Wie hilfreich ist ein geriatrisches Assessment vor urologischen Operationen im Hinblick auf kognitive Veränderungen?

Zusammenfassung

Hintergrund: Spätestens mit dem Krankenhausbedarfsplan 2015 fordert die Landesregierung die Erfassung von Patienten mit „geriatrischem Behandlungsbedarf“ und sieht einen „interdisziplinären Dialog, in den Behandlungsaspekte aller Fachabteilungen einfließen“ als erforderlich an. Ein solcher Aspekt ist der kognitiver Veränderungen nach urologischen Operationen wie der TURP oder 180-Watt-XPS-Greenlight-Laserung (GLL), die jedoch europaweit noch nie untersucht wurden.

Methoden: Untersucht wurden kognitive Veränderungen nach der TURP und der GLL mit dem „Minimental State Examination MMSE“ und dem „Uhrentest“ präoperativ und am 2. postoperativen Tag. Diese wurden mit klinischen Parametern wie Patientenalter, Prostatagröße, Operationsdauer, Begleiterkrankungen, Co-Medikation, Veränderungen des Hämoglobins und des Natriums korreliert.

Ergebnisse: Die transurethral elektroresezierten (n=88) und mit dem GLL (n=114) operierten Patienten waren hinsichtlich des Alters, der Prostatagröße und der Operationszeit vergleichbar. Gelaserte Patienten zeigten dabei hinsichtlich potentieller postoperativer kognitiver Veränderungen ein erhöhtes Risikopotenzial mit im Mittel 3,8 Begleiterkrankungen (TURP: 3,11; p=0,005) auf und waren in größerem Ausmaß mit der Einnahme von 6,79 Medikamenten (TURP: 5,24; p<0,001) multimediziert. Dennoch kam es weder für den MMSE noch für den Uhrentest im Mittel zu einem verschlechterten mittleren postoperativen Punktwert (Differenz post-präop. MMSE+0,6±1,6 für die GLL und+0,6±1,6 für die TURP, p=0,944; Differenz post-präop. Uhrentest+0,43±1,44 für die GLL bzw. 0,13±1,17 für die TURP, p=0,097). Weder für das postoperative Hämoglobin noch das postoperative Natrium als sicherheitsrelevante Parameter konnten klinisch relevante Veränderungen nachgewiesen werden. Insgesamt verschlechterte sich der besser als der Uhrentest graduierte Punktwert im MMSE bei 21,1% der gelaserten und 20,5% der elektroresezierten Patienten. Die Subgruppenanalyse der Patienten, die bereits präoperativ mit einem MMSE-Punktwert von ≤ 23,7 eine eingeschränkte Kognition aufwiesen, zeigten 28,6% eine weitere Verschlechterung gegenüber 19,2% der Patienten mit einem präoperativen MMSE-Punktwert von>23,7.

Schlussfolgerungen: Weder für die GLL noch für die TURP ließen sich Veränderungen der Kognition im Minimental State Examination Test oder dem Uhrentest nachweisen. Patienten mit präoperativ eingeschränkter Kognition hatten jedoch ein höheres Risiko, sich weiter zu verschlechtern, als Patienten mit präoperativ uneingeschränkter kognitiver Leistungsfähigkeit. Hier ist ein geriatrisches Assessment hilfreich, diese Risikogruppe zu identifizieren und die kognitive Einschränkung zu quantifizieren.

Abstract

Objective: Detection of changes in cognition after transurethral resection (TURP) or 180-Watt green-light XPS laser treatment (GLL) of the prostate is required by the German “Krankenhausbedarfsplan” which demands an interdisciplinary dialogue including special aspects of the operating discipline. This has as yet not been investigated in Germany or in Europe.

Methods: Assessments of the cognitive capacity were made by application of the “Mini Mental State Examination” and the “Uhrentest” preoperatively and on postoperative day 2 in addition to documentation of clinical parameters such as patient age, prostate size, duration of surgery, comorbidities, co-medication, changes in haemoglobin and sodium.

Results: Patients treated with transurethral resection (n=88) or GLL (n=114) were comparable regarding age, prostate size and operative time. Baseline characteristics of the patients who would be treated with laser showed an increased potential for postoperative cognitive changes: they had an average of 3.8 comorbidities (TURP: 3.11, p=0.005) and were to a greater extent using multiple medications 6.79 (TURP: 5.24, p<0.001). However neither the MMSE nor Uhrentest demonstrated a decrease in the average postoperative score (difference post-preop. MMSE+0.6±1.6 for the GLL and+0.6±1.6 for TURP, p=0.944; difference post- and preoperative Uhrentest+0.43±1.44 for the GLL and 0.13±1.17 for the TURP, p=0.097). Neither the postoperative haemoglobin nor the postoperative sodium, as safety-relevant parameters, demonstrated clinically relevant changes. The differences between the surgical procedures were not statistically significant. 28.6% of the patients with a preoperatively impaired cognition measured by an MMSE-score of≤23.7 incurred a further decline of their cognitive capability in comparison with patients without preoperative cognitive impairment with a further decline in 19.2%.

Conclusions: Neither the GLL nor transurethral prostate resection demonstrated changes in cognition by comparing the preoperative Mini Mental State Examination or the Uhrentest. In this study, the baseline characteristics of lasered patients showed a higher number of comorbidities and a higher use of medication, in particular, with anticholinergic potency. Patients with a preoperatively impaired cognition had an increased risk of further worsening of their cognitive capabilities and should be treated carefully.

Schlüsselwörter

Prostatahyperplasie - benignes Prostatasyndrom - operative Therapie - 180-Watt-XPS-Greenlight-Laserung der Prostata - transurethrale Prostataresektion - TURP - Kognition

Key words

prostate hyperplasia - benign prostate syndrome - operative therapy - 180-Watt green light laser - transurethral resection of the prostate - TURP - cognition

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