良性前列腺增生微创术后逆行射精的解剖功能机制与预防策略体系建立

Anatomical and functional mechanisms of retrograde ejaculation following minimally invasive surgery for benign prostatic hyperplasia and the establishment of a preventive strategy framework

摘要

尽管良性前列腺增生（BPH）微创手术技术日趋成熟，能够显著缓解下尿路梗阻并改善排尿症状，但术后逆行射精（RE）发生率仍然较高，严重影响患者性生活质量、生育计划和心理健康。传统观点多将 RE归因于膀胱颈闭合不全，近年来的解剖学与功能研究进一步提示，精阜近侧“射精肌”系统、射精管开口的空间取向以及尿道黏膜闭合效应在维持顺行射精过程中同样发挥关键作用。以电切和激光为能量平台的经尿道前列腺切除、剜除或汽化术在缓解尿路梗阻的同时易造成上述关键结构损伤，从而显著增加 RE和射精功能障碍的风险。本综述在系统梳理BPH 与逆行射精共同发病机制、总结不同微创术式对射精功能影响的基础上，结合近年来的循证证据和本中心临床实践经验，提出以术前射精功能及生育意愿评估、术中射精相关解剖结构的精细保护、术后基于患者报告结局（PROMs）的规律随访与功能康复为核心的一体化管理体系，旨在为临床医生制定射精功能保护导向的个体化BPH 微创治疗策略提供参考，并为后续开展前瞻性研究奠定理论基础。

Abstract

Despite the increasing sophistication of minimally invasive surgical techniques for benign prostatic hyperplasia (BPH)，which can significantly relieve lower urinary tract obstruction and improve voiding symptoms，the incidence of postoperative retrograde ejaculation(RE) remains high.This severely impacts patients' sexual quality of life，fertility plans and psychological well-being.While traditional viewpoints often attribute RE to bladder neck incompetence，recent anatomical and functional studies suggest that the“ejaculation muscle” system proximal to the verumontanum，the spatial orientation of the ejaculatory duct orifices，and the urethral mucosal coaptation effect also play crucial roles in maintaining antegrade ejaculation. Transurethral prostate resection，enucleation，or vaporization procedures using electrocautery or laser as energy platforms，while relieving urinary tract obstruction，readily cause damage to these key structures，thereby significantly increasing the risk of RE and ejaculatory dysfunction.Based on a systematic review of the shared pathogenesis of BPH and RE，and a summary of the impact of different minimally invasive procedures on ejaculatory function，this review integrates recent evidence-based findings and clinical experience from our center.It proposes an integrated management system centered on preoperative assessment of ejaculatory function and fertility intentions，intraoperative meticulous protection of ejaculation-related anatomical structures，and postoperative regular follow-up and functional rehabilitation based on patient-reported outcome measures (PROMs).The aim is to provide clinicians with a reference for formulating individualized BPH minimally invasive treatment strategies oriented towards ejaculatory function preservation and to lay a theoretical foundation for subsequent prospective research.

关键词

良性前列腺增生 / 微创手术 / 逆行射精 / 射精功能 / 电切术 / 激光手术 / 中医药

Key words

benign prostatic hyperplasia / minimally invasive surgery / retrograde ejaculation / ejaculatory function / electroresection / laser surgery / traditional Chinese medicine

参考文献

[1] OELKE M， BACHMANN A， DESCAZEAUD A ，et al；European Association of Urology. EAU guidelines on the treatment and follow-up of non-neurogenic male lower urinary tract symptoms including benign prostatic obstruction[J]. Eur Urol， 2013，64（1）： 118-140.

[2] MAHON JT， WELLIVER C. National trends in the management of lower urinary tract symptoms associated with benign prostatic hyperplasia[J]. Curr Urol Rep， 2020，21（12）： 63.

[3] DEVLIN CM， SIMMS MS， MAITLAND NJ. Benign prostatic hyperplasia-what do we know? [J]. BJU Int， 2021，127（4）： 389-399.

[4] SOANS J， VAZIRIAN-ZADEH M， KUM F， et al. Can surgical treatment for benign prostatic hyperplasia improve sexual function? A systematic review[J]. Aging Male， 2020，23（5）： 770-779.

[5] DE NUNZIO C， ROEHRBORN CG， ANDERSSON KE， et al. Erectile dysfunction and lower urinary tract symptoms[J]. Eur Urol Focus， 2017，3（4-5）： 352-363.

[6] MARTÍNEZ-SALAMANCA JI， CARBALLIDO J， EARDLEY I， et al. Phosphodiesterase type 5 inhibitors in the management of non-neurogenic male lower urinary tract symptoms：critical analysis of current evidence[J]. Eur Urol， 2011，60（3）： 527-535.

[7] GIONA S， GANGULY I， MUIR G. Urologists' attitudes to sexual complications of LUTS/BPH treatments[J]. World J Urol， 2018，36（9）： 1449-1453.

[8] MANFREDI C， GARCÍA-GÓMEZ B， ARCANIOLO D， et al. Impact of surgery for benign prostatic hyperplasia on sexual function：a systematic review and meta-analysis of erectile function and ejaculatory function[J]. Eur Urol Focus， 2022，8（6）： 1711-1732.

[9] CHEN SS， CHIU AW， LIN AT， et al. Clinical outcome at 3 months after transurethral vaporization of prostate for benign prostatic hyperplasia[J]. Urology， 1997，50（2）： 235-238.

[10] KÜPELI S， BALTACI S， SOYGÜR T， et al. A prospective randomized study of transurethral resection of the prostate and transurethral vaporization of the prostate as a therapeutic alternative in the management of men with BPH[J]. Eur Urol， 1998，34（1）： 15-18.

[11] LIAO J， ZHANG X， CHEN M， et al. Transurethral resection of the prostate with preservation of the bladder neck decreases postoperative retrograde ejaculation[J]. Wideochir Inne Tech Maloinwazyjne， 2019，14（1）： 96-101.

[12] YANG SS， TSAI YC， CHEN JJ， et al. Modified transurethral incision of the bladder neck treating primary bladder neck obstruction in young men：a method to improve voiding function and to preserve antegrade ejaculation[J]. Urol Int， 2008，80（1）： 26-30.

[13] BRANT A， CHO A， POSADA CALDERON L， et al. Ejaculatory hood-sparing vaporization of the prostate and its impact on erectile，ejaculatory，and sexual function[J]. Urology， 2020，144： 177-181.

[14] HU ZJ， LIU F， LI BH， et al. Preservation of sexual function with blue laser vaporization in the treatment of benign prostatic hyperplasia：a prospective study[J]. Aging Male， 2025，28（1）： 2473609.

[15] GEMMA L， PECORARO A， SEBASTIANELLI A， et al. Impact of minimally invasive surgical procedures for male lower urinary tract symptoms due to benign prostatic hyperplasia on ejaculatory function：a systematic review[J]. Prostate Cancer Prostatic Dis， 2024，27（3）： 404-421.

[16] XU X， JIANG D， LIU G， et al. In vitro evaluation of the safety and efficacy of a high-power 450-nm semiconductor blue laser in the treatment of benign prostate hyperplasia[J]. Lasers Med Sci， 2022，7（1）： 555-561.

[17] CHE X， ZHOU Z， CHAI Y， et al. The efficacy and safety of Holmium laser enucleation of prostate compared with bipolar technologies in treating benign prostatic hyperplasia：a systematic review and meta-analysis of 10 randomized controlled trials[J]. Am J Mens Health， 2022，16（6）： 15579883221140211.

[18] JUNG JH， MCCUTCHEON KA， BOROFSKY M， et al. Prostatic arterial embolization for the treatment of lower urinary tract symptoms in men with benign prostatic hyperplasia[J]. Cochrane Database Syst Rev， 2022，3（3）： CD012867.

[19] WANG XY， ZONG HT， ZHANG Y. Efficacy and safety of prostate artery embolization on lower urinary tract symptoms related to benign prostatic hyperplasia：a systematic review and meta-analysis[J]. Clin Interv Aging， 2016，11： 1609-1622.

[20] ELTERMAN D， SHEPHERD S， SAADAT SH， et al. Prostatic urethral lift (UroLift) versus convective water vapor ablation (Rezum) for minimally invasive treatment of BPH：a comparison of improvements and durability in 3-year clinical outcomes[J]. Can J Urol， 2021，28（5）： 10824-10833.

[21] GILLING P， BARBER N， BIDAIR M， et al. Three-year outcomes after aquablation therapy compared to TURP：results from a blinded randomized trial[J]. Can J Urol， 2020，27（1）： 10072-10079.

[22] YALÇIN S， TUNÇ L. Indications，techniques，and role of new minimally invasive benign prostate hyperplasia surgical options[J]. Turk J Urol， 2020，46（Supp 1）： S79-S91.

[23] 徐晓龙， 满超， 岳传超， 等. 蓝激光前列腺汽化切除术对良性前列腺增生患者术后性功能及下尿路症状的影响[J]. 现代泌尿外科杂志， 2024，29（6）： 501-504， 509.

[24] 姚实林. 中药治疗良性前列腺增生的机制研究进展[J]. 安徽中医药大学学报， 2025，44（6）： 106-112.

[25] 何建业. 中药治疗前列腺术后出血58例[J]. 广西中医学院学报， 2001，4（3）： 32-33.

[26] MURAD L， LAYNE E， GANJAVI C， et al. The current state of artificial intelligence for benign prostatic hyperplasia[J]. Eur Urol Focus， 2025，11（6）： 999-1003.

基金资助

首都卫生发展科研专项项目(首发2022-2-2044)

北京市医院管理中心“登峰”人才培养计划项目(DFL20190502)

首都医科大学教育教学改革研究课题(2024JYY200)