尿管、抗凝治疗、手术时间及切除的前列腺重量等因素对HoLEP术中失血量(血红蛋白与红细胞比容的丢失量)的影响。结果 268例接受HoLEP治疗的患者平均手术时间为50.56(18~120) min，平均切除组织重量为67.22(8~226) g，平均血红蛋白由术前的13.99 g/dL降至术后的12.77 g/dL(P < 0.01)，平均红细胞比容由术前的41.65%降至术后的37.71%(P < 0.01)。血清PSA水平和切除的前列腺重量是影响术中出血量的主要因素(P < 0.05)。手术时间与术中失血量呈正相关。年龄、糖尿病、高血压病、泌尿系感染、膀胱结石、术前留置尿管及抗凝治疗等因素对术中失血量的影响不明显。HoLEP术中平均失血量(血红蛋白丢失量)为1.22 g/dL，显著低于TURP的1.61 g/dL(P < 0.05)。结论 HoLEP具有良好的安全性。血清PSA水平和切除的前列腺重量是影响术中出血量的主要因素，合并手术时间较长的患者术中出血风险更高。
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关键词:
- 经尿道钬激光前列腺剜除术 /
- 前列腺增生 /
- 手术出血 /
- 多因素分析
Abstract: Objective To evaluate the amount of bleeding during transurethral holmium laser enucleation of the prostate (HoLEP) and to explore the related factors affecting the amount of bleeding.Methods Clinical data of 299 patients (268 patients underwent HoLEP and 31 patients underwent TURP) with benign prostatic hyperplasia (BPH) were analyzed retrospectively. Hemoglobin and hematocrit were measured before and on the first morning after operation, and postoperative blood transfusion was recorded. The effects of age, diabetes, hypertension, serum PSA, urinary tract infection, bladder calculi, preoperative indwelling catheter, anticoagulant therapy, operation time and the weight of resected prostate on the intraoperative blood loss (loss of hemoglobin and hematocrit) of HoLEP were analyzed.Results The average operation time of 268 patients treated with HoLEP was 50.56 (18-120) min, the average weight of resected tissue was 67.22 (8-226) g, hemoglobin decreased from preoperative average 13.99 g/dL to postoperative 12.77 g/dL (P < 0.01), hematocrit decreased from 41.65% before operation to 37.71% after operation (P < 0.01). The level of serum PSA and the weight of resected prostate were the main factors affecting the amount of intraoperative bleeding. There was a positive correlation between operation time and intraoperative blood loss. Age, diabetes, hypertension, urinary tract infection, bladder stone, preoperative indwelling catheter and anticoagulation therapy had no significant effect on intraoperative blood loss. The average intraoperative blood loss (hemoglobin loss) in HoLEP was 1.22 g/dL, which was significantly lower than that in 1.61 g/dL of TURP.Conculsion HoLEP has good security. The level of serum PSA and the weight of resected prostate are the main factors affecting the amount of intraoperative bleeding. Patients with longer operation time have a higher risk of intraoperative bleeding. -
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表 1 影响HoLEP术中出血的单因素分析
X ± S 影响因素 血红蛋白丢失量/ (g·dL-1) t P值 红细胞比容丢失量/% t P值 糖尿病 0.77 0.44 0.99 0.32 有 1.13±0.90 3.59±2.66 无 1.24±1.02 4.04±3.10 高血压病 0.30 0.77 0.79 0.43 有 1.20±0.97 3.78±3.04 无 1.23±1.01 4.07±2.99 血清PSA -2.33 0.02 -2.95 0.00 >4 μg/L 1.32±1.02 4.32±3.06 ≤4 μg/L 1.02±0.90 3.19±2.77 泌尿系感染 0.71 0.48 0.46 0.64 有 1.14±0.91 3.80±2.76 无 1.24±1.02 3.99±3.10 膀胱结石 -0.55 0.58 0.02 0.99 有 1.31±1.36 3.94±4.00 无 1.20±0.89 3.95±2.75 术前留置尿管 0.01 0.99 -0.19 0.85 有 1.22±0.93 4.00±2.82 无 1.22±1.02 3.92±3.10 抗凝治疗 0.19 0.84 0.27 0.78 有 1.21±1.05 3.96±3.07 无 1.17±0.96 3.80±2.77 术式 2.10 0.03 2.57 0.01 TURP 1.61±0.80 5.39±2.37 HoLEP 1.22±0.99 3.94±3.01 
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表 2 影响HoLEP术中出血的相关性分析
影响因素 年龄 手术时间 切除重量 血红蛋白丢失量 红细胞比容丢失量 年龄 1 手术时间 0.1351) 1 切除重量 0.1521) 0.5242) 1 血红蛋白差值 0.037 0.1772) 0.2362) 1 红细胞比容差值 0.037 0.2082) 0.2592) 0.9442) 1 1)双侧P < 0.05，2)双侧P < 0.01。
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表 3 影响HoLEP术中出血的多因素分析
变量 血红蛋白丢失量 红细胞比容丢失量 B SE β t P值 B SE β t P值 常量 0.552 0.206 - 2.682 0.008 1.466 0.624 - 2.350 0.020 PSA 0.135 0.149 0.063 0.909 0.364 0.613 0.451 0.093 1.360 0.175 手术时间 0.004 0.004 0.082 1.022 0.308 0.016 0.013 0.098 1.243 0.215 切除重量 0.006 0.003 0.198 2.487 0.014 0.020 0.008 0.205 2.612 0.010 注：血红蛋白丢失量模型：F=5.420;P < 0.05;R2=0.074;校正R2=0.060。红细胞比容丢失量模型：F=7.002;P < 0.01;R2=0.093;校正R2=0.080。
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