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Langzeitergebnisse nach endoskopischer Enukleation der Prostata

Von der monopolaren Enukleation zu HoLEP und EEP

Long-term outcome after endoscopic enucleation of the prostate

From monopolar enucleation to HoLEP and from HoLEP to EEP

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Zusammenfassung

Hintergrund

In den letzten 20 Jahren haben sich zahlreiche transurethrale endoskopische Enukleationstechniken als Konkurrenz zur offenen Adenomenukleation (offene Prostataenukleation, OP) und transurethralen Resektion der Prostata (TURP) etabliert. Seit der diesjährigen Novelle der „EAU guidelines on management of non-neurogenic male lower urinary tract symptoms (LUTS) inclusive benign prostatic obstruction (BPO)“ werden Holmium-Laserenukleation (HoLEP) und bipolare Enukleation als anatomische endoskopische Enukleationstechniken (EEP) subsummiert und als Verfahren der ersten Wahl zur Behandlung der BPO bezeichnet.

Fragestellung

Die verfügbare Datenlage zu Langzeitergebnissen aller EEP wird dargestellt.

Material und Methode

Pubmed/Medline- und Scopus-Suche mit folgendem Suchalgorythmus: long term, HoLEP, ThuLEP, vapoenucleation, TmLEP, ThuVARP, vaporesection, ThuVEP, DiLEP, ELEP, GreenlEP, Greenlight enucleation, bipolar enucleation, plasmakinetic enucleation, monopolar enucleatino und transurethral enucleation. Selektion von Studien mit einem Nachbeobachtungszeitraum ≥48 Monate.

Ergebnisse

Es wurden 5 randomisiert kontrollierte Studien (2 HoLEP, 2 biplare Enukleation, 1 Thulium-Laserresektion der Prostata in Tangerine-Technik [TmLR-TT]), 3 prospektive Kohortenstudien: 2 Thulium-Vapoenukleation [ThuVEP], 1 TmLRP-TT) sowie 2 retrospektive Studien mit hoher Patientenzahl ausgewählt. Alle EEP erwiesen sich bezüglich der Effektivität und Nachhaltigkeit gleichwertig der Operation. Die Adenomrezidivoperationsrate von HoLEP, ThuVEP, bipolarer Enukleation und Tangerine-Technik (TmLRP-TT) liegt bei 0–1,2 %, die Urethrotomierate bei 1,9–3,75 %, die Blasenhalsresektionsrate bei 0,9–4 %. Es ergab sich für die Einzelstudien kein signifikanter Unterschied zur Operation. Im Vergleich bipolare Enukleation vs. TURP waren nach 60 Monaten die Parameter maximaler Harnfluss, Restharn und IPSS signifikant besser für bipolare Enukleation. Beim Vergleich TmLRP-TT und TURP nach 48 Monaten fand sich kein signifikanter Unterschied.

Schlussfolgerung

Verschiedene transurethrale endoskopische Enukleationen (EEP) der Prostata können vor dem Hintergrund der transurethralen anatomischen Enukleation der Prostata als gleichermaßen sicher und effektiv für die Behandlung der BPO betrachtet werden. Alle EEP erreichen die Nachhaltigkeit der offenen Operation. Die Wahl der Energiequelle für die EEP erscheint vor diesem Hintergrund sekundär und eher bedingt durch die Verfügbarkeit von Ressourcen oder persönliche Präferenz des erfahrenen Operateurs bedingt.

Abstract

Background

In the last 20 years various transurethral endoscopic enucleation techniques (EEP) have been established as a substitute for open prostatectomy (OP) and TURP. Since the 2016 update of the “EAU Guidelines on Management of Non-Neurogenic Male Lower Urinary Tract Symptoms (LUTS), including Benign Prostatic Obstruction (BPO)”, Holmium laser enucleation of the prostate (HoLEP) and bipolar enucleation being summarized as anatomical enucleating techniques are proposed as first choice for the surgical management of BPO of large volume prostates.

Objectives

The purpose of this review is to demonstrate the available data on long-term outcomes of current EEP techniques.

Materials and methods

PubMed/Medline and Scopus were searched using the terms: long term, HoLEP, ThuLEP, ThuVEP, DiLEP, ELEP, GreenlEP, Greenlight enucleation, bipolar enucleation, plasmakinetic enucleation, monopolar enucleation, and transurethral enucleation. Studies with a follow-up ≥48 months were selected.

Results

In all, 5 randomized controlled trials (2 HoLEP, 2 bipolar enucleation, 1 Thulium laser resection of the prostate in tangerine technique [TmLR-TT]), 3 prospective cohort studies (2 thulium vapoenucleation [ThuVEP], 1 TmLRP-TT), and 2 retrospective studies with large patient cohorts were selected. All EEP were equivalent to OP with regard to effectivity and durability of results. The rate of secondary surgical procedures in HolEP, ThuVEP, bipolar enucleation and tangerine technique (TmLRP-TT) was 0–1.2 % for reTURP, 1.9–3.75 % for urethrotomy, and 0.9–4 % for bladder neck resection. No significant difference in the individual studies was found when compared to OP. For bipolar enucleation vs. TURP long-term results for uroflow, residual urine, and IPSS were significantly better at 60 months for bipolar enucleation. One RCT TmLRP-TT vs. TURP at the 48-month follow-up found no significant difference.

Conclusion

Various transurethral EEP can be considered as equally safe and effective anatomical enucleation techniques. All displayed EEPs match the durability of OP. The choice of energy source for EEP seems to be secondary and a function of resources and personal preference of the skilled surgeon.

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  1. Klinik für Urologie und urologische Onkologie, Medizinische Hochschule Hannover (MHH), Carl Neuberg Str. 1, 30625, Hannover, Deutschland

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T.R. Herrmann gibt Beratertätigkeit, Vortragshonorare Karl Storz GmbH. Beratertätigkeit, Vortragshonorare, Advisory Board Boston Scientific; Vortragshonorare LisaLaser oHG; Vortragshonorare Asclepion, Advisory Board, Beratertätigkeit; Vortragshonrare Ipsen Pharma AG, Kongressgebühren Janssen an. Der Autor gibt an, dass kein Interessenkonflikt besteht.

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Herrmann, T.R.W. Langzeitergebnisse nach endoskopischer Enukleation der Prostata. Urologe 55, 1446–1454 (2016). https://doi.org/10.1007/s00120-016-0245-8

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