Lasertherapie der benignen Prostatahyperplasie

Zusammenfassung

Für die Lasertherapie der benignen Prostatahyperplasie kommen verschiedene Verfahren in Betracht, die mit unterschiedlichen Lasersystemen und Applikationstechniken unterschiedliche qualitative und quantitative Effekte am Gewebe generieren, die Koagulation, Vaporisation bzw. Ablation sowie die Inzision, wobei bei entsprechender Technik eine Resektion bzw. Enukleation resultiert. Da diese Verfahren als Alternative zur transurethralen Resektion der Prostata (TURP) betrachtet werden, ist das Ziel der Lasertherapie die mit der TURP vergleichbare Besserung der Symptomatik und Lebensqualität, aber auch der maximalen Harnstrahlstärke bzw. eine Verringerung der Blasenauslassobstruktion mit geringerer Begleitmorbidität und kürzerer Krankenhausverweildauer. Die Vielzahl der zur Lasertherapie der BPH publizierten Fall-Kontroll- und randomisierten Studien zeigen heterogene Ergebnisse sowohl bezüglich der Verbesserung der subjektiven und der objektiven Miktionsparameter, als auch bezüglich der Komplikationen. Dies liegt zum einen am Laser bzw. dessen qualitativer Wirkung, zum anderen am Behandler und dem von diesem bestimmten quantitativen Effekt. Die biophysikalischen Zusammenhänge zwischen den Laserparametern und den Gewebeeffekten werden diskutiert. Die biologische Wirkung hängt nicht nur von der Eindringtiefe und der Streuung, sondern auch von anderen Parametern des Lasers ab. Für die Erzeugung von großvolumigen Koagulationsnekrosen mit Lasern des Wellenlängenbereiches von ca. 800 bis 1100 nm muss eine Karbonisation der Oberfläche vermieden werden. Für die thermische Vaporisation eignen sich z. B. der Nd:YAG-Laser mit kontaktfreier Applikation oder mit Kontaktspitzen sowie Diodenlaser verschiedener Wellenlängen. Besonders geeignet sind der KTP-Laser sowie der LBO-Laser. Auch mit dem Ho:YAG-Laser ist eine Ablation möglich. Ein Schneiden, damit Resezieren bzw. Enukleieren lässt sich ebenfalls mit verschiedenen, auch thermischen Lasersystemen. effektiver mit einem Dauerstrichlaser von ca. 2000 nm. Der Ho:YAG-Laser erreicht einen athermischen Schnitt, dessen Qualität von der Pulsenergie und dem Zeitverhalten der Laserimpulse abhängt.

Abstracts

Various procedures operating with different laser systems and application techniques are available for laser treatment of benign prostate hyperplasia (BPH). They generate differing qualitative and quantitative effects in tissue such as coagulation, vaporisation or, respectively, ablation as well as incisions leading according to technique to a resection or enucleation. Since these procedures are considered as alternatives to transurethral resection of the prostate (TURP), the objective of laser therapy is not only to achieve, in comparison to TURP, an equivalent improvement of the symptoms and quality of life but also a maximal urinary flow strength or, respectively, a reduction of obstruction to bladder emptying with lower accompanying morbidity and shorter hospitalisation. Most of the published case control and randomised studies on laser therapy for BPH show heterogeneous results both with regard to the improvement of subjective and objective urination parameters as well to complications. This is due, on the one hand, to the laser or its qualitative action and, on the other hand, to the operator and the resulting specific quantitative effect. The biophysical relationships between the laser parameters and the tissue effects are a topic of current discussion. The biological effect depends not only on the depth of penetration and the scattering but also on other parameters of the laser. For the generation of voluminous coagulation necrosis with a laser in the ca. 800 to 1100 nm wavelength region, a carbonisation of the surface must be avoided. For thermal vaporisation, for example, the Nd:YAG laser with contract-free application or contact tips as well as diode lasers of varying wavelengths are suitable. Especially suitable are the potassium titanyl phosphate (KTP) laser and the lithium triboride (LBO) laser. Ablation is also possible with the Ho:YAG laser. An incision and thus resection or enucleation is also possible with various laser systems including thermal ones, but is more effective with a continuous beam laser of ca. 2000 nm. The Ho:YAG laser achieves an athermal incision the quality of which depends on the pulse energy and the time behaviour of the laser impulse.

Schlüsselwörter

benigne Prostatahyperplasie - BPH - Therapie - Lasertherapie - Laserkoagulation - Laservaporisation - Laserinzision - Laserresektion - Laserenukleation

Key words

benign prostatic hyperplasia - BPH - therapy - laser therapy - laser coagulation - laser vaporization - laser incision - laser resection - laser enucleation

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1 Der Begriff der „Photoselektiven Vaporisation” beschreibt im Falle des 532-nm-Lasers den Prozess der Absorption dieser Wellenlänge durch Hämoglobin. Grundsätzlich kann dieser Terminus allerdings auf jede beliebige Paarung aus starker Absorption durch einen natürlichen Körperfarbstoff und der entsprechenden Laserwellenlänge angewendet werden – z. B. auch Wasser und 2 oder 3 µm.

2 Gilt nur für Holmiumlaser, der Zahlenwert hängt vom erwärmten Volumen ab, das wiederum bei ausreichend kurzer Pulsdauer vom Absorptionskoeffizienten der jeweiligen Wellenlänge bzw. von der Eindringtiefe bei der verwendeten Laserwellenlänge abhängt.

3 Mit der Verfärbung kommt es auch zu einer dramatischen Änderung der optischen Eigenschaften und damit auch zur Absorption für sichtbare Wellenlängen.