A systematic review of holmium laser prostatectomy for benign prostatic hyperplasia

PURPOSE: We undertook a systematic review to assess the safety and efficacy of holmium laser prostatectomy compared to transurethral resection of the prostate. MATERIALS AND METHODS: We searched literature databases through August 2002. Holmium laser studies, including holmium laser resection of the prostate (HoLRP) and holmium laser enucleation of the prostate (HoLEP), of any design, and the transurethral prostatectomy (TURP) arms of randomized controlled trials (RCTs) with sample sizes greater than 50 patients, date restricted to 1995 onward, were included for comparison. RESULTS: Three RCTs comparing HoLRP and TURP, and 2 RCTs comparing HoLEP and TURP were identified. For each of the holmium procedures there was also 1 nonrandomized comparative study and a number of case series (HoLRP 13, HoLEP 10). With the exception of 1 randomized trial the quality of the available evidence was poor, with the other RCTs lacking information regarding methods of randomization, allocation concealment and blinding. The majority of studies were characterized by relatively short followup periods and significant losses to followup. In terms of safety the data suggest that the holmium laser procedures are superior to TURP with regard to a number of key indicators of blood loss (transfusion rates, postoperative bladder irrigation, duration of catheterization and length of hospital stay), although amount of blood loss was rarely reported. In terms of efficacy the holmium laser procedures appear to be similarly effective to TURP in relieving the symptoms of benign prostatic hyperplasia. CONCLUSIONS: Holmium laser prostatectomy is at least as effective as TURP for managing the symptoms of benign prostatic hyperplasia. However, at the present time the long-term durability of the holmium procedures with respect to TURP cannot be determined due to a lack of published studies with sufficient followup.     

Bifluranol in the treatment of benign prostatic hyperplasia (BPH)

Bifluranol, a fluorinated bibenzyl drug with antiandrogenic properties has been studied for its efficacy in the treatment of benign prostatic hyperplasia. Thirty five patients with bladder outflow obstruction received either Bifluranol 1.5 mg orally, t.d.s. or placebo in a double-blind trial. After twelve weeks there was improvement in symptoms of flow, urinary stream (p <0.01) and frequency (p <0.05) in the Bifluranol treated group. A significant reduction in residual urine volume was noted in the active treated group (p <0.05) but mean and peak urine flow rates, voided volume and prostate volume did not reach statistical significance. It is concluded that Bifluranol has a measurably beneficial effect in urinary outflow obstruction due to BPH and further investigative studies with this drug are in progress.     

980nm半导体红激光汽化术在良性前列腺增生治疗中的应用

目的:探讨980 nm半导体红激光汽化术治疗良性前列腺增生(BPH)的安全性和疗效。方法:应用980 nm半导体红激光对92例BPH患者行激光汽化切除术。患者年龄65～89岁,平均前列腺体积为(50.1±13.0)ml,观察记录手术时间、出血量、手术并发症,记录并统计分析手术前后国际前列腺症状评分(IPSS)、生活质量评分(QOL)、最大尿流率(Qmax)及残余尿量(PVR)等指标的差异有无统计学意义。结果:手术全部成功,手术时间平均(70.2±16.9)min,术中无明显出血,无输血病例。患者术后留置尿管2～5 d,平均留置尿管时间(2.4±0.3)d,IPSS术后1个月为(8.7±2.0)分,3个月为(7.7±1.1)分,明显低于术前[(17.9±3.7)分,P<0.01],Qmax及PVR明显好于术前(P<0.01),无患者出现尿失禁及明显的膀胱刺激征。结论:980 nm半导体红激光汽化切除术治疗BPH是安全有效的。     

双波长半导体激光“分叶整体切割法”治疗前列腺增生的疗效评估

目的:探讨经尿道双波长半导体激光系统(Ceralas HPD)治疗良性前列腺增生(BPH)的手术方法和临床效果,并评估其安全性。方法:2013年1月25日~2013年6月25日期间,应用经尿道Ceralas HPD手术治疗51例BPH。患者平均年龄(69.5±7.3)岁,前列腺术前体积平均(73.5±17.7)ml,术前IPSS评分(20.4±7.3)分,最大尿流率(Qmax)(7.2±3.4)ml/s。采用"分叶整体切割法",先在5、7、12点处分别切开一沟槽,内至膀胱颈,外不超过精阜,宽约0.5~1.0cm,深达外科包膜,然后从12点处开始,贴近包膜整体切除左侧叶,再切除右侧叶,最后切除中叶。结果:手术时间平均(51.2±19)min,术中无明显出血,手术过程中视野清晰,无手术并发症,无输血病例。术后导尿管留置时间平均2.7(1~3)d。术后1个月IPSS评分(7.0±2.3)分,最大尿流率Qmax(24.3±5.6)ml/s,与术前相比均有显著改善(P0.05)。结论:Ceralas HPD能高精度地切割组织,同时具备强大的汽化功能和良好的止血功能,对组织的热损伤小。双波长半导体激光"分叶整体切割法"前列腺切除术具有切除速度快,组织切除彻底,并发症少,安全性高等优点,是一种较理想的前列腺切除方法。     

Serenoa repens monotherapy for benign prostatic hyperplasia (BPH): an updated Cochrane systematic review

What's known on the subject? and What does the study add? For the past 30 years Serenoa repens has become a widely used phytotherapy in the USA and in Europe, mostly because of positive comparisons to α‐blockers and 5α‐reductase inhibitors. During the last 4 years we have seen two very high quality trials comparing Serenoa repens to placebo and up to 72 weeks' duration. These trials found Serenoa repens no better than placebo, even (in one trial) at escalating doses.

OBJECTIVE

• ? To estimate the effectiveness and harms of Serenoa repens monotherapy in the treatment of lower urinary tract symptoms (LUTS) consistent with benign prostatic hyperplasia (BPH).

MATERIALS AND METHODS

• ? We searched MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials (CENTRAL), and other sources through to January 2012 to identify randomised trials.
• ? Trials were eligible if they randomised men with symptomatic BPH to receive Serenoa repens extract monotherapy for at least 4 weeks in comparison with placebo, and assessed clinical outcomes and urodynamic measurements.
• ? Our primary outcome was improvement in LUTS, based on change in urological symptom‐scale scores.

RESULTS

• ? In all, 17 randomised controlled trials (N= 2008) assessing Serenoa repens monotherapy (typically 320 mg/day) vs placebo met inclusion criteria, although only five reported American Urological Association Symptom Index (AUASI) or International Prostate Symptom Scores (IPSS). Trial lengths ranged from 4 to 72 weeks. The mean age of all enrolees was 64.3 years and most participants were of White race. The mean baseline total score was 14 points, indicating moderately severe symptoms. In all, 16 trials were double blinded and adequate treatment allocation concealment was reported in six trials.
• ? In a meta‐analysis of three high quality long‐to‐moderate term trials (n= 661), Serenoa repens therapy was no better than placebo in reducing LUTS based on the AUASI/IPSS (weighted mean difference [WMD]?0.16 points, 95% confidence interval [CI]–1.45 to 1.14) or maximum urinary flow rate (Q_max; WMD 0.40 mL/s, 95% CI ?0.30 to 1.09). Based on mostly short‐term studies, Q_max measured at study endpoint were also not significantly different between treatment groups (WMD 1.15 mL/s, 95% CI ?0.23 to 2.53) with evidence of substantial heterogeneity (I² 58%).
• ? One long‐term dose escalation trial (72 weeks) found double and triple doses of Serenoa repens extract did not improve AUASI compared with placebo and the proportions of clinical responders (≥3 point decrease in the AUASI) were nearly identical (43% vs 44% for Serenoa repens and placebo, respectively) with a corresponding risk ratio of 0.96 (95% CI 0.76–1.22).
• ? Long‐term, Serenoa repens therapy was no better than placebo in improving nocturia in one high‐quality study (P= 0.19). Pooled analysis of nine short‐term Permixon® trials showed a reduction in the frequency of nocturia (WMD ?0.79 times/night, 95% CI–1.28 to ?0.29), although there was evidence of heterogeneity (I² 76%)
• ? Adverse events of Serenoa repens extracts were few and mild, and incidences were not statistically significantly different vs placebo. Study withdrawals occurred in ≈10% and did not differ between Serenoa repens and placebo.

CONCLUSIONS

• ? Serenoa repens therapy does not improve LUTS or Q_max compared with placebo in men with BPH, even at double and triple the usual dose.
• ? Adverse events were generally mild and comparable to placebo.

     

Laser treatment of benign prostatic hyperplasia

To evaluate the role of lasers that allow acute removal of obstructing tissue in the surgical treatment of benign prostatic hyperplasia (BPH). A MEDLINE search over the last 6 years focused on randomized trials, large case series and review articles. A total of more than 4,000 patients were analyzed with respect to the morbidity and outcome, and the advantages and disadvantages of the various lasers. Laser treatment of BPH has evolved from coagulation to enucleation. Blood loss is significantly reduced as compared to transurethral resection and open prostatectomy. Ablative/vaporizing techniques have recently become popular again with the marketing of new high-powered 80 W potassium-titanyl-phosphate (KTP) and 100 W holmium lasers. Vaporization immediately removes obstructing tissue, but tissue specimen cannot be obtained. KTP short-term results are promising, but long-term results and randomized trials are lacking. Postoperative volume reduction is less than with holmium laser enucleation of the prostate (HoLEP), and the KTP laser can be used for BPH treatment only. HoLEP allows whole lobes of the prostate to be removed. Prostates of all sizes can be operated on. It is at least as safe and effective as TURP and open prostatectomy, with significantly lower morbidity, as shown by several well-designed randomized clinical trials. It provides specimen for histological evaluation. In addition, the holmium laser can be used for the endourological treatment of stones, strictures and tumors. HoLEP appears to be a size-independent new “gold standard” in the surgical treatment of BPH.     

1470 nm激光三沟逆切法汽化剜除术治疗良性前列腺增生症的效果分析

目的:探讨1 470nm激光三沟逆切法汽化剜除术(1 470nm diode laser vapoenucleation of the prostate-three passageway antidrom,DiLEP-TPA)治疗良性前列腺增生症(BPH)的临床疗效。方法:回顾性分析2015年1月~2016年1月于我院行DiLEP-TPA治疗54例BPH患者的临床资料,观察其围手术期指标、术后并发症情况及手术前后患者国际前列腺症状评分(IPSS)、生活质量评分(QOL)、残余尿量(PVR)、最大尿流率(Q_max)变化。结果:所有手术顺利完成,无中转经尿道前列腺电切术(TURP)及开放手术。手术时间平均(63.8±11.6)min,膀胱冲洗时间平均(25.0±3.0)h,留置尿管时间平均(52.3±12.4)h,住院时间平均(2.9±0.8)d,术中出血量平均为(45.4±10.9)ml,术后2h血红蛋白减少量平均(2.3±0.9)g/L。术后6个月患者IPSS、QOL、PVR、Q_max均较术前明显改善(P<0.01)。术中无明显出血,无包膜穿孔、膀胱及直肠损伤病例;术后无输血、永久性尿失禁、电切综合征(TURS)等发生。结论:DiLEP-TPA治疗BPH安全、有效。     

Trends in adverse events of benign prostatic hyperplasia (BPH) in the USA, 1998 to 2008

Study Type – Harm (Cohort) Level of Evidence 2b What’s known on the subject? and What does the study add? In clinical trials, oral medications for BPH have been effective at managing LUTS and preventing progression to urinary retention, urinary infections, and renal insufficiency. Population‐level trends of these adverse outcomes are poorly characterized. We identified a 400% increase in hospitalizations for BPH with acute renal failure, indicating that severe adverse events of BPH persist despite widespread use of oral therapies in the USA.

OBJECTIVE

? To determine if the adverse events (AEs) of benign prostatic hyperplasia (BPH) have declined in tandem with increased use of oral therapy.

MATERIALS AND METHODS

? We used the Nationwide Inpatient Sample, a 20% sample of USA community hospitals, weighted to estimate national numbers to characterize the prevalence of AEs of BPH from 1998 to 2008. ? We calculated the age‐adjusted prevalence of BPH and associated conditions and analyzed prevalence trends with regression modelling.

RESULTS

? Of 134 million estimated eligible discharges during the study period, 7 464 730 (5.6%) had either a primary or secondary diagnosis of BPH. ? The age‐adjusted prevalence of BPH among all hospitalizations, irrespective of primary diagnosis, increased from 4.3% to 8% (P < 0.001) during the study period. ? The age‐adjusted prevalence of BPH as a primary diagnosis decreased from 0.88% to 0.48% (P < 0.001). ? Discharges for BPH surgery decreased 51% (odds ratio [OR] 0.49, 95% confidence interval [CI] 0.45–0.54, P‐trend <0.001) over time. Discharges for primary BPH with acute renal failure increased >400% (OR 4.28, 95% CI 3.22–5.71, P‐trend <0.001). ? There were no significant changes in discharges for primary BPH with urinary retention (P‐trend = 0.636), bladder stones (P‐trend = 0.117), or urinary infection (P‐trend = 0.101) over time.

CONCLUSIONS

? Increased hospitalizations for BPH with acute renal failure and stable hospitalizations for other AEs of BPH indicate that severe AEs of BPH persist despite widespread use of oral therapies in the USA. ? Further studies are needed to explain these trends.     

Current role of lasers in the treatment of benign prostatic hyperplasia (BPH)

OBJECTIVE: Evaluate the current role of lasers in the treatment of benign prostatic hyperplasia (BPH). METHODS: The results of a MEDLINE search for randomised trials and case series of the last 5 yr and published review articles were analysed for the safety and efficacy of neodymium:yttrium aluminum garnet (Nd:YAG), potassium-titanyl-phosphate (KTP), and holmium (Ho):YAG laser prostatectomy. The analysis includes 12 reports on randomised clinical trials, 2 comparative studies, 10 review articles, and a total of >5000 patients. RESULTS: Laser treatment of BPH has evolved from coagulation to enucleation. Blood loss is significantly reduced compared with transurethral resection and open prostatectomy. Visual laser ablation of the prostate and interstitial laser coagulation cause coagulative necrosis with secondary ablation. Long postoperative catheterisation, unpredictable outcomes, and high reoperation rates have restricted the use of these techniques. Ablative/vaporising techniques have become popular again with the marketing of new high-powered 80-W KTP and 100-W Ho lasers. Vaporisation immediately removes obstructing tissue. Short-term results are promising, but large series, long-term results, and randomised trials are lacking. Holmium laser enucleation (HoLEP) allows whole lobes of the prostate to be removed, mimicking the action of the index finger in open prostatectomy. Prostates of all sizes can be operated on. It is at least as safe and effective as transurethral resection of the prostate and open prostatectomy, with significantly lower morbidity. It is the only laser procedure that provides a specimen for histologic evaluation. CONCLUSIONS: HoLEP appears to be a size-independent new "gold standard" in the surgical treatment of BPH.     

重度前列腺增生症20例经尿道电切术治疗总结

目的 探讨重度前列腺增生症经尿道电切治疗效果。方法 采用经尿道前列腺电切术（TURP）治疗重度BPH20例,随访3～18个月。结果 切除前列腺重量平均73g,平均手术时间75min。术后平均留置导尿管4d,术后平均住院时间7d。最大尿流率（Qmax）由术前的（6.3±1.5）ml/s上升至术后3个月的（15.1±4.7）ml/s,前列腺症状评分（IPSS）术前为（29.7±1.2）分,术后3个月降至（5.1±1.0）分（P〈0.01）。结论 TURP安全、并发症少、疗效好。重度BPH不是TURP的禁忌证。     

Sexual outcome of patients undergoing thulium laser enucleation of the prostate for benign prostatic hyperplasia

Treatment of patients with lower urinary tract symptoms (LUTS) secondary to benign prostatic hyperplasia (BPH) may affect the quality of sexual function and ejaculation. The effect of new surgical procedures, which are currently available to treat BPH, on erection and ejaculation, has been poorly studied. This study aimed to assess the effect of thulium laser enucleation of the prostate (ThuLEP) on sexual function and retrograde ejaculation in patients with LUTS secondary to BPH. We performed a prospective study in 110 consecutive patients who had undergone ThuLEP to analyze changes in sexual function and urinary symptoms. To evaluate changes in erection and ejaculation, and the effect of urinary symptoms on the quality of life (QoL), five validated questionnaires were used: the ICIQ-MLUTSsex, MSHQ-EjD, International Index of Erectile Function 5, International Prognostic Scoring System (IPSS) questionnaire, and QoL index of the intraclass correlation coefficients. Patients also underwent IPSS and flowmetry to assess the outcome of flow. Patients were evaluated before surgery and 3–6 months after ThuLEP, whereas those with previous abdominal surgery were excluded. The patients’ mean age was 67.83 years. Postoperative urinary symptoms improved after surgery. No significant differences in erectile function before and after surgery were observed. As compared with other techniques described in the literature, the percentage of patients with conserved ejaculation increased by 52.7% after ThuLEP. ThuLEP positively affects urinary symptoms and their effect on the QoL of patients as assessed by questionnaire scores. While endoscopic management of BPH (e.g. transurethral resection of the prostate) causes retrograde ejaculation in most patients, those who undergo ThuLEP have conserved ejaculation and erectile function.     

前列腺增生症患者合并前列腺炎对血清PSA的影响

目的前列腺增生患者合并前列腺炎症对血清前列腺特异性抗原的影响。方法研究对象为在本院就诊,行经尿道前列腺电切术的前列腺增生71例患者,术前均经B超或CT、MRI诊断为前列腺增生,术后病理确诊为前列腺增生合并炎症。术前评估项目包括：年龄、前列腺体积、血清PSA、残余尿量、最大尿流率、国际前列腺症状评分（IPSS）、生活质量评分、尿中白细胞数、肌酐及术后病理诊断。纳入前列腺体积和年龄等因素的同时,分析前列腺腺周炎症、前列腺腺体炎症及基质炎症是否影响血清PSA浓度。结果前列腺体积（t=5.10）、基质炎症（χ2=10.35）、尿路感染（χ2=10.00）与血清PSA升高有关。结论血清PSA值与前列腺增生患者年龄及前列腺体积有关,前列腺炎的基质炎症与尿路感染也是前列腺增生患者血清PSA升高的危险因素。     

经尿道前列腺选择性绿激光手术与经尿道前列腺电切术的疗效比较

目的评价经尿道前列腺选择性绿激光手术（greenlight photoselective vaporization of prostate,PVP）与经尿道前列腺电切术（transurethral prostatectomy,TURP）的临床疗效。方法将178例良性前列腺增生（benign prostatic hyperplasia,BPH）患者随机分为两组,95例行PVP术（PVP组）,83例行TURP术（TURP组）,比较两种术式的平均手术时间、术中出血量、输血量、近期疗效及并发症等情况。结果 PVP组和TURP组平均手术时间分别为（47.4±5.1）min和（61.7±6.2）min,前者显著低于后者,PVP组术中出血量、输血量、术后膀胱冲洗时间、留置尿管时间及住院时间均显著少于TURP组,PVP组近期并发症发生率明显小于TURP组,两组术后前列腺国际症状评分（IPSS）、生活质量评分（QOL）、最大尿流率、剩余尿量较术前均有显著改善。结论 PVP是一种安全有效的治疗BPH的理想微创术式,具有手术时间短、创伤小、出血少、恢复快、并发症发生率低等特点。     

前列腺增生症手术前后雄性激素变化的研究

目的　为了研究、探讨前列腺增生症手术前后雄性激素的变化和对全身的影响。方法　 2 3例前列腺增生症病例分别在手术前 1周和手术后 2周 ,采集血清样本 ,以测定血清中T、FT、DHT浓度 :采用经膀胱耻骨上前列腺内腺体摘除术 ,观察手术前后病人雄激素的改变和性激素改变发生的一系列主诉症状。结果　在前列腺内腺体摘除手术前后 ,血清中T、FT、DHT存在着明显的差异 ,分别下降 34.4 5 % ,33.5 3% ,5 0 .4 1% ,以DHT下降尤为明显 (P <0 .0 0 1)。前列腺摘除术后由于体循环中主要的雄激素明显下降 ,病人有雄激素下降的临床症状。结论　前列腺内腺体摘除术以后血清中雄激素将发生明显的变化 ,对于这个变化临床上应引起重视