Prostatachirurgie beim benignen Prostatasyndrom >200 ml: Endoskopisch, robotisch oder doch offen?

Zusammenfassung

Die operativen Therapieansätze der benignen Prostatahyperplasie (BPH) wurden in den letzten Jahrzenten weiterentwickelt und diversifiziert. Während die Wirksamkeit der operativen Verfahren bei moderaten Prostatagrößen in zahlreichen Studien dokumentiert wird, bleibt die Datenlage bei großen Prostatavolumina >200 ml unzureichend. Hierdurch bleiben wichtige Fragen hinsichtlich ihrer Effektivität und Sicherheit offen. Aufgrund dessen ist die Auswahl und Anpassung der geeigneten Therapieoptionen für diese spezielle Patientengruppe oft eine große Herausforderung. In dieser Übersichtsarbeit werden nach einer umfassenden Literaturrecherche die aktuellen Erkenntnisse zu den operativen Therapiemöglichkeiten bei großen Prostatavolumina >200 ml zusammengefasst und diskutiert.

Die operative Behandlung von Prostatavolumina >200 ml ist unabhängig von der gewählten Operationsmethode eine Herausforderung. Minimalinvasive Ansätze sollten heutzutage Standard sein. Die anatomische endoskopische Enukleation ist das Verfahren mit der geringsten Morbidität und ist prinzipiell größenunabhängig durchführbar. Da das Verfahren auch in Spinalanästhesie durchführbar ist, ist es auch für Patienten mit erhöhtem Narkoserisiko geeignet. Bei extremen Prostatavolumina stellt dieses Verfahren aber auch erfahrene Operateure vor Herausforderungen. Besonders in Kombination mit einer Adipositas sollte der Operateur verschiedene Exit-Strategien kennen. Die roboterassistierte Adenomenukleation bietet eine minimalinvasive Alternative, mit welcher begleitende Pathologien (Divertikel oder große Blasensteine) mitbehandelt werden können. Allerdings sind die Invasivität und das Narkoserisiko durch den abdominellen Zugang vergleichsweise höher. Jede Klinik und jeder Operateur sollte individuell entscheiden, in welcher Methode die größte Expertise vorliegt und welche Option für den jeweiligen Fall am besten geeignet ist. Sollte die Expertise begrenzt sein, ist es ratsam, den Patienten einem Zentrum mit entsprechender Spezialisierung zuzuweisen.

Abstract

Surgical approaches for benign prostatic hyperplasia have evolved and diversified over the past decades. While numerous studies document the efficacy of surgical procedures for moderate prostate sizes, there remains insufficient data for large prostate volumes >200 ml, leaving important questions unanswered regarding their effectiveness and safety. Consequently, selecting and adapting suitable therapeutic options for this specific patient group often poses a significant challenge. In this context, this review comprehensively summarizes and discusses current insights into surgical treatment options for large prostate volumes (>200 ml) following an extensive literature review.

In summary, the surgical treatment of prostate volumes >200 ml is a challenge regardless of the chosen surgical method. Minimally invasive approaches should be considered standard practice today. Anatomical endoscopic enucleation of the prostate is a size-independent method and has the lowest morbidity. As it may be performed in spinal anaesthesia, endoscopic enucleation is feasible in patients with an increased anaesthetic risk. In extremely large prostate glands, the procedure poses challenges even for highly experienced surgeons. Especially in obese patients, the surgeon should be familiar with different exit strategies. Robot-assisted simple prostatectomy provides a minimally invasive alternative that may also treat pathologies such as diverticula or large bladder stones in the same surgical session. Due to its transabdominal approach, the morbidity and anaesthetic risk is comparatively higher. Each centre and surgeon should individually decide in which method they have the greatest expertise and which option is best suited for the specific case. In cases of limited expertise, it is advisable to refer patients to a centre with appropriate specialization.

Schlüsselwörter

BPH - Prostatahyperplasie - Enukleation - Roboter

Keywords

Benign Prostatic Hyperplasia - BPH - Enucleation - Robotic

Publication History

Received: 30 January 2024

Accepted after revision: 02 April 2024

Article published online:
28 May 2024

• Literatur

• 1 Hartung FO, Kowalewski KF, von Hardenberg J. et al. Holmium Versus Thulium Laser Enucleation of the Prostate: A Systematic Review and Meta-analysis of Randomized Controlled Trials. Eur Urol Focus 2022; 8: 545
• 2 Robert G, Cornu JN, Fourmarier M. et al. Multicentre prospective evaluation of the learning curve of holmium laser enucleation of the prostate (HoLEP). BJU Int 2016; 117: 495 DOI: 10.1111/bju.13124. (PMID: 25781490)
• 3 EAU Guidelines, Edn. presented at the EAU Annual Congress Milan March 2023, 2023.
• 4 Li Z, Chen P, Wang J. et al. The impact of surgical treatments for lower urinary tract symptoms/benign prostatic hyperplasia on male erectile function: A systematic review and network meta-analysis. Medicine (Baltimore) 2016; 95: e3862 DOI: 10.1097/MD.0000000000003862. (PMID: 27310968)
• 5 Lin Y, Wu X, Xu A. et al. Transurethral enucleation of the prostate versus transvesical open prostatectomy for large benign prostatic hyperplasia: a systematic review and meta-analysis of randomized controlled trials. World J Urol 2016; 34: 1207 DOI: 10.1007/s00345-015-1735-9. (PMID: 26699627)
• 6 Enikeev D, Okhunov Z, Rapoport L. et al. Novel Thulium Fiber Laser for Enucleation of Prostate: A Retrospective Comparison with Open Simple Prostatectomy. J Endourol 2019; 33: 16
• 7 Tricard T, Xia S, Xiao D. et al. Outcomes of holmium laser enucleation of the prostate (HoLEP) for very large-sized benign prostatic hyperplasia (over 150 mL): open simple prostatectomy is dead. World J Urol 2023; 41: 2249
• 8 Xia Z, Li J, Yang X. et al. Robotic-Assisted vs. Open Simple Prostatectomy for Large Prostates: A Meta-Analysis. Front Surg 2021; 8: 695318 DOI: 10.3389/fsurg.2021.695318. (PMID: 34355017)
• 9 Kowalewski KF, Hartung FO, von Hardenberg J. et al. Robot-Assisted Simple Prostatectomy vs Endoscopic Enucleation of the Prostate: A Systematic Review and Meta-Analysis of Comparative Trials. J Endourol 2022; 36: 1018
• 10 Pandolfo SD, Del Giudice F, Chung BI. et al. Robotic assisted simple prostatectomy versus other treatment modalities for large benign prostatic hyperplasia: a systematic review and meta-analysis of over 6500 cases. Prostate Cancer Prostatic Dis 2023; 26: 495 DOI: 10.1038/s41391-022-00616-4. (PMID: 36402815)
• 11 Hartung FO, Kowalewski KF, Morina F. et al. Perioperative Outcome of Thulium Laser Enucleation of the Prostate versus Robot-Assisted Simple Prostatectomy: A Propensity Score-Matched Analysis. Urol Int 2023; 107: 678 DOI: 10.1159/000530627. (PMID: 37307804)
• 12 Zell MA, Abdul-Muhsin H, Navaratnam A. et al. Holmium laser enucleation of the prostate for very large benign prostatic hyperplasia (≥200cc). World J Urol 2021; 39: 129
• 13 Kim M, Piao S, Lee H-E. et al. Efficacy and safety of holmium laser enucleation of the prostate for extremely large prostatic adenoma in patients with benign prostatic hyperplasia. Korean J Urol 2015; 56: 218
• 14 Glybochko PV, Rapoport LM, Enikeev ME. et al. Holmium laser enucleation of the prostate (HoLEP) for small, large and giant prostatic hyperplasia: tips and tricks. Urologia 2017; 84: 169 DOI: 10.5301/uj.5000232. (PMID: 28497447)
• 15 Boxall NE, Georgiades F, Miah S. et al. A call for HoLEP: AEEP for mega-prostates (≥200cc). World Journal of Urology 2021; 39: 2347 DOI: 10.1007/s00345-021-03708-3. (PMID: 33978810)
• 16 Helfand BT, Glaser AP, Kasraeian A. et al. Men with lower urinary tract symptoms secondary to BPH undergoing Aquablation with very large prostates (>150mL). Can J Urol 2021; 28: 10884
• 17 Helfand BT, Kasraeian A, Sterious S. et al. How I do it: Aquablation in very large prostates (>150mL). Can J Urol 2022; 29: 11111
• 18 Stone BV, Chughtai B, Forde JC. et al. Safety and Efficacy of GreenLight XPS Laser Vapoenucleation in Prostates Measuring Over 150 mL. J Endourol 2016; 30: 906 DOI: 10.1089/end.2016.0288. (PMID: 27203515)
• 19 Castillo O, Vidal-Mora I, Rodriguez-Carlin A. et al. Modified urethrovesical anastomosis during robot-assisted simple prostatectomy: Technique and results. Prostate Int 2016; 4: 61
• 20 Coelho RF, Chauhan S, Sivaraman A. et al. Modified technique of robotic-assisted simple prostatectomy: advantages of a vesico-urethral anastomosis. BJU Int 2012; 109: 426 DOI: 10.1111/j.1464-410X.2011.010401.x. (PMID: 21851543)
• 21 Rodrigues GJ, Sawczyn GV, Guglielmetti GB. et al. Robot-assisted simple prostatectomy: the evolution of a surgical technique. Int Braz J Urol 2021; 47: 682 DOI: 10.1590/S1677-5538.IBJU.2020.0744. (PMID: 33621025)
• 22 Anceschi U, Amparore D, Prata F. et al. Predictors of mid-term functional outcomes for robot-assisted Madigan simple prostatectomy: results of a multicentric series according to the BPH-6 achievement. Minerva Urol Nephrol 2023; 75: 607 DOI: 10.23736/S2724-6051.23.05373-9. (PMID: 37728496)
• 23 Porpiglia F, Checcucci E, Amparore D. et al. Urethral-sparing Robot-assisted Simple Prostatectomy: An Innovative Technique to Preserve Ejaculatory Function Overcoming the Limitation of the Standard Millin Approach. Eur Urol 2021; 80: 222 DOI: 10.1016/j.eururo.2020.09.028. (PMID: 33032850)
• 24 Kuo RL, Kim SC, Lingeman JE. et al. Holmium laser enucleation of prostate (HoLEP): the Methodist Hospital experience with greater than 75 gram enucleations. J Urol 2003; 170: 149
• 25 Matlaga BR, Kim SC, Kuo RL. et al. Holmium laser enucleation of the prostate for prostates of >125mL. BJU Int 2006; 97: 81 DOI: 10.1111/j.1464-410X.2006.05898.x. (PMID: 16336333)
• 26 Krambeck AE, Handa SE, Lingeman JE. Holmium laser enucleation of the prostate for prostates larger than 175 grams. J Endourol 2010; 24: 433
• 27 Humphreys MR, Miller NL, Handa SE. et al. Holmium laser enucleation of the prostate--outcomes independent of prostate size?. J Urol 2008; 180: 2431 DOI: 10.1016/j.juro.2008.08.019. (PMID: 18930490)
• 28 Zell MA, Abdul-Muhsin H, Navaratnam A. et al. Holmium laser enucleation of the prostate for very large benign prostatic hyperplasia (≥200cc). World Journal of Urology 2021; 39: 129
• 29 Rodríguez Socarrás M, Fernández Del Álamo J, Gómez Rivas J. et al. En bloc MoLEP (MOSES HoLEP) with early apical dissection and preservation of the sphincter's mucosa. Surgical technique and technology developments that allow a new paradigm of endoscopic prostate enucleation. Arch Esp Urol 2020; 73: 689
• 30 Heiman J, Krambeck A, Agarwal D. et al. Temporary Perineal Urethrostomy During Holmium Laser Enucleation of the Prostate (HoLEP). International Journal of Surgical Case Reports 2020; DOI: 10.31487/j.IJSCR.2020.02.04.
• 31 Tiburtius C, Leavitt D, Netsch C. et al. Prostate Morcellation After Transurethral Prostate Enucleation: Technique, Tips, and Tricks. Videourology 2015; 29 DOI: 10.1089/vid.2015.0003.
• 32 Becker B, Orywal AK, Hausmann T. et al. A Prospective Randomized Study Comparing Disposable with Reusable Blades for a Morcellator Device. J Endourol 2017; 31: 314
• 33 Wymer KM, Thao V, Narang G. et al. Evaluation of Private Payer and Patient Out-of-Pocket Costs Associated With the Surgical Management of Benign Prostatic Hyperplasia. Urology 2024; 184: 87-93 DOI: 10.1016/j.urology.2023.10.038. (PMID: 38065310)
• 34 Shelton TM, Drake C, Vasquez R. et al. Comparison of Contemporary Surgical Outcomes Between Holmium Laser Enucleation of the Prostate and Robotic-Assisted Simple Prostatectomy. Curr Urol Rep 2023; 24: 221