陶令之 來永慶 魏本林 關(guān)志忱

急性尿潴留前列腺穿刺的意義

陶令之 來永慶 魏本林 關(guān)志忱

目的探討是否應(yīng)該對PSA升高的急性尿潴留患者先進(jìn)行前列腺穿刺活檢。方法回顧分析2003年1月～2009年4月我科收治的109例血清PSA濃度均大于4ng／mL的男性急性尿潴留患者(無尿道狹窄，神經(jīng)原性膀胱等病因)。根據(jù)是否活檢分為2組，20例為前列腺穿刺活檢組，年齡54～85(68.907.64)歲，前列腺體積38～130(70.9427.97)ml，血清PSA4.30～487.46(48.12106)L。89例為未活檢組，年齡54～97(71.788.64)歲，前列腺體積16～293(61.7943.77)ml，血清PSA4.06～411.2(24.9052.61)ng／mL，2組間年齡、前列腺體積和血清PSA比較無統(tǒng)計(jì)學(xué)差異(P＞0.05)；未活檢組56例經(jīng)尿道前列腺切除術(shù)(TURP)，5例經(jīng)開放手術(shù)。結(jié)果活檢組20例，病理發(fā)現(xiàn)前列腺癌5例，陽性率25%；未活檢組89例手術(shù)標(biāo)本發(fā)現(xiàn)前列腺癌4例，均為經(jīng)TURP者。陽性率4.49%。活檢組和未活檢組間比較有顯著統(tǒng)計(jì)學(xué)差異(P＜0.01)。結(jié)論經(jīng)直腸前列腺穿刺活檢發(fā)現(xiàn)PSA升高的急性尿潴留患者前列腺癌的發(fā)生率至少在25%以上，比未經(jīng)穿刺而經(jīng)手術(shù)發(fā)現(xiàn)的前列腺癌發(fā)生率高21%，有顯著統(tǒng)計(jì)學(xué)差異，而手術(shù)發(fā)現(xiàn)的前列腺癌給再次根治性手術(shù)增加了難度。本研究證明PSA升高的急性尿潴留患者應(yīng)該先進(jìn)行前列腺穿刺活檢。

急性尿潴留(AUR)；前列腺特異性抗原(PSA)；前列腺穿刺活檢；經(jīng)尿道前列腺切除術(shù)(TURP)；前列腺癌

作為前列腺癌的篩選指標(biāo)，血清前列腺特異性抗原PSA檢測在臨床中廣泛應(yīng)用。通常認(rèn)為，PSA血清濃度大于10ng/mL是患者行前列腺穿刺活檢的絕對指征。但血清 PSA水平受很多生理和病理因素的影響，傳統(tǒng)認(rèn)為前列腺增生急性尿潴留會導(dǎo)致血清PSA顯著升高[1]，尿潴留時(shí)PSA增高似乎不是前列腺癌的征象，治療也曾多以解除梗阻為主，近年來隨著對前列腺癌認(rèn)識的提高，這一觀點(diǎn)受到了挑戰(zhàn)，對于PSA增高的尿潴留病人是否要先進(jìn)行穿刺活檢充滿爭議。出于這個(gè)目的，現(xiàn)將本院近6年收治的急性尿潴留患者的臨床資料進(jìn)行回顧性研究，探討是否應(yīng)該對PSA升高的急性尿潴留患者先進(jìn)行前列腺穿刺活檢。

1 資料與方法

1.1 研究對象 回顧分析2003年1月～2009年4月我科收治的109例血清PSA濃度均大于4ng/ml的男性急性尿潴留患者(無尿道狹窄，神經(jīng)原性膀胱等病因)。根據(jù)是否活檢分為2組，20例為前列腺穿刺活檢組，89例為未活檢組。

1.2 方法 血清PSA測定采用放射免疫法，經(jīng)超聲測量前列腺3徑(前后、左右、上下)，按公式計(jì)算前列腺體積：上下徑×前后徑×左右徑×0.52。20例為前列腺穿刺活檢組，年齡54～85(68.90±7.64)歲，前列腺體積38～130(70.94±27.97)ml，血清PSA4.30～487.46(48.12±106.92)ng／ml。89例為未活檢組,年齡54～97(71.78±8.64)歲，前列腺體積16～293(61.79±43.77)ml，血清PSA4.06～411.2(24.90±52.61)ng／ml，未活檢組56例經(jīng)尿道前列腺切除術(shù)(TURP), 5例經(jīng)開放手術(shù)。2組間年齡、前列腺體積和血清PSA比較無統(tǒng)計(jì)學(xué)差異 (P＞0.05)。

2 結(jié)果

活檢組20例，病理發(fā)現(xiàn)前列腺癌5例，陽性率25%；未活檢組89例手術(shù)標(biāo)本發(fā)現(xiàn)前列腺癌4例，均為經(jīng)TURP者。陽性率4.49%?；顧z組和未活檢組間比較有顯著統(tǒng)計(jì)學(xué)差異(P＜0.01)見表1。

3 討論

自從1979年Wang等[2]首先用免疫沉淀法成功地從人前列腺組織中分離和提純出PSA以來，PSA在臨床上得到了廣泛的研究和應(yīng)用，成為前列腺癌診斷、治療、隨訪中最重要的腫瘤標(biāo)志物。PSA是前列腺組織特異性抗原而非前列腺癌特異性抗原，許多生理和病理因素如前列腺增生(BPH)、前列腺缺血、急性尿潴留(AUR)、細(xì)菌性前列腺炎、前列腺按摩等都可引起血清PSA的升高[3]，其中以急性尿潴留作用甚為明顯。Semjonow等[4]報(bào)道急性尿潴留時(shí)血清PSA水平較尿潴留緩解后高6倍。PSA為一種能催化肽類物質(zhì)水解的蛋白酶，由前列腺上皮細(xì)胞分泌。正常情況下，前列腺腺泡內(nèi)容物(富含PSA)與淋巴系統(tǒng)之間存在由內(nèi)皮層，基底細(xì)胞層和基底膜構(gòu)成的屏障，當(dāng)癌腫或其它病變破壞這道屏障時(shí)，腺泡內(nèi)容物即可漏入淋巴系統(tǒng)而進(jìn)入血循環(huán)導(dǎo)致血清PSA升高[5]。急性尿潴留致血清PSA升高可能與AUR引起前列腺急性炎癥或微灶性壞死病變破壞這道屏障有關(guān)。

表1 2組前列腺癌陽性率的比較

由此對PSA升高的急性尿潴留患者如何進(jìn)行診治存在一定的爭議。傳統(tǒng)觀點(diǎn)將患者血清PSA的升高歸因于急性尿潴留的影響，認(rèn)為對并發(fā)AUR的前列腺增生患者即使PSA＞10ng/ml者，如術(shù)前肛門指診(DRE)前列腺質(zhì)地不硬且無結(jié)節(jié)，經(jīng)直腸前列腺超聲檢查未見明顯異常情況，則可無需行前列腺穿刺活檢，而直接行前列腺增生手術(shù)解除梗阻[6]，定期隨訪PSA的變化。

近年來隨著對前列腺癌認(rèn)識的提高，這一觀點(diǎn)受到了挑戰(zhàn)，在本研究中，經(jīng)直腸前列腺穿刺活檢發(fā)現(xiàn)PSA升高的急性尿潴留患者前列腺癌的發(fā)生率至少在25%以上，比未經(jīng)穿刺而經(jīng)手術(shù)發(fā)現(xiàn)的前列腺癌發(fā)生率高21%，有顯著統(tǒng)計(jì)學(xué)差異，這說明如果PSA升高的急性尿潴留患者未經(jīng)穿刺活檢而直接手術(shù)或隨訪觀察，就有至少21%～25%的前列腺癌患者失去最佳診斷治療時(shí)機(jī)，這種傳統(tǒng)的處置方式雖然在一定程度上減少了對部分患者進(jìn)行不必要的前列腺穿刺活檢，但是如此高的漏診率是臨床醫(yī)師所不能接受的，同時(shí)手術(shù)發(fā)現(xiàn)的前列腺癌給再次進(jìn)行根治性手術(shù)增加了難度。自1989年Hodge等[7]提出經(jīng)直腸超聲引導(dǎo)6點(diǎn)前列腺系統(tǒng)穿刺活檢術(shù)，到1997年Eskew等[8]首先報(bào)道了經(jīng)直腸超聲引導(dǎo)13點(diǎn)前列腺系統(tǒng)穿刺活檢術(shù)診斷前列腺癌的臨床應(yīng)用以來，采用經(jīng)直腸超聲引導(dǎo)下前列腺系統(tǒng)穿刺的方法使前列腺癌的臨床檢出率得到明顯提高，并發(fā)癥也隨著技術(shù)的不斷改進(jìn)而減少。所以我們認(rèn)為，對PSA升高的急性尿潴留患者無論DRE是否正常都應(yīng)該先行TRUS引導(dǎo)下前列腺系統(tǒng)穿刺活檢。

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Objective To explore whether a prostate biopsy should first conduct in patients with acute urinary retention combined with elevated serum PSA. Methods A total of 109 cases of men with acute urinary retention were retrospectively studied, and patients with urethral stricture and neurogenic bladder were excluded.Serum PSA concentration greater than 4ng/mL for selected.divided into two groups according to whether to biopsy or not.For 20 cases of prostate biopsy group, aged 54-85(68.90±7.64)years old, prostate volume of 38-130(70.94±27.97)ml, serum PSA 4.30-487.46(48.12±106.92)ng/mL. For 89 cases of non-biopsy group, aged 54-97(71.78±8.64)years old, prostate volume of 16-293(61.79±43.77)mL,serum PSA 4.06-411.2(24.90±52.61)ng/mL. In the non-biopsy group 56 cases conducted transurethral resection of prostate (TURP), 5 cases conducted open surgery. There were no statistically differences between the two groups in age, serum PSA and prostate volume(P＞0.05). Results: For 20 cases of prostate biopsy group, 5 cases of prostate cancer, the positive rate was 25%; For 89 cases of non-biopsy group,4 cases of prostate cancer,all were diagnosed by TURP, the positive rate was 4.49%. There were statistically significant differences between the two groups(P＜0.01). Conclusion The incidence of prostate cancer diagnosed by transrectal prostate biopsy in patients with acute urinary retention combined with elevated serum PSA was at least more than 25%, 21% higher than which diagnosed by surgery without biopsy, there were significant statistically differences, these operations without biopsy increased the difficulty of radical surgery. This study demonstrate that a prostate biopsy should first conduct in patients with acute urinary retention combined with elevated serum PSA.

acute urinary retention (AUR); prostate specific antigen(PSA); prostate needle biopsy; transurethral resection of prostate(TURP);prostate cancer

10.3969/j.issn.1009-4393.2010.14.009

518000 北京大學(xué)深圳醫(yī)院泌尿外科 (陶令之 來永慶魏本林 關(guān)志忱)