Standard transurethral resection of the prostate (TUR-P), in which each of the many methods must be measured, such as laser procedures, TUMT, TUNA and stents. The selection is based on the findings and other criteria.
After the examination results are available and the decision for surgery has fallen (for details see treatment planning ), the most appropriate in each individual case is selected:
If a compelling reason (absolute indication; see treatment planning ) for operation consists primarily ablative methods are called in the first place, in which the excess prostate tissue is removed immediately: TURP, open prostate surgery, HoLEP or laser vaporization of the prostate (see below for descriptions ). In a large surgical risk of the person concerned (eg due to concomitant diseases) are the stent implantation and secondary ablative methods, in which the body rejecting the tissue treated or degrades slowly: ILC, HE-TUMT or TUNA (all below). Is not this, too, a urinary diversion by catheter remains (through the urethra = transurethral or above the pubic area = suprapubic). If there is no absolute indication for surgery, a primary or a secondary ablative procedures can be selected.
The standard applies transurethral resection of the prostate (TUR-P, see below), in which all other methods must be measured. Currently, there are a whole host of very different procedure and it constantly develops new. All have two goals: First, to avoid the discomfort and urine flow to improve as quickly as possible, good and durable as well as serious consequences of the BPS (see signs and complications ). And secondly by the engagement of the load and its potential complications to a minimum.
Unfortunately they contradict these goals: the more prostate tissue is removed, the clearer and more durable, the symptoms and improve (to a lesser extent) the urine flow. The sooner but also to be expected complications of the procedure. An ideal method there is not so (yet). So will the select the most appropriate in a particular case only after a thorough explanation by the doctor. Because of the diversity of this process and the procedures below may only be summarized and presented very briefly.
Selection criteria for the surgical procedure are, for example:
- Examination findings: You can select significantly limit (eg, bleeding).
- Objective: Complete or partial, permanent or temporary improvement of symptoms and urine flow.
- Exposure to the intervention: Outpatient or inpatient implementation, catheter-wearing time and discomfort after the procedure, time to help ease the discomfort and to healing.
- Long-term success: Because the prostate gland is not completely removed, can regrow tissue remaining and again cause BPS (relapse), so that further intervention may be required. The risk is all the greater, the more tissue remains and the more time goes by.Also, complications such as scarring (see below) may reduce the long-term success. A comparison between the TURP and new, especially minimally invasive (little engaging) method so it is important to consider as long as possible (for long-term results at least 10 years). And studies are put to strict requirements.
- Availability and Cost: Some methods are only available in specialized centers, and it begs the question of reimbursement.
- Removal or damage of the tissue: Only removed tissue can be examined for the presence of prostate cancer (after TURP and Adenomenukleation in up to 15% of the time available).
- Incidents during and soon after anesthesia and surgery (depending on the type of anesthesia, age, comorbidities, among other things, at TURP total of 11.8%): For example, bleeding (with TURP 3.6%), TUR syndrome (disease caused by Wash in washing liquid into the blood during the operation, in TUR-P 1.1%), urinary tract infection (in TUR-P 3.7%).
- Problems with urination during healing.
- Urinary incontinence (involuntary loss of urine): After TUR-P to 10%, may require further treatment (see urinary incontinence ).
- Erectile dysfunction ("impotence", erectile dysfunction , ED): Consists in part before surgery, is not a common side effect of TURP.
- Retrograde ("dry") ejaculation: The emptying of the semen during ejaculation into the bladder (reverse) occurs after TUR-P very common (60-90%), because the prostate tissue part of the muscle of the internal sphincter is removed. Libido ("Lust") and orgasm (sexual climax) are not affected.
- Obstruction of Harnabflusses by scarring in the urethra or bladder neck.
- Reoperation due to recurrence (recurrence) or scars: In TURP 8-15% in 8 years, in some minimally invasive procedures more frequently and almost always performed as TURP.
Removal of the tissue (resection) with an electric loop in anesthesia through the urethra (transurethral) under visual (endoscopic). Most urological surgery, second oldest method of operation at BPS, standard procedures. Excellent and lasting improvement of symptoms and urine flow with low complication with proper patient selection and modern technology. Numerous developments with equally good results (long-term data are partially missing) and fewer complications (eg low pressure systems, bipolar resection, vaporisation = removal by evaporation). Minimum TUR-P: Partial removal of the tissue, only in critically ill patients.
Adenomenukleation (AE, open prostate surgery)
Remove (Triggering = enucleation) of the enlarged prostate parts (the adenoma ) in anesthesia by open access (through the abdominal wall, then through the bladder or between the bladder and pubic bone). Oldest operation method when BPS, standard procedures, for example, appears at very large prostates (mostly from 70ml) and concomitant diseases such as bladder stones, protuberances (diverticulum) of the urinary bladder wall and hernia. Results and complication about the same as TURP.
Transurethral incision of the prostate (TUIP)
Incision (incision) in the bladder neck and prostate through the urethra under direct vision, possibly removing interfering tissue. Recommended for so-called bladder neck rigidity and in younger, sexually active men with small prostates. It can be used (less than 30 ml) as an alternative to TURP in smaller prostates. Approximately the same effectiveness as the TURP with fewer complications (but often second operations).
Laser procedures
Numerous laser types for many different methods are already in use or under development.According to the characteristics of the laser light and the irradiation technique they act primarily or secondarily ablative ("peels"): the former by resection (removal) or vaporization (evaporation) of the fabric, second option by coagulation (boiling down) with subsequent shedding or degradation of the tissue.
Compared to TURP and open surgery, the follow-up periods in studies with more than 5 years for the laser method significantly shorter, the results, at best, equally good and something rare complications (eg, bleeding). Laser procedures can be especially used when the slightly higher complication of TURP and open surgery for the patient appear unreasonable or can not be accepted from him. Many procedures are considered minimally invasive (less intrusive). Some may outpatients and / or carried out under local anesthetic (eg, ILC and laser vaporization).The following are currently being clinically significant:
Interstitial laser coagulation (ILC): coagulation (boiling down) of the tissue after insertion of the laser fiber into the prostate (in the interstitial tissue = interstitium) of the dam from.Secondary ablative procedures (first swelling, then rejection or degradation of the tissue).Good relief of symptoms, improvement of Harnabflusses slightly lower than the TURP, fewer complications, catheter longer necessary to be at high surgical risk.
Holmiumlaserenukleation of the prostate (HoLEP): Triggering (enucleation) or removal (resection) of the tissue through the urethra under direct vision. About the same good results as TURP, fewer complications, but harder to learn (a lot of experience necessary). Is with a significant Harnabflussbehinderung through the prostate as an alternative to TURP and open surgery.
Laser vaporization of the prostate (also: Photoselective vaporization of the prostate, PVP): vaporization (evaporation) of the tissue with the KTP laser ("Green Light process") through the urethra under direct vision. Is probably as effective as the TURP with less complications and therefore an alternative to TURP and open surgery (only relatively short-term results are available).
Transurethral microwave thermotherapy (TUMT)
Heating the tissue with microwave with a water-cooled catheter through the urethra, either with low-energy (NE-TUMT) or high-energy (HE-TUMT). Both are possible on an outpatient basis without anesthesia. The NE-TUMT does not ablate (destroy no tissue), has no effect on the urinary obstruction, alleviates symptoms such as the HE-TUMT and so far could not prevail.
The HE-TUMT acts secondarily ablative (first swelling of the tissue, so catheter necessary). It relieves the symptoms less than TURP, urine flow improved lower, has less complications and secondary interventions but requires more (within 5 years of follow-up, demonstrated only for a few devices). A further development with temperature probe seems to produce the same results as TURP with fewer complications (follow-up of 5 years, still unconfirmed).
The HE-TUMT can be used in patients with moderate symptoms and urinary obstruction and in patients with acute urinary retention ( ischuria ) and high surgical risk as an alternative to TURP. They may want to consider as an alternative to TURP, if less tissue has to be removed at a moderate urinary obstruction or if the slightly higher rate of complications of TURP not appear reasonable for the patient or will not be accepted from him.
Transurethral needle ablation of the prostate (TUNA)
Heating the tissue with radiofrequency waves on needle antennas through the urethra under direct vision. The TUNA can be done without anesthetic and acts secondarily ablative (first swelling of the tissue, hence not necessary catheter). It improves urine flow and symptoms over medicines, but less than the TURP, rarely has complications, often requiring re-treatment (including medication, max 5 years follow-up.).
The TUNA is especially suitable for patients with moderate to severe symptoms and lower urinary obstruction. It can be used in patients with acute urinary retention ( ischuria ) and high surgical risk as an alternative to TURP. They may want to consider as an alternative to TURP, if only little tissue has to be removed at a low urinary obstruction or if the slightly higher rate of complications of TURP not appear reasonable for the patient or will not be accepted from him.
Prostatic stents
Tube-shaped implants made of different materials that are used in local anesthesia transient (temporary) or permanently (permanent) in the urethra within the prostate. Stents act non-ablative (no damage prostate tissue) and improve urine flow similar to TURP. Due to frequent complications (eg, persistent urge to urinate, increased discomfort, displacement of the stent) they often have to be removed (up to 50% in 10 years).
Therefore, stents come only in well-selected patients in question with significant comorbidities and limited life expectancy, for example, pronounced urinary obstruction or acute urinary retention ( ischuria ). Temporary stents need to be changed regularly, are an alternative to the catheter and can contribute to temporary urinary diversion in secondary ablative procedures (ILC, HE-TUMT, TUNA, all so) may be indicated. Permanent stents are an alternative to permanent bladder catheter in selected patients.
Other methods of treatment
Numerous other methods are currently being tested for the surgical treatment of the BPS, but can not be assessed due to lack of data, for example, injection of alcohol or botulinum toxin (see the magazine Surgical procedures for BPH and botulinum toxin in prostate disease ), balloon dilation (expansion by balloon catheter), HIFU (high intensity focused ultrasound), WIT (water-induced thermotherapy), and robot-assisted endoscopic Adenomenukleation.
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