Minimally invasive techniques for the treatment of lower urinary tract symptoms secondary to benign prostatic hyperplasia: An update

Benign prostatic hyperplasia (BPH) primarily affects middle-aged and elderly men. Consequently, medical and surgical treatments for this condition are some of the most common therapies administered in medical practice. Many minimally invasive techniques for the treatment of BPH have been introduced over the past several years to achieve comparable efficacy without the morbidity and mortality associated with transurethral resection of the prostate (TURP), the current gold standard for the surgical management of BPH. Many procedures have not sustained satisfactory results over time, whereas others have been reported as possible alternatives, in selected cases, to TURP. It may not be a simple question of comparative efficacy with TURP for these less invasive treatments, but rather a question of whether lower complication and side-effect rates are a suitable tradeoff for somewhat reduced symptom relief and possibly a need for future retreatment. This article reviews current minimally invasive therapies, addressing methods of tissue ablation, short-and long-term results, and comparisons with TURP.     

Management of benign prostatic hyperplasia. Alternatives to standard therapy.

Benign prostatic hyperplasia is a significant cause of morbidity in the elderly male population. The standard therapy for symptomatic prostatic obstruction has been prostatectomy by transurethral resection (TURP) or, less frequently, by open surgery. Innovative alternative treatments of benign prostatic hyperplasia, both surgical and nonsurgical, will be discussed. Additionally, an appraisal of TURP will be made.     

Recent Advances and Emerging Technology in the Surgical Management of BPH-Related Voiding Dysfunction

As transurethral resection of the prostate (TURP) continues to be the standard of care to alleviate voiding dysfunction in men with benign prostatic hyperplasia (BPH), novel techniques are being addressed to promote operative efficacy and long-term results for improved voiding. This review addresses recent literature over the past year on various transurethral technologies and procedures as well as the developing practice of prostatic arterial embolization (PAE) to improve lower urinary tract symptoms in the setting of BPH. The transurethral technologies include bipolarity, which has come to the forefront in the resection of large prostates as it reduces the risk of TUR syndrome, and plasmakinetic enucleation and diode laser enucleation which have both recently been demonstrated to improve tissue resection for larger prostate glands. The Oyster Procedure, described below, is a specific method of adenoma resection which has been demonstrated to be effective in the treatment of large obstructing prostates. HoLEP, which has been established as an effective tool for large prostates, has now been described to be useful in patients requiring retreatment of LUTS secondary to BPH. Prostatic artery embolization (PAE) has recently come to the forefront of a minimally invasive alternative to TURP with a reduction of symptoms and recovery time in patients who have had unsuccessful or refractory treatments for LUTS. While TURP aids in improving voiding dysfunction, it is known to affect sexual function. New implants, such as those explained in the UroLift procedure below, can improve LUTS while preserving sexual function. Finally, The GreenLight laser prostatectomy has now been demonstrated to be safe and effective in an office setting with conscious sedation, thereby reducing surgical risk with anesthesia for those with comorbidities. The studies discussed in this review focus on improving procedures for treating larger prostates, prostates with prior surgical interventions or refractory BPH, patients who wish to maintain sexual function, and assessing interventions for the elderly and those with comorbidities. As new technologies continue to expand, their use among both novice and experienced surgeons will be vital to advancing the treatments for BPH.     

Value of transurethral resection of the prostate (TURP) for treatment of symptomatic benign prostatic obstruction (BPO): an analysis of efficiency and complications in 1015 cases

1015 patients with benign prostatic hyperplasia who underwent transurethral resection (TURP) within the last seven years were analysed concerning indication, complications and results by evaluation of quality. The actual value of TURP should also be compared with that of alternative procedures of treatment. The transfusion rate (0.69 %), TUR syndrome (0.78 %) and the urinary infection rate (1.1 %) are all very low. In 4.7 % a re-operation was necessary, mostly due to significant haematuria. The mortality rate perioperatively was 0.1 %. With regard to the voiding outcome, the uroflow relatively improved in 131 % and post-void residual urine diminished in 81 %. The low rate of complications, high efficiency and satisfaction of the patients are of importance also for the evaluation of alternative procedures. At the present time these modes of treatment do not have the potential to substitute for TURP.     

Paroxysmal atrial fibrillation during acute myocardial infarction associated with subclinical hyperthyroidism, severe three vessels coronary artery disease and elevation of prostate-specific antigen after TURP

Subclinical hyperthyroidism is an increasingly recognized entity that is defined as a normal serum free thyroxine and free triiodothyronine levels with a thyroid-stimulating hormone level suppressed below the normal range and usually undetectable. Paroxysmal atrial fibrillation is a frequent complication of acute myocardial infarction. It has been reported that subclinical hyperthyroidism is not associated with CHD or mortality from cardiovascular causes but it is sufficient to induce an increase in atrial fibrillation rate and increased factor X activity in patients with subclinical hyperthyroidism represents a potential hypercoagulable state. It has also been reported that serum prostate-specific antigen (PSA) decreases drastically in patients who undergo transurethral resection of the prostate(TURP). We present a case of paroxysmal atrial fibrillation during acute myocardial infarction associated with subclinical hyperthyroidism, severe three vessels coronary artery disease and elevation of PSA after TURP in a 78-year-old Italian man.     

经尿道等离子电切和经典电切治疗老年人高危大体积前列腺增生的疗效比较

目的 比较经尿道等离子双极电切术(PKRP)与经尿道单极电切术(TURP)治疗老年、高危、大体积前列腺增生患者的疗效.方法 对36例老年、高危、大体积前列腺增生患者,分别采取PKRP16例,TURP20例,比较两组的手术时间、术中出血量、切除的前列腺标本重量、术后冲洗时间、拔尿管时间、术后6个月国际前列腺症状(IPSS)评分和最大尿流率.结果 PKRP组和TURP组比较,手术时间分别为(62±23)min和(68±35)min,切除的前列腺标本重量分别为(52±15)g和(56±18)g,术后冲洗时间分别为(16±12)h和(18±10)h,拔管时间分别为(5±2)d和(6±1)d,术后IPSS评分分别为(6.8±3.4)和(7.4±4.2)分,最大尿流率分别为(15.8±6.2)ml/s和(15.2±5.3)ml/s,组间比较,差异无统计学意义;术中出血量,PKRP组为(283±155)ml,少于TURP组的(465±264)ml(P<0.05);且PKRP组无术中输血,TURP组有1例(P<0.01);两组术后6个月IPSS评分、最大尿流率均较术前显著改善,PKRP组IPSS分别为(27.8±3.5)和(6.8±3.4)分,最大尿流率分别为(4.5±2.7)ml/s和(15.8±6.2)ml/s;TURP组IPSS分别为(29.2±6.1)和(7.4±4.2)分,最大尿流率分别为(5.2±3.6)ml/s和(15.2±5.3)ml/s,组内差异有统计学意义(P<0.01).结论 PKRP与TURP有相似的电切效率和手术效果,但PKRP出血较少,对高危、大体积前列腺患者更安全.     

Post transurethral resection of prostate incontinence in previously radiated prostate cancer patients

OBJECTIVES: This is a retrospective review evaluating the incidence of incontinence post transurethral resection of prostate (TURP) in patients who have had previous external beam radiation (XRT) for prostate cancer (PCA). MATERIALS AND METHODS: 1,230 patients underwent XRT for PCA between January 1985 and April 1996. From this group, 16 patients mean age of 67.8 years (range 48-84) at the time of XRT had a subsequent TURP for obstructive symptoms a median of 3.25 years later (range 3 months to 10.2 years). Patients have been followed post TURP for a median of 5.0 months (range 1 to 81 months). RESULTS: Nineteen percent (3) patients developed incontinence post TURP. An additional patient remained in retention and continued to suffer overflow incontinence. Incontinence was associated with a shorter time interval between XRT and TURP (13 months versus 55.3 months) and with a greater amount of prostatic resection (19 grams versus 11.4 grams) when compared to the continent group, but did not meet statistical significance. CONCLUSION: A high risk of incontinence post TURP in previously radiated patients was demonstrated. The association with a shorter time interval between procedures and the larger resection suggests that a conservative approach is warranted. Studies with the use of preop and post TURP urodynamics would be useful in further defining risk factors in this population.     

经尿道前列腺电切术与2μm（铥）激光前列腺汽化切除术并发症的比较

目的比较分析经尿道前列腺电切术（TURP）与2μm（铥）激光前列腺汽化切除术（TmLRP）的并发症。方法分别用TURP及TmLRP治疗良性前列腺增生症（BPH）患者114例（TURP组）和82例（TmLRP组）。两组患者年龄、前列腺体积差异无统计学意义（均P＞0.05）。比较分析采用两种术式发生术中电切综合征、包膜破裂及术后严重膀胱痉挛、急性附睾炎、尿失禁、勃起功能障碍等并发症情况。结果 TmLRP组术中发生电切综合征、包膜破裂等并发症明显少于TURP组（P＜0.05）。术后1周内,TmLRP组发生严重膀胱痉挛、急性附睾炎并发症明显少于TURP组（P＜0.05）;术后1周～1个月内,TmLRP组发生术后继发性出血、严重膀胱刺激征、腺体残留导致排尿困难并发症明显少于TURP组（P＜0.05）;术后1～3个月内,TmLRP组发生尿失禁明显少于TURP组（P＜0.05）;术后3～6个月内,TmLRP组发生勃起功能障碍明显少于TURP组（P＜0.05）。结论 TmLRP组术中及术后并发症明显少于TURP组,是一种安全有效的手术方式。     

Preoperative diagnosis and management for hilar cholangiocarcinoma]

Liver resection with extrahepatic bile duct resection, wide lymph node dissection and caudate lobectomy has become the standard treatment for patients with hilar cholangiocarcinoma. More extended surgery, such as hepatopancreatoduodenectomy, combined portal vein and liver resection, has been accepted for treatment. Such aggressive resection could only offers better chance of long-term survival, but postoperative morbidity and mortality is still high. Various preoperative diagnostic and management modalities including PTBD, PTCS, angiography, MR angiography, MR cholangiography, DCT, CT angiography and PTPE are very important for optimal treatment and reduced mortality. It is recommended that surgeons, physicians, endoscopists, and radiologists, including interventional radiologists should perform the diagnosis and preoperative management of patients with hilar cholangiocarcinoma in a concerted way.     

Transfusion thresholds in common elective surgical procedures in Finland

Background and Objectives: Transfusion practices and thresholds in common elective surgical procedures were investigated in a nationwide multicenter survey in Finland. Materials and Methods: The records of 764 total hip replacement (THR), 397 total knee replacement (TKR) and 343 transurethral resection of the prostate (TURP) patients were reviewed by four anesthesiologists. Results: The allogeneic red cell (RBC) transfusion rates in THR, TKR and TURP operations were 92, 84 and 18%, respectively. In THR and TKR, 74% of patients who lost 20% or less of their blood volume during hospitalization were transfused with RBCs. Postoperatively, the median pretransfusion hemoglobin values were 9.6 g/dl in orthopedic operations and 10.7 g/dl in TURP. In some hospitals, the median transfusion threshold in TURP patients was as high as 11.2 g/dl. Conclusion: The transfusion thresholds in all operations were liberal compared to recent international recommendations. Inappropriate thresholds were reflected in the high transfusion rates. This study accentuates the need for continuous discussion and educational measures to find optimal indications for transfusion in surgery, and to rationalize the transfusion policy in Finland.     

palliative care and end-stage colorectal cancer management:The surgeon meets the oncologist

Colorectal cancer(CRC)is a common neoplasia in the Western countries,with considerable morbidity and mortality.Every fifth patient with CRC presents with metastatic disease,which is not curable with radical intent in roughly 80%of cases.Traditionally approached surgically,by resection of the primitive tumor or stoma,the management to incurable stageⅣCRC patients has significantly changed over the last three decades and is nowadays multidisciplinary,with a pivotal role played by chemotherapy(CHT).This latter have allowed for a dramatic increase in survival,whereas the role of colonic and liver surgery is nowadays matter of debate.Although any generalization is difficult,two main situations are considered,asymptomatic(or minimally symptomatic)and severely symptomatic patients needing aggressive management,including emergency cases.In asymptomatic patients,new CHT regimens allow today long survival in selected patients,also exceeding two years.The role of colonic resection in this group has been challenged in recent years,as it is not clear whether the resection of primary CRC may imply a further increase in survival,thus justifying surgeryrelated morbidity/mortality in such a class of shortliving patients.Secondary surgery of liver metastasis is gaining acceptance since,under new generation CHT regimens,an increasing amount of patients with distant metastasis initially considered non resectable become resectable,with a significant increase in long term survival.The management of CRC emergency patients still represents a major issue in Western countries,and is associated to high morbidity/mortality.Obstruction is traditionally approached surgically by colonic resection,stoma or internal by-pass,although nowadays CRC stenting is a feasible option.Nevertheless,CRC stent has peculiar contraindications and complications,and its long-term cost-effectiveness is questionable,especially in the light of recently increased survival.Perforation is associated with the highest mortality and remains mostly matter for surgeons,by abdominal lavage/drainage,colonic resection and/or stoma.Bleeding and other CRC-related symptoms(pain,tenesmus,etc.)may be managed by several mini-invasive approaches,including radiotherapy,laser therapy and other transanal procedures.     

Hepatic resection in cirrhotic liver for treatment of hepatocellular carcinoma in Egyptian patients. Experience with 140 cases in a single center

BACKGROUND/AIMS: In many centers hepatic resection is still the treatment of choice for hepatocellular carcinoma in cirrhotic liver. Several factors affect the prognosis; one of them is the extent of resection. This study retrospectively evaluates outcome after different types of hepatic resection in cirrhotic liver. METHODOLOGY: Hepatectomy was performed in 245 patients. From them, 140 patients were subjected to hepatic resection for hepatocellular carcinoma in cirrhotic liver. According to the type of resection the patients were divided into three groups (A, B and C), major resection (group A) in 79 (56.3%), segmental resection (group B) 31 (22.1%) and localized resection (group C) in 30 (21.4%). Early postoperative mortality and morbidity as well as long-term survival and recurrence were assessed. RESULTS: The overall hospital mortality rate was (8.6%) with total complications 26%, recurrence rate 32.8% and median survival was 24 months (3-120). Group A showed high incidence rate of hospital mortality, total complications and hepatic cell failure than the other two types (p>0.05). On the other hand, group C patients showed high incidence of wound infection and recurrence rate after hepatic resection than the other two types (p>0.05). At the end of the study, the median survival was 18 months (4-120), 24 months (3-48) and 24 months (3-120) for the three groups respectively without significant difference. The overall 5-year survival rate was 20%, 0% and 15.3% for the three groups respectively (p>0.05). CONCLUSIONS: Although major liver resection in cirrhotic liver has high incidence of early mortality and morbidity, it gives low incidence of recurrence and better survival in comparison with segmental and localized resection. However it has to be reserved for large tumor in good liver and early cirrhosis.     

Surgery for adult polycystic liver disease

Adult polycystic liver disease, commonly associated with polycystic kidney disease, can result in massive hepatomegaly and debilitating symptoms. Surgical intervention for symptomatic polycystic liver disease, such as cyst fenestration or liver resection has been associated with significant morbidity and inconsistent long-term palliation. However, selected patients with severe symptoms benefit from liver resection and extensive fenestration with acceptable morbidity and mortality. Total hepatectomy and orthotopic liver transplantation may be considered for patients with severe adult polycystic liver disease.     

经尿道前列腺等离子剜除术与电切术治疗前列腺增生的疗效比较

目的 比较经尿道前列腺等离子双极电切剜除术(TUPKEP)与经尿道前列腺电切术(TURP)治疗良性前列腺增生(BPH)的临床疗效及安全性.方法 将142例BPH患者分为两组,TUPKEP组72例,年龄52～90岁,平均(70.5±7.6)岁,前列腺质量27～126 g,平均(75.6±10.3)g;TURP组70例,年龄51～87岁,平均(70.2±6.8)岁,前列腺质量25～118 g,平均(73.8±9.9)g.两组患者术前年龄、前列腺质量、前列腺症状评分(IPSS)、剩余尿量、最大尿流率、生活质量评分(QOL)比较,差异均无统计学意义(t值分别为0.2873、1.0612、1.0832、0.9522、0.0000、1.0774;P值分别为0.7743、0.2904、0.2806、0.3426、1.0000、0.2832).比较两组手术时间、术中出血量、术后尿管留置时间、住院天数、术后并发症发生率及疗效.结果 TUPKEP组72例均获成功(100.0%),TURP组成功69例(98.6%).TUPKEP、TURP组平均手术时间分别为(46.2±6.4)min、(58.4±9.6)min,组间比较差异有统计学意义(t=8.9404,P-0.0000);两组术中出血量分别为(105.9±12.2)ml、(148.6±14.3)ml,组间比较差异有统计学意义(t=19.1608,P=0.0000);两组术后平均留置尿管时间分别为(3.5±1.0)d、(5.0±1.0)d(t=8.9364,P=0.0000);两组术后平均住院时间分别为(5.1±1.9)d、(7.0±0.6)d(t=4.9819,P=0.0000).TUPKEP组术后发生暂时性尿失禁1例,继发前列腺出血2例,尿道外口狭窄1例,并发症发生率5.56%,TURP组发生经尿道前列腺电切综合征2例,尿外渗1例,术后暂时性尿失禁2例,继发前列腺出血3例,尿道外口狭窄2例,并发症发生率14.29%.术后随访3个月,两组最大尿流率较术前明显增加,IPSS、剩余尿量、QOL均较术前明显下降,组间比较差异均无统计学意义(t值分别为1.1131、0.2543、1.2959、0.7252;P值分别为0.2676,0.7996、0.1971、0.4696).结论 TUPKEP与TURP治疗BPH的疗效相近,但TUPKEP平均手术时间短、术中出血量少、围手术期及术后并发症发生率低,手术安全性更高.     

Laser therapy for benign prostate hyperplasia

Various procedures operating with different laser systems and application techniques are available for laser treatment of benign prostate hyperplasia (BPH). They generate differing qualitative and quantitative effects in tissue such as coagulation, vaporisation or, respectively, ablation as well as incisions leading according to technique to a resection or enucleation. Since these procedures are considered as alternatives to transurethral resection of the prostate (TURP), the objective of laser therapy is not only to achieve, in comparison to TURP, an equivalent improvement of the symptoms and quality of life but also a maximal urinary flow strength or, respectively, a reduction of obstruction to bladder emptying with lower accompanying morbidity and shorter hospitalisation. Most of the published case control and randomised studies on laser therapy for BPH show heterogeneous results both with regard to the improvement of subjective and objective urination parameters as well to complications. This is due, on the one hand, to the laser or its qualitative action and, on the other hand, to the operator and the resulting specific quantitative effect. The biophysical relationships between the laser parameters and the tissue effects are a topic of current discussion. The biological effect depends not only on the depth of penetration and the scattering but also on other parameters of the laser. For the generation of voluminous coagulation necrosis with a laser in the ca. 800 to 1100 nm wavelength region, a carbonisation of the surface must be avoided. For thermal vaporisation, for example, the Nd:YAG laser with contract-free application or contact tips as well as diode lasers of varying wavelengths are suitable. Especially suitable are the potassium titanyl phosphate (KTP) laser and the lithium triboride (LBO) laser. Ablation is also possible with the Ho:YAG laser. An incision and thus resection or enucleation is also possible with various laser systems including thermal ones, but is more effective with a continuous beam laser of ca. 2000 nm. The Ho:YAG laser achieves an athermal incision the quality of which depends on the pulse energy and the time behaviour of the laser impulse.     

Urinary Retention and Incontinence after Low-Dose-Rate Brachytherapy for Prostate Cancer

Low dose rate permanent prostate brachytherapy is an excellent choice for men with localized prostate cancer. We review the contemporary understanding of genitourinary toxicity after prostate brachytherapy with particular attention directed toward urinary retention and incontinence. Urinary retention, though typically transient, has been reported in 1.5-34 % of patients, and significantly impacts health-related quality of life. Pre-treatment predictors include prostate size and high pre-treatment urinary symptom score. Validated nomograms have recently been developed to prospectively identify those at risk for urinary retention. In patients with refractory bladder outlet obstruction, a minimal transurethral resection of the prostate (TURP) is employed following a time interval sufficient for delivery of the full prescribed radiation dose. Urinary incontinence is uncommon following brachytherapy but is strongly associated with prior or subsequent TURP, where published incidence reports range from 0-19 %. Ongoing research seeks to identify genetic polymorphisms that may select individuals at greater risk of developing radiation related toxicities.     

Long-term results of surgical management of pulmonary metastases from renal cell carcinoma

BACKGROUND: Metastatic renal cell carcinoma (RCC) has a poor prognosis and conventional treatments such as chemoradiotherapy show little efficacy. Surgical resection of pulmonary metastases from RCC is a widely accepted treatment, even if selection criteria based on prognostic factors have still not been defined. The aim of this study was to determine the long-term survival, clinical outcome and prognostic factors after surgery. METHODS: Between 1988 and 2004, 59 patients underwent resection of pulmonary metastases from RCC. Univariate and multivariate analysis of prognostic factors was carried out. RESULTS: Complete resection was achieved in 54 (91.5 %) patients. No intra- or postoperative mortality occurred, 5 (8.5 %) patients experienced postoperative complications. Overall, the 1-, 3-, and 5-year survival rates were 86.5 %, 63 % and 53 %, respectively. Age at the time of pulmonary resection was found to be the only independent factor influencing prognosis. CONCLUSION: Pulmonary resection of metastases from RCC is a safe and effective treatment associated with a low morbidity and mortality and with high long-term survival. The lack of other effective therapies suggests use of the surgical approach whenever possible.     

经尿道前列腺切除术切除前列腺组织质量及比例的影响因素分析

目的 探讨影响经尿道前列腺切除术(TURP)切除的前列腺组织质量及比例的临床相关因素.方法 收集2007年1月至2009年6月接受TURP并术后病理证实为BPH的患者458例,分析术前临床指标与TURP中切除前列腺质量、前列腺切除比例之间的相关性.结果 458例患者平均年龄69.5岁,体质指数24.3 kg/m2,前列腺特异性抗原(PSA)6.1μg/L,前列腺测量体积85.5 ml,最大尿流率8.4 ml/s,残余尿量31.8 ml,前列腺切除质量32.9 g,前列腺切除率37.6%.前列腺体积、体质指数与前列腺切除体积呈正相关,体质指数与前列腺切除比例正相关,前列腺体积与腚前列腺切除比例无相关,但前列腺体积＜40 ml与＞40 ml患者的前列腺切除率差异有统计学意义.非那雄胺对前列腺切除质量、前列腺切除比例无明显影响.结论 前列腺体积、PSA和体质指数与TURP切除前列腺组织质量正相关.TURP切除前列腺组织的比例与体质指数正相关,前列腺体积＜40 ml的切除比例较高;非那雄胺对前列腺切除质量及比例无影响.

Abstract：

Objective To evaluate the impact factors on weight and proportion of prostate tissue resected by transurethral resection of prostate (TURP) in patients with benign prostatic hyperplasia (BPH). Methods The patients undergoing TURP from January 2007 to June 2009 and diagnosed as BPH according to postoperative pathological results were enrolled in this study. The prostate volume measured by transrectal ultrasound (TRUS), prostate specific antigen (PSA), maximum flow rate (MFR), residual urine volume and body mass index (BMI) were measured and calculated. The prostate tissue collected at resection was weighed, and the proportion of the prostate resected was the percentage of the pre-operative estimated weight. Results For the 458 patients with the average age of 69.5 years, average BMI was 24. 3 kg/m2 , PSA 6. 1 μg/ml, prostate volume 85.5 ml, MFR 8. 4ml/s, residual urine volume 31.8 ml, resected prostate weight 32.9 g, proportion of resection 37. 6%Prostate volume and BMI were positively related with resected prostate weight. BMI was positively related with proportion of prostate resection. There was no linear correlation between prostate volume and resected proportion. But there was significant difference in resected proportion between patients with prostate volume more than and less than 40 ml. Finasteride had no influence on the weight and resected proportion. Conclusions Prostate volume, PSA and BMI are correlated with weight and proportion of prostate tissue resected by TURP. Finasteride has no influence on the resected weight and proportion.     

老年人腹股沟疝修补术与尿道前列腺电切术同期进行的疗效观察

目的 探讨治疗老年腹股沟疝并存前列腺增生症（BPH）患者一次性完成手术的可能性及疗效观察。方法 回顾性分析50例（65～78岁），老年腹股沟疝并存良性前列腺增生患者，采用腹股沟无张力疝修补术的同时行经尿道前列腺电切术（TURP）的临床资料。结果 手术顺利，手术时间60～90min，伤口疼痛较轻，手术切口均为甲级愈合。术后无并存疾病加重，均于术后5～9d出院。50例患者均获得随访，随访6个月至4年，未见疝复发和补片移位，排尿通畅，无尿失禁及尿道狭窄等并发症。结论 老年腹股沟疝并存前列腺增生症患者可在行腹股沟无张力疝修补术同时行TURP，可减少手术的费用，手术安全，术后并发症少。     

Radical surgery: vascular and pancreatic resection for cholangiocarcinoma

Recent progress in vascular surgical techniques has made it possible to combine liver and portal vein and/or hepatic artery (HA) or retrohepatic inferior vena cava (IVC) resection and reconstruction in cases of locally advanced cholangiocarcinoma. Reports of the success of this difficult surgery have been published. Aggressive Japanese surgeons have applied hepatopancreatoduodenectomy (HPD) not just in cases of advanced gallbladder cancer, but also in locally advanced cholangiocarcinoma with or without superficial spread. The above extended surgeries were associated with high postoperative morbidity and mortality, but recent progress in perioperative management and surgical techniques has improved the outcome of these types of surgery. Combined portal vein and liver resection provides R0 resection and contributes to longer survival in resected patients with locally advanced cholangiocarcinoma than in unresected patients. Portal vein invasion is a strong prognostic factor of cholangiocarcinoma and the actual number of 5-year survivors is limited. The number of clinical cases of liver resection combined with IVC or HA resection and reconstruction is still limited, and therefore the long-term survival benefit from these procedures has not been clarified. HPD carried high morbidity and mortality rates in the 1990s, but the outcome has been improving and an increasing number of 5-year survivors has been reported. Although the clinical value of the above extended surgeries has not been evaluated prospectively, with the increasing number of retrospective studies it has been concluded that combined liver and portal vein and/or HA or IVC resection or HPD could be indicated for selected patients with locally advanced cholangiocarcinoma.