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Differenziertes operatives Management unterschiedlicher Patienten mit benignem Prostatasyndrom (BPS)

Sophisticated surgical management of distinctive patients with benign prostatic hyperplasia (BPH)

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Zusammenfassung

In diesem Artikel werden vier häufige klinische Szenarien zur invasiven Therapie des benignen Prostatasyndroms (BPS) aufgearbeitet. Für den Standardpatienten (Prostatavolumen 30–80 ml, Lebenserwartung >10 Jahre) bleibt auch im Jahr 2020 die transurethrale Resektion der Prostata (TURP) die Methode der Wahl, die endoskopische Enukleation kann als Alternative angeboten werden. Patienten mit einem prominenten, in die Harnblase ragenden Mittellappen profitieren am meisten von TURP, endourologischer Enukleation oder Laservaporisation. Bei einem nicht vorhandenen oder wenig prominenten Mittellappen und keiner relevanten Blasenauslassobstruktion bieten sich auch minimal-invasive Verfahren wie Rezūm®, UroLift® oder die Prostataarterienembolisation (PAE) an. Langzeitergebnisse liegen allerdings in dieser Indikation für keines der neueren Verfahren vor. Vor allem von jüngeren Patienten wird oft der Wunsch nach Ejakulationserhalt geäußert. Bei deutlicher Obstruktion sind ejakulationsprotektive TURP/endoskopische Enukleation oder AquaBeam® Methoden der Wahl mit einem Ejakulationserhalt von 60–90 %. Rezūm® und UroLift® ermöglichen einen Ejakulationserhalt bei >90 % der Patienten, die Daten zur PAE sind kontrovers. Für Patienten mit kleiner Prostata und deutlicher Restharnbildung kommt der präoperativen Diagnostik eine besondere Bedeutung zu. Kurz- und mittelfristig liefern desobstruierende Verfahren zwar zufriedenstellende Ergebnisse; die Langzeiteffizienz ist aber schlecht und nur ungenügend untersucht. Die breite Palette an therapeutischen Optionen ermöglicht heute eine individualisierte minimal-invasive oder chirurgische Therapie des BPS, welche u. a. Patientenwünsche, anatomische Faktoren oder urodynamische Faktoren berücksichtigt. Die Zeit der „One-therapy-fits-all“-Strategie für BPS-Patienten ist definitiv passé.

Abstract

Herein we describe four clinical scenarios. For the standard patient (prostate volume 30–80 ml, life expectancy >10 years) transurethral resection of the prostate (TURP) remains the standard of care, while endoscopic enucleation is a valuable alternative. Patients with a relevant middle lobe profit most from TURP, endourological enucleation procedures, or laser vaporization. In the case of the absence or a moderate-sized middle lobe and the absence of severe bladder outlet obstruction (BOO), minimally invasive procedures such as Rezūm®, UroLift® or prostate artery embolization (PAE) can be offered. Patients have to be informed that long-term data on this specific indication are lacking. Particularly younger men requiring BPH surgery are interested in preserving ejaculatory function. In the presence of severe BOO, ejaculatory-protective TURP or endoscopic enucleation by preserving the pericollicular region or aquablation are the methods of choice providing an antegrade ejaculation in 60–90% of cases. Rezūm®, AquaBeam®, and UroLift® enable preservation of ejaculation in almost 100%; data on PAE with this respect are more controversial. For patients with a small prostate and significant post void residual, a thorough preoperative work-up, including urodynamics and bladder/detrusor wall thickness measurement, is of great importance. Desobstructive surgery provides satisfactory short- and midterm outcome, yet the long-term outcome is disappointing and remains to be determined in greater detail. The broad spectrum of therapeutic options enables today an individualized minimally invasive or surgical management of BPH considering patient wishes, anatomical factors or urodynamic factors. The time of a “one therapy fits all” strategy is definitely history.

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Authors and Affiliations

  1. Abteilung für Urologie, Klinikum Favoriten, Kundratstraße 3, 1100, Wien, Österreich

    S. Madersbacher

  2. Sigmund Freud Privatuniversität, Wien, Österreich

    S. Madersbacher

  3. Klinik für Urologie, St. Antonius-Hospital, Gronau, Deutschland

    M. Oelke

  4. Marienhaus Klinikum Hetzelstift, Akademisches Lehrkrankenhaus der Johannes, Gutenberg-Universität Mainz, Stiftstraße 10, 67434, Neustadt a.d. Weinstraße, Deutschland

    A. Häcker

  5. Klinik für Urologie, Klinikum Weiden/Kliniken Nordoberpfalz, Weiden, Deutschland

    T. Bschleipfer

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  4. T. Bschleipfer
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Correspondence to S. Madersbacher.

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S. Madersbacher, M. Oelke, A. Häcker und T. Bschleipfer geben an, dass kein Interessenkonflikt besteht.

Für diesen Beitrag wurden von den Autoren keine Studien an Menschen oder Tieren durchgeführt. Für die aufgeführten Studien gelten die jeweils dort angegebenen ethischen Richtlinien.

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Madersbacher, S., Oelke, M., Häcker, A. et al. Differenziertes operatives Management unterschiedlicher Patienten mit benignem Prostatasyndrom (BPS). Urologe 59, 1168–1176 (2020). https://doi.org/10.1007/s00120-020-01310-w

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