前列腺癌放射治疗后的问题
Radiation therapy is an essential treatment for prostate cancers. 放射引起的并发症非常罕见, but occasionally men can develop a urethral stricture after radiation treatment. The radiation, even many years after treatment, can cause the urethra or urinary channel to scar. 当尿道出现疤痕, men have difficulty in passing their urine and have obstruction of their flow. 这会导致尿急和尿频等症状, 膀胱过度活动引起的尿失禁, 或膀胱溢满, 疼痛, 膀胱感染.
Often this damage occurs in the first few years after treatment, 但也可能发生在许多年后, 即使前列腺癌已经完全治愈. These strictures can be very hard to treat because the radiation damages the surrounding tissues and the urethra has a hard time healing after surgery.
治疗
Basic treatments procedures for this complication include:
- 内部扩张/检查程序 -辐射后, internal dilations or scope procedures to cut the scar rarely will cure a stricture of the urethra.
- 导管插入术 - Some patients have a permanent catheter placed through the abdomen into the bladder called a suprapubic tube, and others will perform self-catheterization of the urethra once a day to keep the stricture open. 然而, many patients do not like having a permanent catheter and find self-catheterization very 疼痛ful.
- 手术 -对导管不起作用的病人, a surgery can be done to remove the scar tissue and reconnect the urethra to the prostate. We have had many successes with this surgery at University of Utah Health despite the radiation damage to the urethra.
重新连接尿道的手术
不同的手术适用于不同的情况. For instance in some men the entire urethra through the prostate is scarred from radiation or attempts to clear the channel with scope procedures. In this circumstance the prostate needs to be removed and the urethra can be connected to the bladder (salvage prostatectomy).
在其他病人中, when the scarring is limited to the bottom of the prostate, a surgery through the perineum (the space between the scrotum and the anus) can be performed to remove the scar tissue and reconnect the urethra to the prostate (urethroplasty).
Figures: Two examples of radiation damage from prostate cancer treatment causing a stricture or scar at the junction of the lower prostate and the urethra. 1)第一个是来自植入的近束治疗种子. 2) The second is from the combination of high dose brachytherapy and external beam radiotherapy.
术后泌尿控制
Most often scarring after radiation involves the urinary sphincter muscle at the bottom of the prostate (external sphincter). The sphincter muscle allows men to keep urine in their bladder and prevents leakage. 幸运的是, men have two sphincter muscles and there is one at the opening of the bladder where the bladder meets the prostate (internal sphincter). Even if the lower sphincter is destroyed because of the radiation damage, 上括约肌可以防止男性漏尿.
在某些情况下, 然而, the upper sphincter does not work or needs to be removed because the scarring is extensive. If this happens then patients need to have an artificial urinary sphincter placed after they have healed from the urethral surgery.
人工尿括约肌（AUS）
An 人工尿括约肌 is a silicone donut, which is placed around the urethra (the cuff). This sphincter or cuff is connected internally to a pump within the scrotum and a reservoir in the abdomen. The pump sits next to the testicle and when someone wants to urinate they squeeze the pump and the cuff deflates and allows urine to flow. Over the next two minutes or so the cuff self inflates and puts pressure back on the urethra.
人工括约肌放置的等待时间
Unfortunately patients need to wait long enough to make sure that the urethra has completely healed. This is about three months after the catheters are all removed from the urethral surgery. Then another surgery is done to place the artificial sphincter around the urethra.
改善手术效果
Your surgeon may talk to you about the use of hyperbaric oxygen. Hyperbaric oxygen involves going to a wound care center and having 20–40 treatments in a dive chamber with very highly concentrated oxygen. These treatments last about one to two hours and are usually done once a day. Hyperbaric oxygen treatment may improve the damage surrounding the scar tissue and may make the surgery more successful.
Unfortunately the hyperbaric oxygen treatment will not cure the stricture. 并不是每个地方都有高压氧治疗中心, 对于那些无法获得这种治疗的病人, 手术仍有可能成功. Another thing your surgeon might recommend is laying a piece of muscle from your inner thigh underneath the area of surgery. This may act to increase the blood supply to the area of the surgery and protect the area from complications of very slow healing.
这个手术真的有用吗?
The outcomes of this type of surgery is not as good as urethral stricture surgery that is done without radiation damage, but we have gotten this surgery to work out well in many patients. Many patients have come to see us believing that nothing can be done because of the information they have been told about radiation damage. Usually we can find some plan that will improve patient’s quality of life even if the damage from radiation is severe.