[Endoscopic enucleation of the prostate]. / Endoskopische Enukleation der Prostata.

The spectrum of surgical procedures for the minimally invasive treatment of benign prostatic hyperplasia (BPH) has significantly increased over the last two decades. The simple suprapubic prostatectomy (subtotal prostatectomy, SP) has largely lost relevance in current practice. On the other hand, transurethral resection of the prostate (TURP) has been further standardized and potentially made safer by the introduction of the bipolar technique and low-pressure systems.Transurethral (endoscopic) enucleation techniques (endoscopic enucleation of the prostate, EEP) are increasingly competing with the current gold standard TURP and are replacing SP for treatment of larger adenomas. This approach is especially related to the rapid development of laser technology, which has sustainably changed the face of modern BPH treatment in a similar way to stone therapy. This has been incorporated in the clinical patient management, clinical studies and standardization of numerous surgical techniques that are systematically described in this article. Additionally, efforts have also been made to use other energy sources, such as bipolar current in EEP. With respect to scientific objectivity, high-quality clinical trials are regularly published which further strengthen the position of EEP.

[Surgical treatment of benign prostatic hyperplasia-resection, vaporization or enucleation?] / Operative Therapie des benignen Prostatasyndroms ­ resezieren, vaporisieren oder enukleieren?

BACKGROUND: Benign prostatic hyperplasia (BPH) is the most common condition affecting the male lower urinary tract. Besides transurethral resection of the prostate (TURP), vaporization of the prostate and endoscopic enucleation of the prostate are available. OBJECTIVES: To provide an overview of the current status of surgical therapies for BPH. MATERIALS AND METHODS: Narrative review of the literature on the surgical treatment of BPH. RESULTS: Besides TURP, which still can be regarded as the reference technique for surgical treatment of BPH in men with a prostate volume <80 cc, greenlight laser vaporization of the prostate (GLV) and endoscopic enucleation of the prostate (EEP) are established and evidence-based alternatives. A multitude of prospective randomized trials could show comparable functional outcomes of GLV or EEP in comparison to TURP. Based on lower comorbidity and comparable outcomes, bipolar TURP rather than monopolar TURP should be regarded as the surgical reference technique. In patients with ongoing oral anticoagulation of thrombocyte aggregation inhibition, GLV provides high intra- und postoperative safety. Endoscopic enucleation of the prostate is the only transurethral surgical method which provides high level evidence concerning safety and efficacy in patients with prostates >80 cc. CONCLUSIONS: Choice of surgical treatment of BPH should be individualized and based on prostate size, comorbidities and surgical experience.

Aquablation of the prostate: single-center results of a non-selected, consecutive patient cohort.

PURPOSE: Aquablation of the prostate using the AquaBeam™ system promises equivalent functional outcomes, reduced learning curve, and improved sexual function compared to transurethral prostate resection as shown in prospective randomized trials. This prospective cohort study aims to evaluate if published results can be transferred into the clinical routine in a non-selected patient collective. METHODS: This study includes all patients treated between September 2017 and June 2018 with Aquablation of the prostate. Patients have been evaluated prospectively for the perioperative course and early follow-up. Besides voiding parameter and symptom score, TRUS-volume change, ejaculatory function, and adverse events have been recorded. RESULTS: 118 consecutive patients have been treated in the given time. Aquablation could be carried out successfully in all patients. IPSS, QoL, Qmax, and PVR improved significantly after the procedure and continued to improve during 3-month follow-up. Mean OR time was 20 min, TRUS volume decreased by 65%, and 73% of the patients retained antegrade ejaculation. Thirteen adverse events (> Clavien-Dindo I) occurred in 10 patients. CONCLUSION: The surgical ablation of the prostate using Aquablation achieved significant and immediate improvement of functional voiding parameters Qmax and PVR as well as symptomatic improvement of IPSS and QoL. Aquablation seems to be safe and effective with a low perioperative complication profile even in a non-selected group of patients.

[Long-term outcome after endoscopic enucleation of the prostate : From monopolar enucleation to HoLEP and from HoLEP to EEP]. / Langzeitergebnisse nach endoskopischer Enukleation der Prostata : Von der monopolaren Enukleation zu HoLEP und EEP.

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.

Evaluation of the learning curve for Thulium VapoEnucleation of the prostate (ThuVEP) using a mentor-based approach.

INTRODUCTION: To evaluate the learning curve of Thulium:YAG VapoEnucleation of the prostate (ThuVEP) for patients with symptomatic benign prostatic obstruction (BPO) prospectively. METHODS: ThuVEP was performed using the 120 Watt 2 µm continuous wave Thulium:YAG laser. ThuVEP was done by a resident without experience in transurethral prostate surgery (A, n = 32), an experienced endourologist (B, n = 32), and an experienced surgeon in ThuVEP (C, n = 32), who served as the mentor for A/B. Patients were divided into consecutive subgroups of 8 patients to assess the impact of the learning curve on procedure outcome. Patient demographic, perioperative, and 12-month follow-up data were analysed. RESULTS: ThuVEP was successfully completed in all patients. Enucleation efficiency (g/min) differed significantly between surgeon A (0.48 ± 0.3), B (0.7 ± 0.36), and C (1.4 ± 0.67) (p ≤ 0.001). Enucleation efficiency correlated significantly with the weight of resected tissue in surgeon A (r = 0.88), B (r = 0.73), and C (r = 0.79) (p < 0.001). ThuVEP was performed by surgeon A and B with reasonable enucleation, morcellation, and overall operation efficiency after 8-16 procedures. At 12-month follow-up, 68 (71 %) patients were available for review. IPSS, QoL, Qmax, PVR, PSA, and prostate volume improved significantly at follow-up (p ≤ 0.023). Mean PSA/prostate volume reduction was 81.95/74.5, 80.7/79.4, and 87.6/75.9 % in surgeon A, B, and C, respectively. Urethral stricture and bladder neck contracture developed 2 (A = 1, B = 1; 2.1 %) patients and 1 (C, 1 %) patient each, respectively. CONCLUSIONS: ThuVEP can be performed with reasonable efficiency even during the initial learning course of the surgeon when closely mentored. Previous experience in the field of endourology is beneficial.

[Pharmacological treatment of benign prostatic hyperplasia]. / Medikamentöse Therapie der benignen Prostatahyperplasie.

The majority of men with benign prostatic hyperplasia (BPH) seek medical help because of lower urinary tract symptoms (LUTS). Pharmacological treatment of BPH is indicated if the patient has no absolute indications for prostate surgery or benign prostatic obstruction (BPO), but LUTS with a decrease of quality of life. Plant extracts can be prescribed in men with mild to moderate symptoms. alpha-Blockers can quickly and effectively decrease LUTS and symptomatic disease progression. If patients have predominantly bladder filling symptoms and a small prostate, muscarinic receptor antagonists are a viable treatment option. The combination of an alpha-blocker plus a muscarinic receptor antagonist is more effective than single drugs used alone. Especially in men with larger prostates, 5alpha-reductase inhibitors can decrease LUTS and the probability of acute urinary retention as well as need for prostate surgery. The combination of alpha-blocker plus 5alpha-reductase inhibitor can reduce LUTS and disease progression more effectively than single drugs.

Laser treatments of the prostate vs TURP/ open prostatectomy: systematic review of urodynamic data.

UNLABELLED: Bladder outlet obstruction (BOO) is believed to be the major component of benign prostatic hyperplasia (BPH) that harms the urinary tract. Therefore, BOO relief is the primary treatment objective in patients with obstructive BPH. This systematic review aims to analyze urodynamic data of laser treatment modalities of the prostate in direct comparison with standard treatment (TURP or open prostatectomy). We systematically searched the literature for randomized-controlled trials (RCTs) of prostate laser treatments in which urodynamic results were compared to TURP or open prostatectomy. The literature search included articles that were published between January 1995 and January 2009. Thirty five RCTs were identified encompassing in total 3669 patients. Of all available laser treatments, only one RCT used pressure-flow data to compare the laser treatment of the prostate (holmium laser enucleation, HoLEP) with standard treatment. Improvement of maximum urinary flow rate (Q(max)) of free uroflowmetry was similar for contact laser ablation (CLAP) with Nd:YAG, interstitial laser coagulation with Nd:YAG, potassium potassium-titanyl-phosphate (KTP)/Nd: YAG hybrid treatment, and HoLEP. Qmax improvement was also similar for holmium laser ablation (HoLAP) with 60-80 Watts, holmium laser resection, and thulium laser resection but limited to only one study each. The laser hybrid therapy with CLAP/visual laser ablation of the prostate (VLAP)/Nd:YAG was inferior to TURP. VLAP and KTP showed inhomogeneous RESULTS: Most contemporary laser treatments modalities provide similar Qmax improvement compared to standard treatment. However, precise differences can only be determined by comparative computer urodynamic investigations. Therefore, new laser techniques (such as thulium laser vapoenucleation of the prostate) should be investigated by urodynamic studies in the future.

[Thulium:YAG vaporesection of the prostate. First results]. / Thulium:YAG-Vaporesektion der Prostata. Erste Erfahrungen und Ergebnisse.

OBJECTIVES: Laser treatment of benign prostatic hyperplasia has been introduced. The thulium:YAG (Tm:YAG) laser combines the advantages of established laser systems. This study reports the preliminary results of vaporesection of the prostate, using this 2-microm continuous wave (cw) laser. MATERIAL AND METHODS: A total of 54 consecutive patients were treated with the Tm:YAG laser. The outcomes measured were resection time, catheter time, improvement in urinary flow rate (Q(max)), and post-voiding residual urine (PVR). International Prostate Symptom Score (IPSS) and Quality of Life Index (QoL) were recorded. RESULTS: The mean age was 61 years. Mean prostate volume was 30.3 cc. Average resection time was 52 min. Catheter time was 1.7 days. Qmax significantly improved from 4.2 to 20.9 ml on average. PVR decreased from 86 to 16 ml. IPSS and QoL score improved from 19.8 to 6.5 and 4 to 1, respectively. No patient required re-hospitalization. Transfusions were not necessary. CONCLUSIONS: These preliminary results indicate that Tm:YAG vaporesection of the prostate is safe and efficient. The 18-month follow-up data showed major improvement in voiding symptoms and QoL. Longer follow-up is needed to prove durability of these promising results.

Effect of testosterone, raloxifene and estrogen replacement on the microstructure and biomechanics of metaphyseal osteoporotic bones in orchiectomized male rats.

INTRODUCTION: Currently, osteoporosis research is rarely undertaken in males but an increase in male life expectancy in the company of hypogonadism suggests the necessity for potential therapeutic options. MATERIALS AND METHODS: In this study, the changes in bone structure under standardized testosterone- (T), raloxifene- (R) and estrogen (E)-supplemented diets were analyzed in osteoporotic castrated male rats. RESULTS: Unexpected biomechanical results could be only explained by the histomorphometry, but not by BMD measurements obtained from the qCT. All tested substances showed a significant improvement in the trabecular network (trabecular bone area for C: 2.55 mm(2), T: 4.25 mm(2), R: 4.22 mm(2) and E: 4.28 mm(2)), and suggests that the bone structure was preserved. For the metaphyseal cortical bone, a significant loss was detected in T (CBP: 18.7%) compared to R (CBP: 30.0%), E (CBP: 26.8%) and even to the osteoporotic control (CBP: 28.6%). This explains the observed early mechanical final failure after T supplementation. However, due to the preserved trabecular bone in T, the occurrence of the first microfractures (yL: 49 +/- 21.4 N) was significantly later than in the osteoporotic control (yL: 39.5 +/- 15.5 N). Raloxifene performed well in hindering the bone loss associated with osteoporosis. However, its effect (yL: 83.3 +/- 16.5 N) did not approach the protective effect of E (yL: 99.2 +/- 21.1 N). CONCLUSION: Testosterone only preserved the deterioration of the trabecular bone but not of the cortical bone. Raloxifene prevented the bone loss associated with osteoporosis at all bony structures. This effect did not approach the protective effect of estrogen on trabecular bone, but it is more suitable for male individuals because it has no feminizing effects on the subject.

Transurethral microwave thermotherapy for the treatment of BPH: still a challenger?

Minimally invasive therapies for treatment of benign prostatic hyperplasia (BPH) compete with the gold standard transurethral resection of the prostate (TURP). Comparisons of efficacy and safety have broadened the knowledge of different treatment modalities. Concerns of quality of life such as unaltered sexual function as well as cost considerations drive the market to develop techniques of lower level invasiveness. Among the competitors the office based transurethral microwave thermotherapy (TUMT) provides the broadest scale of scientific data. Numerous manufacturers sell various modifications of this technology. According to different clinical studies TUMT proved to be an effective, safe, and durable therapy for the treatment of lower urinary tract symptoms (LUTS) secondary to BPH. However, TURP still holds the steadier long-term results and is more effective to reduce obstruction as well as other LUTS.