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.

Kaynakça

Gilling P. Laser enucleation of the prostate (HoLEP). BJU Int 2008;101:131–42. [CrossRef]

van Rij S, Gilling PJ. In 2013, holmium laser enucleation of the prostate (HoLEP) may be the new “gold standard”. Curr Urol Rep 2012;13:427–32. [CrossRef]

Gilling PJ, Wilson LC, King CJ, Westenberg AM, Frampton CM, Fraundorfer MR. Long-term results of a randomized trial comparing holmium laser enucleation of the prostate and transurethral resection of the prostate: results at 7 years. BJU Int 2012;109:408–11. [CrossRef]

Gillling PJ, Aho TF, Frampton CM, King CJ, Fraundorfer MR. Holmium laser enucleation of the prostate: results at 6 years. Eur Urol 2008;53:744–9. [CrossRef]

Jaidane M, Arfa NB, Hmida W, Hidoussi A, Slama A, Sorba NB, Mosbah F. Effect of transurethral resection of the prostate on erectile function: a prospective comparative study. Int J Impot Res 2010;22:146–51. [CrossRef]

AUA Practice Guidelines Committee. AUA guideline on management of benign prostatic hyperplasia 2003, Chapter 3: Results of the Treatment Outcomes Analyses. Available at: https:// www.auanet.org/Documents/education/Arc-BPH-Chapter1.pdf

Kuntz RM, Ahyai S, Lehrich K, Fayad A. Transurethral holmium laser enucleation of the prostate versus transurethral electrocautery resection of the prostate: a randomized prospective trial in 200 patients. J Urol 2004;172:1012–6. [CrossRef]

Briganti A, Naspro R, Gallina A, Salonia A, Vavassori I, Hurle R, et al. Impact on sexual function of holmium laser enucleation versus transurethral resection of the prostate: results of a prospective, 2-center, randomized trial. J Urol 2006;175:1817–21. [CrossRef]

Placer J, Salvador C, Planas J, Trilla E, Lorente D, Celma A, et al. Effects of holmium laser enucleation of the prostate on sexual function. J Endourol 2015;29:332–9. [CrossRef]

Elshal AM, Elmansy HM, Elkoushy MA, Elhilali MM. Male sexual function outcome after three laser prostate surgical techniques: a single center perspective. Urology 2012;80:1098–104. [CrossRef]

Terrone C, Castelli E, Aveta P, Cugudda A, Rocca Rossetti S. Iatrogenic ejaculation disorders and their prevention. Minerva Urol Nefrol 2001;53:19–28.

Elliot L, Brendler H. Loss of ejaculation following bilateral retroperitoneal lymphadenectomy. J Urol 1967;98:375–8. [CrossRef]

Narayan P, Lange P, Fraley E. Ejaculation and fertility after extended retroperitoneal lymph node dissection for testicular cancer. J Urol 1982;127:685–8. [CrossRef]

Horenblas S, Meinhardt W, Ijzerman W, Moonen LFM. Sexuality preserving cystectomy and neobladder: initial results. J Urol 2001;166:837–40. [CrossRef]

Meinhardt W, Horenblas S. Sexuality preserving cystectomy and neobladder (SPCN): functional results of a neobladder anastomosed to the prostate. Eur Urol 2003;43:646–50. [CrossRef]

Girgin C, Oder M, Sahin MO, Sezer A, Berkmen S, Aydin R, Dincel C. Erection- and ejaculation-preserving cystectomy with orthotopic urinary diversion: is it feasible? J Androl 2006;27:263– 7. [CrossRef]

Hermabessiere J, Guy L, Boiteux JP. Human ejaculation: physiology, surgical conservation of ejaculation. Prog Urol 1999;9:305–9.

Hasmat Al, Hakim LS. Antegrade ejaculation following transurethral laser ablation of the prostate. J Androl 1994;15:S28– 30.

Ronzoni G, De Vecchis M. Preservation of anterograde ejaculation after transurethral resection of both the prostate and bladder neck. BJU Int 1998;81:830–3. [CrossRef]

Chandrasekera S, De Zylva S, Lamahewage N, Kulasinghe M. Ejaculation preserving transurethral resection of prostate: a pilot study. J Urol 2012;187:e813. [CrossRef]

Tabatabaei S, Choi B, Muir G. Ejaculation-preserving photoselective vaporization of prostate (EP-PVP): six years experience from a multi-centre study. J Urol 2011;185:e910–1. [CrossRef]

Alloussi SH, Lang C, Eichel R, Alloussi S. Ejaculation-preserving transurethral resection of prostate and bladder neck: shortand longterm results of a new innovative resection technique. J Endourol 2014;28:84–9. [CrossRef]

Leonardi R. Preliminary results on selective light vaporization with the side-firing 980 nm diode laser in benign prostatic hyperplasia: an ejaculation sparing technique. Prostate Cancer Prostatic Dis 2009;12:277–80. [CrossRef]

Kim M, Song SH, Ku JH, Kim HJ, Paick JS. Pilot study of the clinical efficacy of ejaculatory hood sparing technique for ejaculation preservation in holmium laser enucleation of the prostate. Int J Impot Res 2015;27:20–4. [CrossRef]

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