Encucleation HK CHINA perspective
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崔 家倫This document discusses tools and techniques for holmium laser enucleation of the prostate (HoLEP). It provides tips for different laser settings for cutting and coagulation. It emphasizes the importance of hemostasis during morcellation and describes techniques for handling the prostate in lobes or en bloc. Potential complications like transient stress urinary incontinence are addressed. Experience levels for surgeons of different prostate sizes are noted, and the value of mentorship programs is highlighted.
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2. It notes that the round window membrane is a neglected part of otological surgery but gaining more attention for procedures like cochlear implants.
3. Key structures that support the round window membrane are described, such as the fustis, a bony column that regulates sound wave flow and pressure differences.
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膀胱癌是全球第9位最常見的惡性腫瘤。
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血尿是膀胱癌最常見的症狀之一，血尿的原因有許多，包括發炎、結石及腫瘤等。乃因腎臟、輸尿管或膀胱等器官，粘膜血管破裂導致，其中最危險性的病因是惡性腫瘤，而泌尿器官較常引起血尿的最常見的惡性腫瘤首推膀胱癌。
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膀胱癌的症狀
血尿是膀胱癌最早期的症狀，這種血尿的最大特點是無痛，而且無緣無故發生。有些人發生血尿是運動劇烈或太過勞累，有些人是結石引起，會合併腹痛、腰痛、噁心、嘔吐等。膀胱癌的血尿卻多是無緣無故發生的無痛性血尿。如果早期不去理它，最後也會發生小便困難、疼痛，甚至解不出尿的情形。
大部份 約80％的患者發現時都是 非肌肉浸潤性膀胱癌 (Non-Muscle Invasive Bladder Cancer NMIBC)。
幾十年來，常規的經尿道膀胱腫瘤切除術 (Transurethral resection of bladder tumor TURBT)一直是淺表性膀胱癌 (Superficial bladder cancer) 的標準治療方法。
其目的是 提供組織作化驗斷診，另一方面就是要將淺表癌腫瘤完全可以切除 ，正確將癌症腫瘤分期 (TNM stage) 。
傳統技術 TURBT存在著一些缺點，利用內視鏡電刀作切除，不論單極 (monopolar) 或雙極 (bilopolar) 電流。 方法亦是將膀胱腫瘤以零碎的方式切除，這違背了一貫外科手術切除腫瘤的理論，外科醫生一般情況下，應盡量將癌症腫瘤整塊切除， 以免破壞組織令病理難以辨認，癌細胞亦會趁機進入血液及傷口做成擴散。
多年來研究亦顯示TURBT手術後 ，最終癌細胞組織遺留率 (Residual rate) 和膀胱逼尿肌缺乏率都高（分別高達35％和60％）。這可以導致早期復發(Early recurrence)，及病人的腫瘤被低估嚴重性( Understage)，腫瘤碎裂，分散並沉積在膀胱內，理論上會做成浮游癌細胞著床(Implantation)於膀胱其他位置。亦可導致疾病早期復發。
膀胱腫瘤的整塊切除Enbloc TURBT，解決了傳統技術的局限性，並且近年來在泌尿科界中引起了更多的關注。整塊切除 (Enbloc TURBT) 的原理就是由腫瘤底部開始切除，因近年雙極電刀的技術經改良後，可以更精準切割，得以可將腫瘤與肌肉層清楚分離。
醫生亦可利用不同的激光(Laser) 能量做切割，得到同一樣的效果，但減少了因閉孔神經反射(Obturator reflex) 而做成的膀胱穿破(Bladder perforation) 風險。
近來，亦有泌尿科醫生利用新式水刀 (Hybrid knife) 作整塊切除 Bladder Tumor Endoscopic Submucosal Dissection(BT-ESD)，其原理是，先用高壓將身理鹽水注入腫瘤底部，將腫瘤升起，後將深層肌肉束在染色情況下清楚切斷，確保有足夠組織可供病理科醫生斷定癌期，避免誤判病情。
香港亦引入先進多参數磁力共震(mpMRI )来分析膀胱腫瘤的局部情况 ，亦稱為 ViRADS膀胱腫瘤評分，利用磁震数据計算，系统化評出腫瘤的例如位置，大小，肌肉層侵蝕等，可在术前更加準確預計手术切除的深淺及範圍，希望減低殘留癌细胞的風險，從而降低復發機會及因癌症死亡率。
最近一份有193案例的對照硏究指出，利用 BT-ESD 方法整塊切除 與 傳统 TURBT 方法 在2013-2017 年一個為期三年的研究结果發现，膀胱腫瘤 少於3 厘米的情況下，手術時間沒有分別，但BT-ESD 手術後，帶尿喉時間及住院時間都較短。另外發現，三年內 BT-ESD 群組的癌症復發率（4.5%），相對用傳統 TURBT 的群組 （20.5%）也較低 。 原因可能由於傳统 TURBT 方法，外科醫生可能因為割穿膀胱及儀器安全所限，導至有多點機會有殘留癌細胞在腫瘤底部，但還需更多隨訪數據才可肯定。
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Point of Care Ultrasound ( urology )
POCUS (Point Of Care UltraSound) should be taught in medical school and can replace the stethoscope. It provides useful information to help diagnosis at the point of care. For flank pain/renal colic, POCUS can help identify upper ureteric stones, distal ureteric stones, and assess hydronephrosis and cortical loss. Doppler ultrasound can differentiate between hydronephrosis and vasculature. POCUS is also useful for identifying renal cysts, perinephric haematomas, and assessing prostate enlargement.
Point Of Care UltraSound in Urology ( POCUS )
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男性泌尿 前列腺 問題
前列腺增生的處理方法
良性前列腺增生是其中之一常見的男性泌尿系统問題。前列腺增生的初期，一般的症状都是因膀胱出口阻塞所引致，如小便難開始，尿流斷斷續續，幼小，有意猶未盡的感覺。如果沒有處理好的話，膀胱就會開始受影響，造成膀胱敏感症。治療前列腺增生，有不同的藥物可以幫到患者。但如果藥物舒緩不到症狀，就可能須要動手術。
現時最普及的是經尿道內視鏡電切術（TURP)，這手術的好處是不會像以往開放式方法的令病人肚皮，及膀胱留有傷口，復元的時間較短。
但近年来的研究顯示 ，TURP 有一個問題就是大慨有一半的增生結節組織是沒有處理到的。因此病症有可能兩三年會再出現，因剩餘结節組織會再次增生，平均十年內10%病人要再做手術。
所以有一種新的手術技巧，經尿道等離子雙極電刀前列腺剜除術(BipoLEP)利用類似的電切儀器達至完全剜除剝離增生的結節组織，令前列腺增生復發機會大大减低。比喻就似广东小吃砵仔糕，運用儀器將结節從“碗底”剝離，留下前列腺的外殼，此殼不會做成復發，因此手術又稱“剜除術”，如果利用用激光進行，有 Holmium Laser Enucleation of Prostate (HoLEP).
BipoLEP能够徹底解决因良性前列腺增生的阻塞，研究表示有效程度可比媲美開放式前列腺切除術。絶大部分的數據顯示BipoLEP的短中期功效與開放式切除術接近，但安全性較高，。
BipoLEP使用雙極等離子內視鏡儀器，並會以生理鹽水灌洗，此技術可减少出血，因此亦能減少經尿道切除綜合症(TUR syndrome) 的風險。
BipoLEP系統的電流不會經過身體傳至皮膚，其雙極電路是完全封閉的迴路，電流 限制於主電極和電切前端(「真正」雙極系統)或電切鏡(「類」雙極系統)。由於兩 極之間的距離較少，因此BipoLEP需要的能量/電壓也較少。迴路的能量傳送至生理鹽水，刺激鈉離子形成電漿，屆時即可以相對較低電壓分離粒子，從而達到切除效果。在凝血時，因熱力於管壁內消散，以致出現有封閉作用的凝塊和膠原收縮。
手術會在全身或半身麻醉下進行。手術期間會 持續灌洗前列腺及膀胱，以便清楚觀察前列腺剜除狀況。良性前列腺增生阻塞部分均在剜出後，以切除或粉碎方式(morcellation) 移除。前列腺碎塊會在手術結束時吸走，並立即止血。此外， 會經尿道放置尿管，以利排尿及灌洗。現時大部分病人可以在術後不用灌洗膀胱，手術後第一天自行小便及出院。
Stress Urinary Incontinence 女士尿失禁
This document discusses female urinary incontinence and the use of surgical mesh. It notes that several governments and regulatory agencies have placed restrictions on transvaginal mesh due to inadequate evidence of long-term safety and efficacy. Alternatives to mesh for treating incontinence mentioned include pelvic floor exercises, retropubic suspensions, and laparoscopic sacrocolpopexy. The document also discusses a non-surgical treatment called BTL Emsella that uses electromagnetic therapy to stimulate pelvic floor muscles. Pilot studies on Emsella show improvements in incontinence based on pad tests and questionnaires. An ongoing study is further evaluating its efficacy and safety.
前列腺局灶治療 HIFU
局部重點定向治療 提升前列腺癌患者生活質素
局部重點定向治療（Focal Therapy）近年來興起，是用於治療低/中危原位局限性前列腺癌的新方法，進一步豐富了前列腺癌治療策略的選擇。近來美國舉行的「全美泌尿科醫師協會年會」有一個臨床研究，五十四名研究對象都是局限於單邊腺體的低/中危前列腺癌患者，採用高能聚焦超聲消融腫瘤所在的單邊前列腺。
70%仍可勃起 無尿失禁
術後平均十七點四個月隨訪發現，五十一名患者的PSA平均下降百分之五十三點二，術後十二個月再穿刺活檢發現十三例，即百分之二十六點五屬前列腺癌，其中八例約百分之八點二為有臨床重要性的癌腫瘤，十例即百分之十九點六患者最後接受了根治性治療；消融術後七成患者保留勃起功能，無尿失禁，生活質量及焦慮指數無改變。
這項研究證明，基於多參數磁力共振（mpMRI）的影像導向高能聚焦超聲半腺體局部重點消融（簡稱HIFU），對治療低/中危原位局限性前列腺癌是安全的。該研究也提示消融術後應用mpMRI作為覆診跟進價值有限（敏感性僅為百分之二十五），可能與消融術後腺體組織結構改變有關。因此，局部重點消融後再穿刺活檢仍然是需要的。
目前局部重點消融治療的方法很多，包括射頻消融、微波消融、冷凍消融、放射性粒子植入消融、高能聚焦超聲等。mpMRI導向消融技術的核心是基於mpMRI的靶向穿刺，所以多參數磁力共振的質素很重要。
待更多臨床研究及數據
局部重點消融優勢在於功能保留，而非絕對的瘤控。事實上多項研究證實了治療對於患者生活質量影響很小。那麼相比於主動監測，局部重點治療又有甚麼優勢呢？首先要明確：主動監測不是不治療，而是推遲根治性治療，如果局部重點治療相比於主動監測在推遲根治性治療方面展現出優勢，便就有其價值。
Stress Urinary Incontinence
This document summarizes the issues surrounding female urinary incontinence and the use of mesh. It notes that several governments and regulatory agencies have placed restrictions on transvaginal mesh due to inadequate evidence of long-term safety and efficacy and risk of harm. Studies show mesh can lead to complications like pain, infection, and erosion. Alternatives to mesh discussed include exercises, bulking agents, and new non-surgical therapies like BTL Emsella which uses electromagnetic stimulation of the pelvic floor muscles.
重複性尿道炎
更年期，帶給女仕的私密處困擾，不僅是陰道萎縮、乾澀和發炎，雌激素大量下降，就連泌尿系統健康也亮起紅燈，若不妥善處理，不單單只是尿頻，更嚴重還可能尿道發炎甚至出現血尿。
更年期不適可以分成2大類。
第1類是熱潮和夜間盜汗，過幾年大多數會好轉；第2類是若管理不好就會變得很差，例如骨質疏鬆，以及生殖泌尿道症狀。
頻尿、漏尿、血尿
更年期泌尿道感染可以很困擾女性，步入更年期後下陰私密處不適很常見，以往醫學界多聚焦於陰道搔癢乾澀或灼熱、性愛疼痛等陰道症狀上，因此以「陰道萎縮症」統一稱之，但在2014年，北美更年期醫學會將其更改名稱為「更年期生殖泌尿系統綜合症」（Genitourinary Syndrome of Menopause)，認為女性更年期出現的排尿赤痛、尿頻、漏尿和血尿等下尿道症狀，一樣值得重視。原因是泌尿道變得脆弱且容易發炎。
根據統計，60歲以上婦女，10％至15％受頻繁尿道感染的困擾。在超過80歲後，高達一半的機率會有尿液中帶菌而面臨的漏尿、頻尿、尿道發炎和血尿等症狀，
女性停經後因身體雌激素的分泌減少，不但尿道黏膜表層會變薄，尿道管腔也會變短、變窄，尿道出口黏膜外翻，促使本来的益生菌，例如乳酸桿菌 (Lactobacillus) 数量下降而致病細菌如大腸桿菌（E. Coli) 更容易進入尿道引起發炎。
而且，陰道口與尿道口的距離大慨有一厘米，若陰道出現發炎感染的症狀，下尿道很難不受到波及。所以想要預防或改善更年期的下尿道感染問題，就需要包括關注陰道保養，實行雙管齊下。
首先要養成多喝水的習慣，美國國立衛生研究院（NIH）建議預防泌尿系統感染的最佳方法就是多喝水，用大量小便沖走細菌。建議份量每日兩至三公升，直至小便澄淡黃色。
紅苺素：
雖然目前文獻認為红苺素對於尿道反覆感染(Recurrent Urinary Tract Infection) 的預防未有任何証實，但因紅苺素的一種成分「原花青素」（Proanthocyanidins）可以避免壞菌附著於尿道，至少可能對未曾發生泌尿道感染的病人有保護作用。亦有研究指出，時常飲用紅莓汁，能使存在尿液及泌尿道中的大腸桿菌鞭毛無法發揮作用，使其不易附著在尿道黏膜壁上、使尿道環境較不利於細菌生長，從而預防泌尿道感染。
私密處專用的雌激素外敷藥膏：
曾有研究發現，更年期的女性在未使用局部雌激素藥膏的情況下，每年發生泌尿道感染的次數平均5.9次，但連續8個月天天使用，每年感染次數大幅降低，平均只有0.5次，因此建議更年期婦女可以在諮詢醫生意見後，適度以此作為私密處的日常保養。雖然私密處專用的雌激素藥膏安全性比口服的雌激素高很多，但如果曾經患有乳癌、子宮內膜癌或有相關家族史，仍建議避免使用。
激光治療：
另外，近年有研究指出陰道雷射激光治療(Vaginal Laser ) 可以刺激膠原蛋白增生，讓陰道黏膜組織變厚，恢復成有利乳酸桿菌生存，從而保護陰道及尿道，減少感染和發炎的機會。
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Encucleation HK CHINA perspective
- 1. Prof Chui Ka Lun Hong Kong private urologist FRCS Edin(Uro) FHKAM Hon Assistant Prof The Chinese University of Hong Kong
- 2. Tools Lumenis P100 Karl Storz 26Fr Laser Scope Karl Storz Uromat EASI irrigation system Karl Storz Drill Cut morcellator
- 3. Tools Lumenis P100 Karl Storz 26Fr Laser Scope with working element Karl Storz Uromat EASI irrigation system Karl Storz Drill Cut morcellator
- 4. Tools Lumenis P100 Karl Storz 26Fr Laser Scope Karl Storz Uromat EASI irrigation system Karl Storz Drill Cut morcellator 4
- 5. Tools Lumenis P100 Karl Storz 26Fr Laser Scope Karl Storz Uromat EASI irrigation system Karl Storz Drill Cut morcellator 5
- 6. Two Pedals are always better than one 6
- 7. Pulse width function Short pulse 2.0J x 45 Hz ● Cutting hardly ● Enucleation ● Plane exploration ● Adenoma Long pulse 1.8J x 40Hz ● Cutting gently ● Coagulation ● Mucosa 7
- 8. Enucleation is Enculeation is ….BUT the essential is Holmium is still the best as still Not depends on blunt dissection by scope manipulation as Shock Waves will find the path for you and Bladder stones fragmented in same session 8
- 9. 9
- 10. Tips and Tricks Immediate / Pre emptive coagulation better than control bleeding Stay close to adenoma Beware Mid gland 3 & 9 oclock, Bladder neck 2 and 10 oclock , unnamed penetrating vessels 10 “ significant bleeders were the 2- 5 and 7-10 o'clock positions in the proximal prostate.” Prof Oh et al.
- 11. Morcellation Safety Haemostasis is the key to morcellation success Trust your hand, palpate bladder Facing morcellator downward Oscillating better VersaCut Keep 900-1000 bpm rate (Karl storz Drillcut) Slow is better than Fast “ significant bleeders were the 2- 5 and 7-10 o'clock positions in the proximal prostate.” Prof Oh et al.
- 12. enbloc or 2 lobe or 3 lobe Surgeon preference start with 3 lobe then enbloc IMHO Midlobe channel opening for better irrigation Less struggling under the “balls” Uvula concept 12
- 13. Typical Uvula day If Atypical Uvula…. 13
- 14. Transient Stress Urinary Incontinence (TSUI) Mucosa-sphincter complex flap Preserve apical mucosal flap extending cranially with sphicter muscle fibres don’t be obsess to enucleate ant lobe feel comfortable to follow short wave opening path 14
- 15. THANK YOU
- 16. Prostate size, step by step Beginner: 40-60gm 30 cases learning curve Intermediate: 60-100gm 50 cases Senior: Redo / >100gm Mentorship program is IMPORTANT Watching online videos repeatedly is useful 16