经尿道铥激光剜除术与电切术对前列腺增生术后患者性功能的影响：一项回顾性队列研究

Impact of thulium laser enucleation of the prostate versus transurethral resection of the prostate on sexual function in patients with benign prostatic hyperplasia：A retro- spective cohort study

摘要

目的：比较经尿道镔激光前列腺剜除术（thulium laser enucleation of the prostate，ThuLEP）与前列腺电切术（transurethral resection of the prostate，TURP）治疗良性前列腺增生（benign prostatic hyperplasia，BPH）对性功能的影响。方法：采用回顾性队列方法，便利选取2022年1月至2023年12月在北京大学第一医院泌尿外科接受 ThuLEP和 TURP 手术治疗的患者临床资料，采用倾向性评分法匹配两组术前基线数据。记录匹配后两组围手术期的手术时间、术中出血量、血红蛋白下降值、切除前列腺腺体重量、膀胱冲洗时间、留置导尿管时间及住院时间等指标，收集两组术前、术后 1 个月及 12 个月的相关指标。比较两组性功能指标和排尿改善指标，包括国际勃起功能指数-5（international index of erectile function，IIEF-5）评分、逆行射精发生率，以及国际前列腺症状评分（international pros-tate symptom score，IPSS）、生活质量评分（quality of life，QOL）。结果：本研究倾向性匹配后共纳入 ThuLEP 组与TURP 组各 98 例患者，术前两组患者在年龄、前列腺体积、IIEF-5 评分、逆行射精发生率、IPSS、QOL 等方面差异均无统计学意义（P>0.05），表明两组间具有可比性。在勃起功能方面，ThuLEP 组和 TURP 组患者术后1个月、术后12个月的 IIEF-5 评分分布与术前相比，差异均无统计学意义（P>0.05）；术后 1 个月时 ThuLEP 组与 TURP 组的IIEF-5 评分分布差异无统计学意义（P>0.05），但术后 12 个月时 ThuLEP 组重度勃起功能障碍发生率显著低于TURP 组（Z=8.522,P=0.036）。在射精功能方面，ThuLEP 组和 TURP 组在术后1个月和12个月时的逆行射精发生率与术前相比，差异均有统计学意义（P<0.05），且随着术后时间延长，两组逆行射精发生率均逐渐升高；术后1 个月和12个月时，逆行射精发生率在 ThuLEP 组和 TURP 组间差异均无统计学意义（9.2% vs. $14.3\mathrm{\%},\mathit{Z}=1.231,\text{ }\mathit{P}=0.267,\text{ }19.4\mathrm{\%}\text{ }\mathit{v}\mathit{s}.25.5\mathrm{\%},\text{ }\mathit{Z}=1.055,\text{ }\mathit{P}=0.304$）。两组手术时间、术中出血量、血红蛋白下降值、切除前列腺腺体重量比较，差异均无统计学意义 (P>0.05) ；与 TURP 组相比，ThuLEP 组住院时间更短 $(4 \mathrm{~d} v s.5 \mathrm{~d}, P<$0.001）、留置导尿管时间更短（3.67 d vs. 4.26 d, P=0.012），但膀胱冲洗时间更长（19.00 h vs. $16.68 \mathrm{~h}, ~ P=$0.001）。术后1个月及12个月的 IPSS、QOL 在两组间差异均无统计学意义（P>0.05），但均较术前有显著改善。结论：ThuLEP 和 TURP 均能改善患者的下尿路症状和排尿情况，ThuLEP 在保护勃起功能、促进术后恢复方面更具潜在优势。

Abstract

Objective：To compare the effects of thulium laser enucleation of the prostate（ThuLEP） and monopolar transurethral resection of the prostate（TURP）on sexual function in patients with benign prostatic hyperplasia（BPH）. Methods：A retrospective cohort study was conducted involving patients who underwent ThuLEP or TURP at the Department of Urology，Peking University First Hospital，be-tween January 2022 and December 2023.Participants were recruited via convenience sampling.Propen- sity score matching（PSM）was subsequently employed to balance preoperative baseline characteristics between the two cohorts.Following propensity score matching，we conducted a comparative analysis of sexual function and voiding improvement metrics between the two cohorts.Sexual function was assessed using the international index of erectile function-5（IIEF-5）scores and the incidence of retrograde ejacu- lation.Voiding outcomes were evaluated based on the international prostate symptom score（IPSS），qua- lity of life（QOL）scores. Results：Following propensity score matching，the study included 98 patients in both the ThuLEP and the TURP groups.Preoperative comparisons between the two groups regarding age，prostate volume，IIEF-5 scores，incidence of retrograde ejaculation，IPSS，and QOL showed no sta- tistically significant differences (P>0.05) ，indicating comparability between the groups.Regarding erectile function，postoperative IIEF-5 scores at 1 month and 12 months in both the ThuLEP and TURP groups did not differ significantly from preoperative scores (P>0.05).At 1 month postoperatively，there was no significant difference in IIEF-5 scores between the ThuLEP and TURP groups (P>0.05).At the 12-month postoperative follow-up，the incidence of severe erectile dysfunction was significantly lower in the ThuLEP group compared with the TURP group (Z=8.522,P=0.036).Regarding ejaculatory func- tion，the incidence of retrograde ejaculation at 1 month and 12 months postoperatively in both the ThuLEP and TURP groups differed significantly from preoperative rates (P<0.05).Moreover，the incidence of retrograde ejaculation increased with time after surgery.At 1 month postoperatively，9.2％of the ThuLEP group and 14.3% of the TURP group experienced retrograde ejaculation，which was not statisti- cally different (Z=1.231,P=0.267).At 12 months postoperatively，the incidence of retrograde ejacu- lation in the ThuLEP and TURP groups was 19.4% and 25.5% ，respectively，also showing no signifi- cant difference (Z=1.055,P=0.304).In terms of surgical parameters，comparisons of operative time，intraoperative blood loss，decrease in hemoglobin levels，and weight of resected prostate tissue be- tween the ThuLEP and TURP groups revealed no significant differences (P>0.05).However，compared with the TURP group，the ThuLEP group had a shorter hospital stay (4 d vs. 5 d,P<0.001) and shor- ter duration of indwelling urinary catheterization（3.67 d vs. 4.26 d，P=0.012），although bladder irri- gation time was longer（19.00 h vs. 16.68 h，P=0.001）.At 1 month and 12 months postoperatively， there were no significant differences between the two groups in IPSS，QOL metrics (P>0.05) ；how- ever，all these parameters showed significant improvement compared with preoperative values. Conclusion： While both ThuLEP and TURP effectively alleviate lower urinary tract symptoms and improve voiding pa- rameters，ThuLEP offers distinct advantages in safeguarding erectile potency and facilitating accelerated postoperative recovery.

关键词

前列腺增生 / 经尿道前列腺切除术 / 激光疗法 / 铎激光 / 性功能障碍，生理性

Key words

Prostatic hyperplasia / Transurethral resection of prostate / Laser therapy / Thulium laser / Sexual dysfunction，physiological

参考文献

[1] Launer BM, McVary KT, Ricke WA, et al. The rising worldwide impact of benign prostatic hyperplasia[J]. BJU Int, 2021, 127 (6):722-728.

[2] Sandhu JS, Bixler BR, Dahm P, et al. Management of lower uri- nary tract symptoms attributed to benign prostatic hyperplasia (BPH):AUA guideline amendment 2023[J]. J Urol, 2024, 211 (1):11-19.

[3] EAU guidelines on the management of non-neurogenic male lower urinary tract symptoms(LUTS)[EB/OL].(2026-03)[2026-03-24]. https://uroweb.org/guidelines/management-of-non-neurogenic-male-luts/publications-appendices.

[4] Rassweiler J, Teber D, Kuntz R, et al. Complications of trans- urethral resection of the prostate(TURP):Incidence,manage- ment,and prevention[J]. Eur Urol, 2006, 50(5):969-980.

[5] Hashim H, Worthington J, Abrams P, et al. Thulium laser trans- urethral vaporesection of the prostate versus transurethral resection of the prostate for men with lower urinary tract symptoms or urinary retention(UNBLOCS):A randomised controlled trial[J]. Lancet, 2020, 396(10243):50-61.

[6] Li B, Hao L, Pang K, et al. Assessment of sexual outcomes in pa- tients undergoing thulium laser prostate surgery for management of benign prostate hyperplasia:A systematic review and meta-analysis[J]. Sex Med, 2022, 10(2): 100483.

[7] Liu Y, Cheng Y, Zhuo L, et al. Impact on sexual function of en- doscopic enucleation vs.transurethral resection of the prostate for lower urinary tract symptoms due to benign prostatic hyperplasia: A systematic review and meta-analysis[J]. J Endourol, 2020, 34 (10):1064-1074.

[8] Dun RL, Mao JM, Yu C, et al. Simplified Chinese version of the international prostate symptom score and the benign prostatic hy- perplasia impact index:Cross-cultural adaptation,reliability,and validity for patients with benign prostatic hyperplasia[J]. Prostate Int, 2022, 10(3):162-168.

[9] 曾令彭, 李杨, 李向阳, 等. 勃起功能障碍和下尿路症状在良性前列腺增生患者中的合并发生率及危险因素分析[J]. 中华男科学杂志, 2024, 30(2):139-144.

[10] Bulai CA, Multescu RD, Geavlete PA, et al. The impact of trans- urethral enucleation therapeutic approach in all-size benign prosta- tic obstruction pathology:From contemporary technological ad- vances to evidence-based clinical progresses[J]. Diagnostics (Basel), 2025, 15(4): 416.

[11] Porto JG, Bhatia AM, Bhat A, et al. Evaluating transurethral re- section of the prostate over twenty years:A systematic review and meta-analysis of randomized clinical trials[J]. World J Urol, 2024, 42(1): 639.

[12] Bearelly P, Avellino GJ. The role of benign prostatic hyperplasia treatments in ejaculatory dysfunction[J]. Fertil Steril, 2021, 116 (3):611-617.

[13] Spirito L, Capra M, Sciorio C, et al. Long-term functional out- comes and predictors of efficacy in thulium laser enucleation of the prostate(ThuLEP)for benign prostatic hyperplasia(BPH):A retrospective observational study[J]. J Basic Clin Physiol Pharmacol, 2024, 35(3):169-174.

[14] 兰孝达, 车新艳, 韩佳凝, 等. 脉冲波铥光纤激光剜除术在前列腺增生治疗中的应用[J]. 中华泌尿外科杂志, 2024, 45 (5):372-378.

[15] Becker B, Netsch C, Bozzini G, et al. Reasons to go for thulium- based anatomical endoscopic enucleation of the prostate[J]. World J Urol, 2021, 39(7):2363-2374.

[16] Dhirubhai Tadha A, Sarkar D, Kumar Pal D. A prospective,ran-domized study comparing the outcome after thulium laser enuclea- tion of the prostate with conventional monopolar TURP for the treat- ment of symptomatic benign prostatic hyperplasia[J]. Urol Res Pract, 2024, 50(1):42-46.

[17] Manfredi C, Napolitano L, Ditonno F, et al. Long-term functional outcomes and surgical retreatment after thulium laser enucleation of the prostate:A 10-year follow-up study[J]. Int Braz J Urol, 2024, 50(3):309-318.

[18] 左超, 杨昆霖, 李志存, 等. ＂双沟双环法＂经尿道铥激光前列腺剜除术单一术者学习曲线分析[J]. 中华医学杂志, 2023, 103(20):1563-1567.

[19] 中华医学会泌尿外科学分会激光学组, 微创学组, 尿控学组, 经尿道激光前列腺剜除术热点问题中国专家共识[J]. 中华泌尿外科杂志, 2024, 45(7):489-496.

[20] Manfredi C, García-Gómez B, Arcaniolo D, et al. Impact of sur- gery for benign prostatic hyperplasia on sexual function:A syste- matic review and meta-analysis of erectile function and ejaculatory function[J]. Eur Urol Focus, 2022, 8(6):1711-1732.

[21] Al Demour SH, Abuhamad M, Santarisi AN, et al. The effect of transurethral resection of the prostate on erectile and ejaculatory functions in patients with benign prostatic hyperplasia[J]. Urol Int, 2022, 106(10):997-1004.

[22] Mishra J, Choudhury S, Sinha S, et al. Assessment of prevalence of sexual dysfunction in patients having lower urinary tract symp- toms with benign prostatic hyperplasia and effect of various treat- ment modalities on sexual function[J]. Urologia, 2024, 91 (4): 715-719.

[23] Bozzini G, Berti L, Maltagliati M, et al. Ejaculation-sparing thu- lium laser enucleation of the prostate(ES-ThuLEP):Outcomes on a large cohort[J]. World J Urol, 2021, 39(6):2029-2035.

[24] Dalton DC, Shelton TM, Rivera M. Laser technology advance- ments in the treatment of benign prostatic hypertrophy[J]. Curr Urol Rep, 2024, 25(4):71-78.

[25] Guldibi F, Altunhan A, Aydın A, et al. What is the effect of laser anatomical endoscopic enucleation of the prostate on the ejaculatory functions?A systematic review[J]. World J Urol, 2023, 41 (12):3493-3501.

基金资助

研究型病房卓越临床研究计划(BRWEP2024W054070103)

中华人民共和国工业和信息化部与国家卫生健康委员会掺铥光纤激光治疗机推广应用项目(2024TGYY33)

中央高水平医院临床科研业务费（北京大学第一医院科研种子基金项目，2024SF80和2025SF083）