Nghien CIXU Y hpc ^ "^"^ ^^- ^° ^^^ ^ ^ " ^ * "^^P 18 * So 1 * 2014
^ N G D U N G LASER T H U L I U M V O I BU^OC S O N G LIEN T U C 2-tiM
TRONG DIEU TRI BU'OU LANH TUYEN TIEN LIET
Nguyin TeKha', Nguyen Phuc Cam Hoang*, Nguyen Nggc Thai"
TOMTAT
^dt van di: nghiai cieu khd ndng duu tii phdu thudt bieon lanh tuyai tien Hit (BLTTL) sie dung nguon nang lugng mai laser Thuliumdaped Yttiium Aluminium Ganid (Tm:YAG) budc song lien tuc 2pm.
Muc dtch: ddnh gid tinh hiiu qua, khd thi, do an todn vd biin chihig cua nguon nang lugng mdi laser Tm:YAG ti-ong dieu tri BLTTL
Doi tugng vd phuong phdp nghien cdu: nghiin dm tien deu toiig cgng 119 tiTidng hgp dugc dieu tri cdt idio vd boc hai (vaporesedion) BLTTL sir dung laser Thulium: yttrium-alumium-gamet (Tm.YAG). Tuoi trung biidi 74,03 ± 9,7 (55-96) tudi. Tlii' tich ti^ng binh tuyai tien Hit trudc phdu thuqt Id 60,29 ± 26,68 (15,25- 124,41) mL. Kel qud sau pMu thudt ddnh gid cdc yai to' thdi gian phdu thuat, ty le truyen mdu, haemo^obin huyei tiianh, Na* huyii thanh, thin gian dqt thong niiu dqo, thai gian nam vien. Cdc yai to'dugc ddnli gid trudc vd sau phau thudt la: bdng diem quoc te ddnh gid tiieu chimg tuyai tien Hit (IPSS: Intemational Prostate Symptom Score), bdng diem chdi lugng cuoc sdng (QoL Quality of Lift Index), luu lugng dong tiai toi da ("Q™.- maximum urinary flow rate), lugng nude tiai ton Iwu (PVR: postvoiding residual urine volume), theo doi sau 1 vd 3 thdng.
Ke't qua: tlidi gian pliau thuqt trung binh 58,03 ± 22,63 (20-120) phdt. Khong co trudng hop ndo phdi ti-u-yen mdu. Kliong co tiudng hgp ndo hi hoi diung ck doi ngi soi Thdi gian dqt thong nieu dqo trung binh 2,6 ± 1,3 (1-7) ngdy. QWM trung binh 42 trudng hgp khong bi tiiu trudc mo 5.42 ± 1,74 (1,8-8,9) mUs, sau phau thudt 1 thdng Id 15,2 ± 3,25 (9-21,6), sau phau thudt 3 Mng Id 17,63 ± 2,62 (12,5-25,3). Q.un 77 tivdng hgp bi tieu hay khong do dwgc trwdc phau thuqt, sau khi phdu thudt 1 thdng Id 15,39 ± 3,07 (9-23), sau khi phdu thudt 3 thdng 17,46 ± 2,9 (9-24,2). Lugng nude tieu ton Iwu sau phau thuqt 1 thdng Id 29,98 ± 25,44 (0-96), sau phau thudt 3 thdng Id 14,55 ± 17,31 (0-68). Dian IPSS ti-iedc plidu thuat Id 30,57 ± 3,25 (18-35), sau phdu thudt 1 thdng 12,14
± 1,68 (8-16), sau ph&u thudt 3 thdng 9,96 ± 1,93 (6-15), Dian QoL frwc phau thuqt la 5,29 ± 0,62 (1-6), sau phdu thuqt 1 thdng 2,19 ± 0,42 (1-3), sau phau thuqt 3 tiidng 1,88 ± 0,44 (1-3).
Ke't ludm Sie dung laser Tliulium vdi budc song liin tuc 2 pm irong dieu tri BLTTL Id an todn, hiiu qud i-fl it biai chimg co khd ndng dp dung rgng rdi. Ddy Id phuong phdp ddy hwa hen c6 the thay the phau thmt cdt dot ngi soi tiiu chuan.
Tit Idioa: biedu Idrdi tuyai tien hit, laser. Thulium, cdt dot ngi sol ABSTRACT
VAPORESECTION FOR MANAGING BENIGN PROSTATIC HYPERPMSM USING A THUUUM 2-^iM CONTINUOUS-WAVE LASER: INTTLM RESULTS
Nguyen Te Kha, Nguyen Phuc Cam Hoang, Nguyen Ngoc Thai
•Y Hoc TP.Ho Chi Minh'Voi. 18- No 1 - 2014:372 - 378 Introduction: The potential ofa iww continuous-wave 2-pm Thulium-doped Yttiium Aluminium Gamd (Tm:YAG) laser frr the endoscopic tivatmait of benign prostatic hypaylasia (BPH) is investigated.
Purpose: "Tlie simidtaneous combination of vaporisation and resection of prostatic tissue in a retiograde
* Khoa Tiet Ni?u, BV Binh Dan
TdcS"'''^'''"^-''^^-^^^S"y^"TeKha 07:0938 898 659 Email npiventekhaMg\'ahoo.com
372 Hpi Nghi Khoa Hpc Ky Thuat BV. Binh Dan 2014
Y Hpc TP. Hb Chi M i n h * Tap 18 * So 1 * 2014 Nghien cmi Y hpc fashion is the main charadenstic of this new laser technique.
Materials and methods: We treated 119 conseaitive patients zvith obstructive BPH using a 2-ftm continuous-ivave laser. The mean age of tlie patiaits was 74,03 ± 9,7 (55-96) years. Befrre laser tieatinait, the patients zoa-e examined. The mean prostatic volume was 60,29 ± 26,68 (15,25-124,41) mL The operative outcomes assessed zvere: resection time, transfusion rate, catheter time, haemoglobin serum and sa-um sodium levels. The follozoing variables wa-e assessed befrre and after vaporesedion: maximum urinai-y flaw rate (Q»ua), postvoiding residual urine volume (PVR), International Prostate Symptom Score (IPSS), Quality of Life Index (QoL), 3-months folloio-up.
Results: vaporesection time was 58.03 ± 22.63 (20-120) min None ofthe patients required a transfusion.
The mean catheter time was 2.6 ± 1.3 (1-7) days. The mean Qm^for 42 patients imthout preoperative urinary retention was 5.42 ± 1.74 (1.8-8 9) mUs, after the P'- month Q™«x- was 152 ± 3.25 (9-21.6) mUs, after the 3 ^ - month was 17 63 ± 2.62 (12.5-25.3) mUs. Q»^ for 77 patiaits with preoperative urinary retention or unable measured was 15.39 ± 3.07 (9-23) mUs after tlie P - month, 17.46 ± 2.9 (9-24.2) mUs afta- the 3'^ - month.. The PVR after the P- month vaporesection was 29.98 ± 25.44 (0-96) mL and afta- the 3"*- month was 14.55 ± 17.31 (0-68) mL The preoperative IPSS is 30.57 ± 3.25 (18-35), after P>- month the IPSS was 12.14 ± 1.68 (8-16), afta- 3"'- month the IPSS wass 9.96 ± 1.93 (6-15). The preoperative QoL 5.29 ± 0.62 (1-6), after 1''- month the QoL was 2.19 ± 0.42 (1-3), after 3'^ month the QoL was 1.88 ± 0.44 (1-3). respectively (P<0.05).
Ccmclusioiv Vaporesection using the 2 pm continuouswave laser for the treatment of obstructive BPH is a safe and effedive ablatiiJe procedure.
Key words: LASER, Tm:YAG, vaporesedion, baiign prostatic hyperplasia D A T V A N D E
Phan Ion dan ong tren 60 tuoi deu it nhieu CO trieu chiing roi logn dirong tieu duai do buou lanh tuyen tien liet {BLTTL)(^). Cit dot noi soi (CDNS) van la tieu chuan vang trong dieu tri phau thuat doi voi BLTTL. Tuy nhien cac bien ehung bao gom: nhiing tai bien va bien chiing nhu: chay mau can phai truyen mau chiem 8%, hoi chiing CDNS chiein 1- 3%.... Trong nhiing thap ky gan day, cac thiet bi LASER khac nhau duac gioi thieu: LASER neodymium-doped yttrium aluminium garnet (Nd:YAG), LASER the holmium-doped YAG (Ho:YAG)P', LASER potassium titanyl phosphate laser (KTP) anh sang xanh la cay"°).
Su khac nhau ve mat nang luong, buoc song, loai phat song (lien tuc hay ngit quang) dan den su khac nhau trong chiic nang, ky thuat ling dung, va do xuyen mo. Viec iing dung loai LASER nao con phu thupc vao nWeu yeu to khac nhau nhu: ket qua chuc nang ngan han hay dai han, do an toan cua phuang phap, bien ehung, thoi gian phau thuat va chi phi.
LASER Tm: YAG (Thulium: yttrium- aluminium-gamet) la the he LASER mai nhat voi dac tinh mi viet hon laser Holmium. LASER Thulium co buac song 2 [nn. va kha nang phat song lien tuc (tot hon so vod LASER Holmium co buoc song 2,1 |jna) danh rieng cho cac iing dung phau tiiuat npi soi trong moi truang nu6c<^>.
Buoc song nay dupe hap thu manh me boi nuoc (buoc song nuoc la 1,94 [im) va dung dich nuoc muoi sinh ly. Buoc song lien tuc 2 fim co vai tro lan trong viec lam boc hoi, cat mo co mach mau va mo khong mach mau, dong thai giiip cam mau tot va it ton tiiuong mo xung quanhf^.
Trong nghien a i u nay, chiing toi su dung LASER Tm: YAG (RevoLix™) (san p h ^ LASER LISA, Katienburg, Germany) trong dieu tri phau thuat BLTTL nham cac muc tieu sau:
- Danh gia tinh hieu qua va kha thi khi sii dung nang luong laser Thulium.
- Danh gia dp an toan va bien chiing cua phau thuat khi sii dung nang Iupng laser Thulium,
Hoi Nghi Khoa Hpc Ky Thuat BV. Binh Dan 2014 373
^Jghien cuu Y hpc
^**^TUQ^JG-PHUiC»sKiH^APNGHIENCUtJ Tong cpng 119 truong hpp co chi dinh phlu thuat dupe dieu tri su dung nang lupng LAER Tm: YAG (buoc song hen tuc 2 pm) tir Ihang 3 nam 20li toi thang 1 nam 2013 t ^ khoa nieu benh vien Binh Dan. Tuoi trung binh la 74,03 ± 9,7 (55-96) tuoL Cac benh nhan duoc tham kham day du truoc phlu tiiuat bao ^ m Ijenh sCr, tham kham hau mon true trang, tong phan tich nuoc tieu, creatinine huyet thanh, PSA huyet thanh.
Trieu chiing duong tieu duoi duoc danh gja b3ng bang dian quoc is danh gia trieu chiing hiyen tien liet (IPSS: Intemational Prostate Symptom Score), bang diein chat lupng cupc song (QoL: Quality of Life Index). Sieu am qua nga bung giiip dA:ih gia the tich :u\e:T rr^n '.iet
\ Hpc TP. Hb Chi Minh * Tap 18 * Sb 1 * 2014 (Vm-) va nuoc tieu tbn luu (NTTL). Benh nhan duoc do meu dong do de danh gia luu luong dong beu tbi da (Q™.: the maximum urinar)' flow rate). Tat ca benh nhan co nghi ngo buou ac qua cac tiiong sb (PSA, tiiam kham hau mon true trang haj' sieu am) deu duoc tien hanh sinh thiet tuyen tien liet. Neu ket qua la ac tinh thi se bi toai khoi nghien ciiu.
Nang lupng Tm: YAG (RevoLix^') (san phain LASER LISA, Katienburg, Germany) voi buoc song 2 fim phat lien tuc sii dung de cit nho, bbc hoi bucru. Day dan truyen LASER (RigjFib 800, san pham laser LISA). Ma\- soi bang quang 26 F (resectoscope) (Karl Storz, Germany).
Nuoc duoc su dung trong phau thuat la nuoc muoi sinh !v
Hinh 1: Mdy plidt laser Tm: YAG Hhth 2: Day ddn truyen laser vd mdy soi bdng quang 26 F (resedoscopc)
Hinh 3a: Vi tri diedng cdt thiiy giiia 5h.7h Hitih 3b: Doi Hinh 3: Qud triidi plidu thuqt
Qua trinh phau thuat dupe tieh hanh nhu sau: xac dinh va danh dau gioi han ciia vung phau thuat so voi u mii, tien hanh cat 6 \'i tri 5h va 7h (miic dp boc hoi dupe Idem soat bang toe dp Clia spi dan laser xuyen mo), tiep tuc c^t tioi ve phia tnroc so voi gioi han da dupe danh dau thiiy giiia, va sau cimg la thiiy t)en. Cac mau buou duoc cat nho va boc hoi nho giong nhu cac
boc hai vj tii 12h Hinh 3c: Cat dot mat cdt TTL mau trong cat dot npi soi. Cac mau nay de dang hiit ra nho bom hiit thuy tinh (resectoscope sheath) ma khong ran dimg den may xay mo (morcelator). Thong nieu dao dupe dat truoc khi ket thiic phau thuat.
Sau phau thuat xac dinh cac yeii to: thoi gian phlu thuat, ty le truyen mau, haemoglobin hu}'et fhanh, Na" huyet thanh, thoi gian dat thong nieu dao. Qua., NTTL, IPSS, QoL. Benh Hpi Nghi Khoa Hpc Ky Thual BV. Binh Dan 2014
Y Hpc TP. H'6 Chi Minh * Tap 18 * So 1 * 2014 Nghien ciiu Y hpc nhan dupe theo doi sau 1 thang va 3 thang.
KETQUA
long cpng 119 truong hop BLTTL dupe dieu tri cat nho va lam bay hoi ttuou su dtmg nguon
nang luong Tm: YAG tu thing 3 nam 2011 tin thang 1 nam 2013 tai khoa nieu benh vien Binh Dan. ehung toi nit ra dupe nhung ket qua sau:
Bang 1: Cdc yeu toti-uac, tiong vd ngay sau phdu thudt Yiut6
T6ng s6 tni'O'ng hop Tu6i PSA (ng/mL)
VTTL(mL) Thdn gian p h l u thuat (phut) Haemoglobin tai'O'c mo (g/dL)
Haennoglobin sau mo (g/dL) P Na huyei thanh taro'c mh (mmol/L)
Na huyet thanh sau m o (mmol/L) P Thcvi gian d | t thong meu <5eo (ngay)
Thcri gian nam vien (ngay)
S d l i e u
'•^H
119 74.03 ± 9 . 7 (55-96) 4,65 ± 3 . 6 8 (0.45-14,78) 60,29 ± 2 6 , 6 8 (15,25-124,41)
58,03 ± 2 2 , 6 3 (20-120) 13,62 ± 1 , 5 9 (8,8-16,7) 12,6 ± 1 , 5 6 (9.2-15,8) cO.05 (test VWIcwxon) 1 3 9 , 4 4 ± 3 . 5 6 (128-146) 1 3 9 , 0 3 ± 3 , 1 6 (128-149)
>0.05 (test Wilcoxon) 2,6 ± 1 , 3 (1-6) 2.86 ± 1 , 2 (1-6)
Bang 2: Bdng so sdnh cdc yeu to trudc vd sou phdu thuqt
Y 6 u t 6 PSA (ng/ml)
Qmax 42 tru'd'ng hp'p khdng bi t d u tnj-d'c PT (mL/s)
Qmax 77 tru'd'ng hpp bi ti^u tru'd'c p h l u thuat hay khdng i3odm7C(mL)
NU'O'C t i l u t 6 n l m j
IPSS
QoL
T n i w c P T 4,65 ± 3 , 6 8 (0.45-14,78) 5.42 ±1,74
( 1 , 8 - 8 , 9 )
30,57 ± 3.25 ( 1 8 - 3 5 ) 5.29 ± 0.62
(1-6)
Sau PT 1 thang 2,08 ± 1 , 5 8 (0,34-7,6) 15,2 ± 3 , 2 5 ( 9 - 2 1 , 6 ) "
15,39 ± 3 , 0 7 ( 9 - 2 3 ) 29,98 ± 25,44
( 0 - 9 6 ) 12,14 ± 1 , 6 8
( 8 - 1 6 ) * 2,19 ± 0,42
(1-3)'
Sau p h i u thuat 3 thaig
17,63 ± 2 , 6 2 (12,5-25,3)*
17,46 ± 2 , 9 (9 - 24,2) 14,55 ±17,31
(0 - 68) 9,96 ± 1 , 9 3
( 6 - 1 5 ) * 1,88 ± 0 . 4 4
(1-3)*
*p < 0,05 so vai tntoc phau thudt
Bdng 3: Kei qud cua Thulium vaporesection ofthe prostate vaporesedion (ThuVARP) so vdi cdc loqi LASER diiu
lac gia
Kuo (2003)"-"
Vavassori(2004)""
Elzayad (2006)''"
Sandhu (2004)'""
Bach (2007)'"
Szlautjr ( 2 0 0 8 ) " "
Fu (2008)""
Nghien CLfU nay
Nang l i j ^ ^ g
HoLEP HoLEP HoLEP KTP-PVP ThuVARP ThuVARP ThuVARP TtiuVARP
Sd b^nh nhdn (n)
206 196 225 64 .54 56 72 119
V T T L ( m L )
n a.
54,3 126 101 30,3 50 65,8 60,29
Thdi gian d^t thdng ni^u d^o
1,1 n.a.
1.3 0,75 1.7 1 1,7 2,6
T h d i gian n i m vien
1.1 1,5 1,2
<1 3,5 5 2,8 2,86
M i t m a u can truy6n(%)
1 0 1,3
0 0 0 0 0
BAN LUAN
CDNS van la tieu chuan vang trong dieu
tri phau thuat doi vol BLTTL. Tuy nhien cae bien chiing bao gom: nhiing tai bien va bien
Hpi Nghi Khoa Hpc Ky Thujt BV. Binh Dan 2014 375