[Surgical and instrumental management of benign prostatic hyperplasia]

In recent decades, several various interventional procedures for the treatment of symptomatic benign prostatic hyperplasia (BPH) have been developed. Most of them were considered potential alternatives to prostatic surgery such as open prostatectomy, transurethral resection of the prostate (TURP), or transurethral incision of the prostate (TUIP). Despite good results observed in the initial clinical studies, most concepts and procedures were never generally accepted. However, they contributed considerably to general knowledge regarding the treatment of symptomatic and obstructive BPH. Only a few procedures could stand the test of time and became part of the urological armamentarium. Currently, interventional therapies are classified by their effects on prostate tissue: procedures with immediate tissue ablation (open prostatectomy, TURP, vaporization techniques, laser resection techniques), thermal coagulating procedures with delayed tissue ablation (transurethral high-energy microwave thermotherapy, transurethral needle ablation, interstitial laser coagulation), and other procedures (TUIP, stents) with deobstruction effects without tissue ablation. The analysis of clinical studies shows a great variety of different results. The main reason for this fact is that the design of past and present studies ignored the pathophysiological aspects of BPS, especially the obstructive component, and the fact that the outcome of most procedures more or less depends on the operator/user.

Funktionelle Ergebnisse nach Laservaporisation der Prostata mit dem KTP-Laser

BACKGROUND

Treatment for bladder outlet obstruction (BOO) caused by benign prostatic hyperplasia (BPH) impairs the quality of life. The potassium tintanyl phosphate (KTP) vaporisation of the prostate offers promising modalities in treatment of BOO. We prospectively determined the impact of KTP-lasertherapy on voiding function, quality of life and sexual function.

PATIENTS AND METHODS

So far a total of n=123 patients complaining of symptomatic BPH were treated with an 80 watt Laser. N= 40 of them agreed to participate in the study and were evaluated prospectively. Preoperative pressure-flow-studies verified significant bladder outlet obstruction in all cases. Disease specific quality of life and sexual function were assessed using the International Prostate Symptom Score (IPSS) and International Inventory of Erectile Function (IIEF). Three months after treatment follow-up video-urodynamics were carried out to determine changements in pressure flow and bladder function.

RESULTS

All patients showed significant improvement after a hospital stay of 4,9 days. The maximum flow rate increased from 9,1 ml/sec preoperatively to 20,2 ml/sec and the amount of residual urine decreased from 98 ml preoperatively to 17 ml immediately after removal of the catheter. Urodynamics after the follow up period showed that the maximum urinary flow improved from 9.7 ml/s preoperatively to 17,6 ml/s and the volume of residual urine decreased from a median of 127.5 ml preoperatively to 45 ml postoperatively. The IPSS and IIEF decreased from a median of 20,4 preoperatively to 8,16 and from a median of 14 preoperatively to 12,7 respectively. The pressure-flow study verified the desobstruction and showed a decline in detrusor pressure at maximum flow from 76,66 cm H2O to 33,79 cm H2O. The urethral opening pressure sank from 75.86 cm H2O preoperatively to 37,51 cm H2O postoperatively.

CONCLUSION

The potassium tintanyl phosphate (KTP) vaporisation of the prostate is a promising new method in the treatment of benign prostatic hyperplasia as shown by the data. Beside its low perioperative and postoperative morbidity due to a high hemostatic property it offers a good tissue debulking effect.

Durability of Probes for Interstitial Laser Coagulation: Impact of Power Setting and Probe Design

BACKGROUND AND PURPOSE

Interstitial laser coagulation (ILC) is a well-established treatment option for patients suffering from benign prostatic hyperplasia (BPH). The vulnerability of the current fibers adds to the high cost of the procedure. The objective was to study the impact of different time-power modes and novel probe designs on tissue effects and fiber durability.

MATERIALS AND METHODS

Standardized interstitial laser (Nd:YAG) applications utilizing different fiber types and power settings were performed in vitro on fresh bovine liver in a fluid medium. The resulting effects on tissue coagulation were evaluated. Additionally, the durability of contemporary probes as well as novel designs was examined.

RESULTS

High-intensity application protocols of 1750 J within 60 seconds were significantly (p < 0.001) more effective in coagulating tissue (4.22 cm3) than the 90 seconds (3.68 cm3) and 120 seconds (3.06 cm3) time-power modes but significantly (p < 0.001) decreased the durability of fibers. Prototype probes significantly improved durability (p < 0.001), whereas efficacy remained unchanged (p > 0.5).

CONCLUSIONS

Using a laboratory model, we could demonstrate that high-intensity time-power settings are more effective in creating tissue coagulation in ILC. The resulting deterioration of the probes can be reduced by applying new fiber designs.

Does Perioperative Outcome of Transurethral Holmium Laser Enucleation of the Prostate Depend on Prostate Size?

BACKGROUND AND PURPOSE

In conventional transurethral resection of the prostate (TURP), perioperative morbidity resulting from causes such as blood loss and TUR syndrome increases with prostate size. Therefore, TURP is restricted to small and medium-sized glands. The present study aimed to find out whether perioperative parameters of holmium laser enucleation of the prostate (HoLEP) other than operation time and weight of resected tissue were dependent on prostate size.

PATIENTS AND METHODS

A total of 384 patients were treated with HoLEP (holmium:YAG laser, 2.0 J, 40 or 50 Hz, 80 or 100 W, 550-nm bare fiber) for acute removal of obstructing benign hyperplastic tissue. Among them, 111 patients (28.9%) had prostates of <40 g (group 1), 152 (39.6%) had prostates of 40 to 79 g (group 2), and 121 (31.5%) had prostates of >/=80 g (range 80-260) (group 3). The perioperative outcomes of the three groups were compared. A total of 346 patients completed the 1-month postoperative assessment.

RESULTS

The mean prostate sizes were 31.8 g, 56 g, and 98.7 g for groups 1, 2, and 3 (P<0.0001 group 1 v group 2 v group 3). The mean resected tissue weight was 19.5 g v 34.4 g (P= 0.009) v 70.1 g (range 50-220) (P< 0.0001). The mean operation time was 64.3 v 84.2 (P= 0.009) v 118.4 minutes (P< 0.0001). The mean hemoglobin loss was 0.9 v 1.2 (NS) v 1.9 g/dL (P< 0.001). The overall correlation between hemoglobin loss and prostate size in all patients was very weak (r = 0.229) and just exceeded the level of significance (r = 0.2). In all three groups, the median postoperative catheter time was 1 day, and the median postoperative hospital stay was 2 days. The HoLEP resulted in an immediate and significant improvement of American Urological Association Symptom Scores, peak urinary flow rates, and postvoiding residual urine volumes (P< 0.0001) 1 month after the operation, without significant differences between the groups. The rate of complications was similar in all three groups. None of the patients needed blood transfusions. There were no perioperative deaths.

CONCLUSION

In HoLEP, perioperative morbidity and postoperative micturition improvement do not depend on prostate size. Therefore, in contrast to TURP, HoLEP is equally suitable for small, medium-size, and large prostate glands.