HoLEP teknikleri antegrad ejakülasyonu koruyabilir mi? Trilober ve bilober tekniklerin karşılaştırmalı analizi

AMAÇ: Benign prostat hiperplazisi (BPH)’ne bağlı alt üriner sistem semptomlarının cerrahi tedavisinde prostatın holmiyum lazer ile enükleasyonu (HoLEP), özellikle orta-büyük hacimli prostatlar için açık cerrahiye iyi bir minimal invaziv tedavi alternatifi olarak tüm dünyada giderek daha yaygın olarak uygulanmaktadır. Bizde bu çalışmamızda HoLEP cerrahisi sırasında “ejakülatuar tepe=ejakülatuar hood” (EH) koruyucu trilober enükleasyon tekniği ile EH korunmayan bilober enükleasyon tekniğini RE oranları açısından karşılaştırdık. GEREÇ ve YÖNTEM: Çalışmaya HoLEP yapılan ve operasyon öncesi ereksiyon/ejakülasyon problemi tariflemeyen 48 hasta dahil edildi. Hastalar; EH koruyucu trilober teknikle (Grup 1) ve EH korunmayan bilober teknikle (Grup 2) opere edilen 24’er hastalık 2 gruba ayrıldı ve HoLEP sonrası en az 3. ayını doldurmuş hastalara antegrade ejakülasyonun devam edip etmediği soruldu. BULGULAR: Çalışmaya alınan toplam 48 hastanın yaş ortalaması 64,7 (51–78) idi. Pre-op prostat hacmi ort.110,5 cc (44–193 cc) ve PSA değerleri ise ort.3,75 ng/mL (1,6–8,2 ng/mL) bulundu. Her iki gruptaki hastalar arasında pre-op ve per-op parametreler açısından istatistiksel olarak anlamlı farklılık tespit edilmedi. EH koruyucu trilober teknikle opere edilen gruptaki (grup 1) 24 hastanın 6’sında (%25), bilober enükleasyon grubunda ise (grup 2) 24 hastanın 4’ünde (%16,6) antegrade ejakülasyonun devam ettiği ancak gruplar arasında istatistiksel anlamlı bir fark olmadığı tespit edildi. (p=0,5) SONUÇ: HoLEP cerrahisi sırasında prostatik adenomun özellikle apikal bölgede komplet çıkarılması sonucu oluşan geniş apikal açıklık ve prostatik kavite nedeniyle tek başına ejakülatuar hoodun korunmasının antegrade ejakülasyonu korumada yetersiz kalmaktadır. Sonuç olarak BPH cerrahisinde minimal invaziv bir yaklaşım olarak HoLEP giderek daha yaygın şekilde uygulansa da; antegrade ejakülasyonun korunması açısından HoLEP tekniğinde yapılacak modifikasyonların çok başarılı olmadığı düşünülmektedir.

Can HoLEP technique preserve antegrade ejaculation? Comperative analyses trilober and bilober technique.

OBJECTIVES: Holmium laser enucluation of prostate (HoLEP) is a valid minimal invasive alternative to open prostatectomy in patients with medium-large prostates and lower urinary tract symptoms resulting from benign prostatic hyperlasia (BPH) and performed more frequently worldwide. In this trial we aimed to compare retrograde ejeculation rates of two techniques; ejeculatory hood(EH) sparing trilober enucluation technique and non-ejeculatory sparing bilober enucluation techniques. MATERIAL and METHODS: 48 patients who underwent HoLEP with no preoperative erection/ejeculation problems were included to the trial. Patients were divided into two groups according to utilized enucluation technique; trilober technique (group 1) and bilober technique (group 2). 24 patients were included to both groups. Patients were questioned about antegrade ejeculation status at postoperative 3. Month. RESULTS: Mean age of patients were 64.7 (51-78) years. Preoperative mean prostate volume was 110.5 cc (44-193) and mean PSA level was 3.75 ng/ml (1.6-8.2). Baseline patient characteristics and peroperative parameters were similar between groups. Antegrade ejeculation was observed in 6 of 24 (25%) patients in EH sparing trilober technique group (group 1) and in 4 of 24 (16%) patients in bilober technique group (group 2). No statistically significant difference was detected between two groups in terms of antegrade ejeculation (p=0.5) CONCLUSION: Ejeculatory hood sparing is not enough to preserve antegrade ejeculation due to large apical defect resulting from complete excision of apical prostatic tissue. As a conclusion it is reasonable to suggest that even if HoLEP is a widely adopted minimal invasive approach currently, technical modifications of HoLEP seem ineffective in preserving antegrade ejeculation.

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