Operative Therapie des benignen Prostatasyndroms – resezieren, vaporisieren oder enukleieren?

A systematic review and meta-analysis of efficacy and safety comparing greenlight laser vaporization with transurethral resection of the prostate for benign prostatic hyperplasia with prostate volume less than 80 ml

We conducted a meta-analysis to evaluate the efficacy and safety of photo selective vaporisation of the prostate (PVP) with the GreenLight Laser versus transurethral resection of the prostate (TURP) for the treatment of small-volume benign prostatic hyperplasia (BPH). As of July 2022, relevant literature in online databases such as Cochrane Library, PubMed, and Embase was searched, including studies published on or before that date, and there were 9 studies in total, including 5 RCTs and 4 non-RCTs. In total 1525 patients were included to compare the efficacy of PVP and TURP in treating BPH. The Cochrane Collaboration criteria were used to evaluate the risk of bias. The software was used for random effect meta-analysis with RevMan 5.3. Data extraction included: clinical baseline characteristics, perioperative parameters, complication rates, International Prostate Symptom Score (IPSS), prostate specific antigen (PSA), post-void residual urine (PVR), maximum flow rate (Qmax), and quality of life (QoL). The pooled analysis showed that PVP was associated with reduced blood loss, blood transfusion, clot retention, catheterization time, definitive catheter removal, and hospital stay, but was associated with longer operative time and more severe dysuria (all p < 0.05). The results of this meta-analysis show that PVP as a technique for the treatment of benign prostatic hyperplasia with a volume of less than 80 cc has similar efficacy to standard TURP in IPSS, PSA, PVR, Qmax and QoL, and is an effective alternative. It outperformed TURP in terms of blood transfusion, catheterization time and hospital stay, while TURP is superior to PVP in terms of operation time.

Necrosis zone depth after bipolar plasma vaporization and resection in the human prostate

Objectives

To compare the depth of thermal necrosis after use of bipolar resection and vaporization technique comparing intra-individually bipolar loop and bipolar button electrodes.

Methods

Transurethral resection and vaporization of the prostate was performed in 55 male patients (260 specimens in total). In a standardized procedure, a bipolar resection loop was used for resection, and a bipolar button electrode was used for vaporization. Both electrodes were applied in each patient, either in the left or in the right lateral lobe. The depth of necrotic zones in the resected or vaporized tissue of each patient was measured in a standardized way by light microscopy.

Results

The mean depth with standard deviation of thermal injury caused by the loop electrode was 0.0495±0.0274 mm. The vaporization electrode caused a mean thermal depth with standard deviation of 0.0477±0.0276 mm. The mean difference of necrosis zone depths between the two types of electrodes (PlasmaButton-resection loop) was -0.0018 mm (p=0.691).

Conclusion

For the first time, we present directly measured values of the absolute necrosis zone depth after application of plasma in the transurethral treatment of benign prostatic hyperplasia. The measured values were lower than in all other transurethral procedures. Standardized procedures of measurement and evaluation allow a statistically significant statement that the low necrosis depth in bipolar procedures is independent of the applied electrodes.

Hounsfield units: A promising non-invasive tool for diagnosing benign prostatic hyperplasia

OBJECTIVE

The clinical symptoms in benign prostatic hyperplasia (BPH) are directly proportional to prostate volume. We aimed to show whom and when to intervene in a noninvasive way, correlating the patient's subjective symptoms with objective diagnostic tools.

MATERIAL AND METHOD

International Prostate Symptom Score (IPSS) was evaluated in patients who consulted the urology outpatient clinic for the first time with lower urinary tract symptoms (LUTS). Subsequently, PSA, urea, creatinine, complete urinalysis, uroflowmetry, urinary tract ultrasound and non-contrast lower abdominal computed tomography (CT) examinations were requested. Prostate central (transitional zone) zone and peripheral zone HU scores, prostatic urethral length and bladder wall Hounsfield units (HU) scores were recorded by using computed tomography (CT). The ellipsoid formula was used for ultrasonographic and tomographic measurements of prostate size (anteroposterior diameter × transverse diameter × longitudinal diameter × 0.52).

RESULTS

A statistically significant negative correlation was found between the prostate peripheral zone/central zone HU ratio and the maximum flow rate measured in the uroflowmetry test.

CONCLUSION

This is the first study in the literature to evaluate the correlation between voiding parameters such as Qmax, Qave and IPSS scores, and prostate and bladder wall HU scores obtained by computed tomography examination in BPH patients. A significant relationship has been detected between the peripheral zone/central zone HU ratio and Q max. Additional studies with larger patient populations could better clarify the contribution of HU in the diagnosis of BPH and treatment decision making of these patients.

Modified simple prostatectomy: an approach to address large volume BPH and associated prostate cancers

Simple prostatectomy is an option for management of patients with enlarged prostates and obstructive symptoms. However, the guidelines still do not state a gold-standard treatment for men with BPH and some of these patients with BPH are also known to harbor prostate cancer. This issue can be a challenge because, in the traditional simple prostatectomy, the prostate capsule is often left in place, and that is usually the area of the prostate cancers. With the robotic approach, our goal is to analyze the outcomes of modified simple prostatectomy (MSP) by the elimination of the entire prostate tissue. Thirty-four patients underwent MSP for BPH diagnosis. We evaluated the pre- and postoperative clinical characteristics as well as pathological data. MSP was performed using the DaVinci Xi robot; the entire prostate was removed. We performed a full nerve sparing bilaterally with an intrafascial plane dissection, minimal apical dissection, seminal vesicles sparing, and full vesicourethral anastomosis. The pre- and postoperative AUA scores were compared on paired T test. The mean operative time and blood loss were 126 min and 160.5 ml, respectively. The final pathology report described 17 patients (50%) with BPH and 17 (50%) with BPH and prostate adenocarcinoma. After surgery, 97% had an AUA score improvement. Regarding the patients with a prostate cancer diagnosis, 97% had PSA lower than 0.01 ng/ml. Modified simple prostatectomy is an acceptable treatment option for men with BPH. The procedure allows for significant symptom relief and removal of chronic catheters. Our modified approach was able to eliminate the entire prostate, which was significant because 50% of these patients had prostate cancer on the final pathology.

Radical prostatectomy after previous transurethral resection of the prostate: oncological, surgical and functional outcomes-a meta-analysis

BACKGROUND

The current study aimed to carry out a comprehensive meta-analysis on the existing evidence to quantify and compare the oncological, surgical and functional outcomes following radical prostatectomy between TURP group and Non-TURP group.

METHODS

A systematic literature search was conducted using EMBASE, PubMed and Cochrane databases to identify relevant studies published in English up to March 2019. A meta-analysis was conducted using Review Manager.

RESULTS

There were 13 studies included in the present study. Our results suggest that TURP group demonstrates a significantly higher positive surgical margin rate, bladder neck reconstruction rate and overall complication rate compared with Non-TURP group (OR = 1.31, 95% CI 1.09-1.58, P = 0.004, I² = 0%; OR = 14.36, 95% CI 2.93-70.45, P = 0.001, I² = 81%; OR = 2.63, 95% CI 1.87-3.71, P < 0.00001, I² = 0%); whereas TURP group demonstrates a significantly lower nerve sparing rate compared with Non-TURP group (OR = 0.30, 95% CI 0.22-0.43, P < 0.00001, I² = 40%); the operation time, blood loss and 1-year urinary continence rate are same between TURP group and Non-TURP group (MD = 4.25, 95% CI - 0.13 to 8.63, P = 0.06, I² = 34%; MD = 27.29, 95% CI - 10.31 to 64.90, P = 0.15, I² = 39%; OR = 0.68, 95% CI 0.43-1.06, P = 0.09, I² = 0%).

CONCLUSION

This meta-analysis demonstrates that Non-TURP group may have a great advantage over TURP group in terms of positive surgical margin rate, bladder neck reconstruction rate, overall complication rate and sparing rate. The operation time, blood loss and 1-year urinary continence rate are comparable between TURP group and Non-TURP group. Therefore, important information should be given to those patients at risk of prostate cancer that TURP procedure may increase perioperative complications in case of a following radical prostatectomy. In the meantime, our meta-analysis found that each of these four subgroups (RARP, LRP, ORP and RARP/ORP) has its own advantages or disadvantages in every pool results. So when radical prostatectomy is performed on patients with TURP history, the appropriate operation method should be selected as per the conditions of patients, doctors and hospitals.