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Transurethrale Laserenukleation der Prostata mit dem Holmiumlaser

Wie viel Leistung ist notwendig?

Transurethral enucleation of the prostate with the holmium:YAG laser system

How much power is necessary?

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Zusammenfassung

Zielsetzung

Die Effektivität eines Holmiumlasersystems mit mittlerer Leistung (50 W) und neuartigem Gewebemorcellator für die transurethrale Laserenukleation der Prostata (TULP) wird analysiert und Literaturergebnissen bisheriger Holmiumlaser-Enukleationen der Prostata (HoLEP; 100 W) gegenübergestellt.

Material und Methoden

Von Dezember 2003 bis Januar 2008 wurden 129 Patienten mit benigner Prostatahyperplasie mittels TULP behandelt. Bei 45 Fällen mit 25-W-Laserleistung (Gruppe A; 2,0 J, 12 Hz) erfolgte die Gewebefragmentierung mit bipolarem Resektoskop (VISTA/ACMI), bei 39 Patienten (Gruppe B; 2,0 J, 12 Hz) wurde ein neuartiger Morcellator (Wolf) verwendet. 45 Patienten wurden mit 40 W (Gruppe C; 2,2 J, 18 Hz) therapiert und mittels Matched-pair-Analyse 45 TURP-Patienten (Gruppe D) gegenübergestellt. Außerdem erfolgte eine Literaturrecherche zur HoLEP.

Ergebnisse

Die bipolare Gewebefragmentierung verlängerte die Operationszeit (135 vs. 131 vs. 96 min) signifikant. Die Morcellationsgeschwindigkeit lag im Mittel bei 2,8 (1,3–5,2) g/min ohne Komplikationen. Die Resektionsgeschwindigkeit der 40-W-TULP war vergleichbar mit der TURP (0,71 vs. 0,76 g/min). Die Transfusionsrate war niedriger als bei TURP (8 vs. 12%) mit entsprechend geringerer Hb-Differenz (3,1 vs. 3,8 mg/dl). Die Katheterzeiten (3,4 vs. 4,1 Tage) waren vergleichbar bei signifikant kürzerem stationärer Aufenthalt nach TULP (5,2 vs. 6,8 Tage). Die Komplikationsrate war signifikant geringer (6,6 vs. 13,3%). Entscheidend für die Effizienz von HoLEP war die Einführung des Morcellators: Die Resektionszeiten stiegen von 0,34–0,61 g/min auf 0,48–0,82 g/min Günstiger als 40-W-TULP erweist sich HoLEP hinsichtlich Transfusionsrate (0–4 vs. 8%) und Katheterzeit (1,1–1,5 vs. 3,4 Tage). Die Komplikationsraten und funktionelle Ergebnisse sind gleichwertig.

Schlussfolgerungen

Die transurethrale Laserenukleation der Prostata lässt sich auch mit einem kostengünstigeren System von maximal 50 W durchführen. Das Verfahren ist technisch anspruchsvoll und erfordert endoskopische Erfahrung. Die Resektionsgeschwindigkeiten sind vergleichbar bei geringerem Blutungsrisiko der HoLEP. Technische Neuerungen (z. B. Thulliumlaser) werden die Handhabung der Laserenukleation verbessern.

Abstract

Purpose

To evaluate the efficacy and safety of an intermediate power (50 W) holmium:YAG laser system for transurethral enucleation of the prostate (TULP) with the use of a new mechanical morcellator. Our results are compared with the results of high-powered holmium laser enucleation (HoLEP) presented in the literature.

Material and Methods

From December 2003 to January 2008, 129 patients with benign prostatic hyperplasia were treated by TULP. In 45 cases (group A; 2.0, 12 Hz) we used a bipolar resectoscope (VISTA/ACMI) for morcellation, whereas after that morcellation was accomplished with a modified endoscopic shaver (Wolf). Thirty-nine patients were treated using 25 W (group B; 2.0 J, 12 Hz), and 45 patients were treated using 40 W (group C; 2.2 J 18 Hz), who were compared with 45 matched-pair patients who received transurethral resection of the prostate (TURP; group D). Finally, the literature on HoLEP was reviewed.

Results

Bipolar morcellation significantly prolonged the operating time (135 vs. 131 vs. 96 min). The morcellation speed averaged 2.8 (range 1.3–5.2) g/min with no complications. The resection speed (retrieval rate) of 40-W TULP was comparable to that for TURP (0.71 vs. 0.76 g/min). The transfusion rate was lower than for TURP (8% vs. 12%), with a smaller Hb difference (3.1 vs. 3.8 mg/dl). Catheter times (3.4 vs. 4.1 days) were similar; however, hospital stay was significantly shorter after TULP (5.2 vs. 6.8 days). The complication rate was significantly lower (6.6% vs. 13.3%). The efficacy of HoLEP significantly improved with introduction of the morcellator: Resection speed increased from 0.34–0.61 g/min to 0.48–0.82 g/min. HoLEP was better than 40-W TULP regarding transfusion rate (0–4% vs. 8%) and catheter time (1.1–1.5 vs. 3.4 days). Complications and functional results were similar.

Conclusion[Überschrift]

The intermediate-power 50-W holmium laser together with the new morcellator enable safe transurethral enucleation of the prostate. As with HoLEP, the procedure has a significant learning curve. The retrieval times of TULP are similar to those for HoLEP, but the risk of bleeding is higher. New modifications (i.e., thullium laser) will further improve the technique of laser enucleation.

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Interessenkonflikt

Der korrespondierende Autor weist auf folgende Beziehung hin: Übernahme der Reisekosten bei Operationsdemonstrationen durch die Firma StarMedTec, Starnberg.

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Authors and Affiliations

  1. Urologische Klinik, Klinkum Heilbronn, Am Gesundbrunnen 20, 74074, Heilbronn, Deutschland

    J. Rassweiler, M. Roder & M. Schulze

  2. Urologische Klnik, Diakonissenkrankenhaus Rotenburg/Wümme, Rotenburg/Wümme, Deutschland

    R. Muschter

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  1. J. Rassweiler
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  2. M. Roder
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  3. M. Schulze
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  4. R. Muschter
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Correspondence to J. Rassweiler.

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Rassweiler, J., Roder, M., Schulze, M. et al. Transurethrale Laserenukleation der Prostata mit dem Holmiumlaser. Urologe 47, 441–448 (2008). https://doi.org/10.1007/s00120-008-1684-7

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